Children's Hospital GME Annual Report Program Information

Department of Health and Human Services	OMB No. 0915-0247
Health Resources and Services Administration	Expiration Date: 03/31/2010

Children’s Hospitals Graduate Medical Education Payment Program Annual Report Checklist
Name of Children’s Hospital:	Address:
City:	State:
Zip Code:	Date of Report:
Medicare Provider Number: Federal fiscal year for application:
Year the hospital first received CHGME funding:

Annual Report Forms	This Column to be Completed by the Applicant Hospital	This Column to be Completed by the CHGME PP
Is the Listed Item Completed and Attached?
HRSA 100-1	Yes No	Yes No
HRSA 100-2	Yes No	Yes No
HRSA 100-3	Yes No	Yes No
HRSA 100-4	Yes No	Yes No
HRSA 100-5	Yes No	Yes No
Computer Disk with Zip Code Data	Yes No	Yes No
One (1) hard copy and (1) electronic copy of the completed Annual Report including relevant forms and the zip code file.	Yes No	Yes No

HRSA 99-5 Page 1 of 1	Created in MS Word 6.0
(Rev. 03-2007)