Form BHPR_CHGME_100-1_F BHPR_CHGME_100-1_FY2011

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Overview

Cover Page
HRSA 100-1-A CHILDREN'S HOSP ID
HRSA 100-1-B CH GME PROG STATUS
HRSA 100-1-C NO. OF TRAINEES SI
HRSA 100-1-D NO OF TRAINEES ROT
HRSA 100-1 - E LIST OF PROGRAMS
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Sheet 1: Cover Page

Department of Health and Human Services						OMB No. 0915-0313
Health Resources and Services Administration						Expiration Date: 11/30/2010
	CHILDREN’S HOSPITALS GRADUATE MEDICAL EDUCATION PAYMENT PROGRAM ANNUAL REPORT FORM HRSA 100-1
	Public Burden Statement
	An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0915-0313. Public reporting burden for the applicant for this collection of information is estimated to average 10 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14 33, Rockville, Maryland, 20857.

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Sheet 2: HRSA 100-1-A CHILDREN'S HOSP ID

Department of Health and Human Services	OMB No. 0915-0313
Health Resources and Services Administration	Expiration Date: 11/30/2010
See detailed guidance for complete instructions.
Children's Hospitals Graduate Medical Education Payment Program
HRSA 100-1-A: Children's Hospital Identification Information
Name of Children's Hospital
Address
City
State
Zip Code
Medicare Provider Number
Relevant fiscal year for application	FY2011
Relevant academic year for application	July 1, 2009 - June 30, 2010
Year your hospital first received CHGME funding
Submission Date of Annual Report	(mm/dd/yy)
Indicate years in which hospital received any CHGME funding :
	0%
	0%
	0%
	0%
	0%
	0%
	0%
	0%
	0%
	0
Type of Application

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Sheet 3: HRSA 100-1-B CH GME PROG STATUS

