Information Collection

Children's Hospital Graduate Medical Eduction Payment Program

IC 6495 under ICR 201103-0915-001 · OMB 0915-0247.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0247 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1-2 Children's Hospital Graduate Medical Eduction Payment Program	Form and Instruction
1-2 HRSA_CHGME_99-1-2 HRSA 99-1and 99-2_with_ACA_changes.xlsx	Form and Instruction
4 HRSA_CHGME_99-4 HRSA 99-4_with_ACA_changes.xlsx	Form and Instruction
HRSA_CHGME_99 HRSA_CHGME_99 hrsaform99_1-12-11.pdf bhpr.hrsa.gov/childrenshospitalgme/apply.htm	Form and Instruction
HRSA_CHGME_99-3 HRSA_CHGME_99-3 hrsaform993_1-12-11.pdf bhpr.hrsa.gov/childrenshospitalgme/apply.htm	Form and Instruction
HRSA_CHGME_99-5 HRSA_CHGME_99-5 hrsaform995_1-12-11.pdf bhpr.hrsa.gov/childrenshospitalgme/apply.htm	Form and Instruction
CHGME Guidance Document for OMB Clearance Package FY2011.doc Application Guidance, Instructions and Forms	IC Document

IC Title:

Children's Hospital Graduate Medical Eduction Payment Program

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1-2	HRSA_CHGME_99-1-2	HRSA 99-1and 99-2_with_ACA_changes.xlsx		Yes	Yes	Fillable Fileable
Form and Instruction	4	HRSA_CHGME_99-4	HRSA 99-4_with_ACA_changes.xlsx		Yes	Yes	Fillable Fileable
Form and Instruction	HRSA_CHGME_99	HRSA_CHGME_99	hrsaform99_1-12-11.pdf	http://bhpr.hrsa.gov/childrenshospitalgme/apply.htm	Yes	