Department of Health and Human Services						OMB No. 0915-0313
Health Resources and Services Administration						Expiration Date: 11/30/2010
Children's Hospitals Graduate Medical Education Payment Program
HRSA 100-1-B: Children’s Hospital GME Training Program Status and Change
Hospital Name:
Medicare Provider Number:	0
Date of Report:	(mm/dd/yy)
How many outside institutions send residents to your hospital?
The table below asks about the accreditation status of your GME programs and whether a program has been added or dropped since the previous academic year. There must be at least two check marks in each row that lists the name of a program. Program Status: For each of the programs listed (and for any additional program in which training is offered), check the box indicating whether the program is sponsored by the hospital and/or whether the hospital serves as a major participating institution/rotation site for the program. (Check all that apply.) If your children’s hospital is not involved in a given program, check “not offered.” Program Change: Also indicate whether each program was added or dropped since the previous academic year by checking the appropriate box. If a program was neither added nor dropped, check “no change.” If you need to add additional programs, please use the “Other: Specify” option at the end of the table and follow the same directions as above. Each row of this table should have at least one check mark in the Program Status section and one check mark in the Program Change section. See detailed guidance for complete instructions and examples.
	PROGRAM STATUS 2009-2010			PROGRAM CHANGE SINCE 2008-2009
	Sponsoring Program	Major Participating Institution or Rotation Site/Other Participating Institution	Not Offered	Program Added Since 2008-2009	Program Dropped Since 2008-2009	No Change
Primary Care Programs
Family Medicine	0	0	0	0	0	0
Pediatrics	0	0	0	0	0	0
Combined Programs			1	1	1
Internal Medicine /Pediatrics	0	0	0	0	0	0
Pediatrics/Dermatology	0	0	0	0	0	0
Pediatrics/Emergency Medicine	0	0	0	0	0	0
Pediatrics/Medical Genetics	0	0	0	0	0	0
Pediatrics/Physical Medicine and Rehab	0	0	0	0	0	0
Pediatrics/Psychiatry/Child & Adolescent Psych	0	0	0	0	0	0
Pediatric Medical Subspecialties
Adolescent Medicine Pediatrics	0	0	0	0	0	0
Child Abuse Pediatrics	0	0	0	0		0
Developmental Behavioral Pediatrics	0	0	0	0	0	0
Hospice and Palliative Medicine	0	0	0	0		0
Medical Toxicology	0	0	0	0		0
Neonatal-Perinatal Medicine	0	0	0	0		0
Neurodevelopmental Disabilities	0	0	0	0		0
Pediatric Cardiology	0	0	0	0		0
Pediatric Critical Care Medicine	0	0	0	0		0
Pediatric Emergency Medicine	0	0	0	0		0
Pediatric Endocrinology	0	0	0	0		0
Pediatric Gastroenterology	0	0	0	0		0
Pediatric Hematology/Oncology	0	0	0	0		0
Pediatric Infectious Disease	0	0	0	0		0
Pediatric Nephrology	0	0	0	0		0
Pediatric Pulmonology	0	0	0	0		0
Pediatric Rheumatology	0	0	0	0		0
Pediatric Transplant Hepatology	0	0	0	0		0
Pediatric Sports Medicine	0	0	0	0		0
Pediatric Surgical Subspecialties			0	0
Pediatric Cardiothoracic Surgery	0	0	0	0		0
Pediatric Neurosurgery	0	0	0	0		0
Pediatric Ophthalmology	0	0	0	0		0
Pediatric Orthopedics	0	0	0	0		0
Pediatric Otolaryngology	0	0	0	0		0
Pediatric Surgery	0	0	0	0		0
Pediatric Urology	0	0	0	0		0
Other Specialties			0	0
Child and Adolescent Psychiatry	0	0	0	0		0
Child Neurology	0	0	0	0		0
Emergency Medicine (Pediatric)a	0	0	0	0		0
Pediatric Anesthesiology	0	0	0	0		0
Pediatric Dermatology	0	0	0	0		0
Pediatric Pathology	0	0	0	0		0
Pediatric Radiology	0	0	0	0		0
Pediatric Rehabilitation Medicine	0	0	0	0		0
General (Non-pediatric) Specialties			0	0
Anesthesiology	0	0	0	0		0
Colon & Rectal Surgery	0	0	0	0		0
Dermatology	0	0	0	0		0
Emergency Medicine	0	0	0	0		0
Medical Genetics	0	0	0	0		0
Neurological Surgery	0	0	0	0		0
Neurology	0	0	0	0	0	0
Nuclear Medicine	0	0	0	0	0	0
Obstetrics and Gynecology	0	0	0	0		0
Ophthalmology	0	0	0	0		0
Orthopedic Surgery	0	0	0	0		0
Otolaryngology	0	0	0	0		0
Pathology	0	0	0	0		0
Physical Medicine & Rehabilitation	0	0	0	0		0
Plastic Surgery	0	0	0	0		0
Preventive Medicine	0	0	0	0		0
Psychiatry	0	0	0	0		0
Radiology	0	0	0	0		0
Surgery	0	0	0	0		0
Thoracic Surgery	0	0	0	0		0
Urology	0	0	0	0		0
Allergy Immunology	0	0	0	0		0
Pediatric Sleep Medicine	0	0	0	0		0
Other (specify):	0	0	0	0		0
Other (specify):	0	0	0	0		0
Other (specify):	0	0	0	0		0
Other (specify):	0	0	0	0		0
Other (specify):	0	0	0	0		0
Other (specify):	0	0	0	0		0
Other (specify):	0	0	0	0		0
Other (specify):	0	0	0	0		0
Other (specify):	0	0	0	0	0	0
Other (specify):	0	0	0	0	0	0
Other (specify):	0	0	0	0		0
Other (specify):	0	0	0	0		0
Other (specify):	0	0	0	0		0
Other (specify):	0	0	0	0		0
Other (specify):	0	0	0	0		0
Other (specify):	0	0	0	0		0
Other (specify):	0	0	0	0		0
Other (specify):	0	0	0	0		0
Other (specify):	0	0	0	0	0	0
Other (specify):	0	0	0	0
Other (specify):	0	0	0	0
Other (specify):	0	0	0	0
Other (specify):	0	0	0	0
Other (specify):	0	0	0	0		0
Other (specify):	0	0	0	0		0
Other (specify):	0	0	0	0		0
Other (specify):	0	0	0	0		0
Other (specify):	0	0	0	0		0
Other (specify):	0	0	0	0		0
Other (specify):	0	0	0	0		0
a. Refers to program in which residents first completed an emergency medicine residency followed by a pediatric emergency medicine fellowship versus initially completing a pediatric residency followed by a pediatric emergency medicine fellowship.

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Sheet 4: HRSA 100-1-C NO. OF TRAINEES SI

Department of Health and Human Services				OMB No. 0915-0313
Health Resources and Services Administration				Expiration Date: 11/30/2010
Children's Hospitals Graduate Medical Education Payment Program
HRSA 100-1-C: Number of FTE Trainees - Sponsoring Institution
Hospital Name:	0
Medicare Provider Number:	0
Date of Report:	(mm/dd/yy)
For each accredited GME program for which your children’s hospital is a sponsoring institution, please indicate the number of approved FTE resident positions, the number of FTE resident positions recruited to fill, number of FTE resident positions filled, and number of residents in FTE training positions in your hospital. Only the programs that are checked on "HRSA 100-1-B Children's Hospital Program Status" appear and should be completed. Please report the total number across all PGY years.
The number of approved (accredited) positions should be entered in the first column. The number of positions the program actively recruited to fill in the most recent academic year should be entered in the second column. The third column is the total number of positions filled for all PGY years. The fourth column is the number of residents (people) in FTE positions in the most recent academic year. Please see guidance for detailed instructions and examples.
	Number of Approved Positions (2009-2010)	Number of Recruited Positions (2009-2010)	Number of Positions Filled for the Total Program (2009-2010)	Number of Residents in FTE Training Positions (2009-2010)
Primary Care Programs
N/A
N/A
Combined Programs
N/A
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Pediatric Medical Subspecialties
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Pediatric Surgical Subspecialties
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Other Specialties
N/A
N/A
N/A
N/A
N/A
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N/A
N/A
General (Non-pediatric) Specialties
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a. Refers to program in which residents first completed an emergency medicine residency followed by a pediatric emergency medicine fellowship versus initially completing a pediatric residency followed by a pediatric emergency medicine fellowship.

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Sheet 5: HRSA 100-1-D NO OF TRAINEES ROT

Department of Health and Human Services					OMB No. 0915-0313
Health Resources and Services Administration					Expiration Date: 11/30/2010
Children's Hospitals Graduate Medical Education Payment Program
HRSA 100-1-D Major Participating Institutions and Rotation Sites - Number of FTE Trainees Meeting 75% Standard
Hospital Name:	0
Medicare Provider Number:	0
Date of Report:	(mm/dd/yy)
Complete the required row information for the highlighted GME program(s). If your hospital is not a major participating institution or rotation site for any GME training programs, no GME training program(s) will be identified or highlighted and you should proceed to the next worksheet (HRSA 100-1-E). For each GME program for which your children’s hospital is a major participating institution or a rotation site, please indicate the number of approved positions, the number of positions recruited to fill in the most recent academic year (2009-2010), the number of approved positions filled in the most recent academic year, the total number of residents rotating in the program for any length of time, and the number of FTEs for which the trainee spends at least 75 percent of their training time training under your hospital's supervision. The first three column headings refer to approved, recruited, and filled positions only. The last two (fourth and fifth) column headings refer to residents (people). If you do not have any approved positions or you have not recruited for any positions, place a "0" in the first three columns. Report on number of residents (people, not positions) in the last two columns. See detailed guidance for complete instructions.
	Number of Approved Positions (2009-2010)	Number of Recruited Positions (2009-2010)	Number of Approved Positions Filled (2009-2010)	Number of Residents Rotating through Programs (2009-2010)	Number of Trainees Spending ³ 75% under Children’s Hospital Supervision (2009-2010)
Primary Care Programs
N/A
N/A
Combined Programs
N/A
N/A
N/A
N/A
N/A
N/A
Pediatric Medical Subspecialties
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
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N/A
N/A
N/A
N/A
Pediatric Surgical Subspecialties
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Other Specialties
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
General (Non-pediatric) Specialties
N/A
N/A
N/A
N/A
N/A
N/A
N/A
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a. Refers to program in which residents first completed an emergency medicine residency followed by a pediatric emergency medicine fellowship versus initially completing a pediatric residency followed by a pediatric emergency medicine fellowship.

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Sheet 6: HRSA 100-1 - E LIST OF PROGRAMS

Department of Health and Human Services				OMB No. 0915-0313
Health Resources and Services Administration				Expiration Date: 11/30/2010
Children's Hospitals Graduate Medical Education Payment Program
HRSA 100-1-E: Programs for which an Annual Report is Required
Hospital Name:	0
Medicare Provider Number:	0
Date of Report:	(mm/dd/yy)
For each program listed below, you must complete the HRSA 100-2 with hospital level data and one HRSA 100-3 for each program listed. Be sure to scroll to the bottom of worksheet to see all highlighted programs. See detailed guidance for complete instructions.
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Sheet 7: .

Initial completion of annual report

Data missing from initial application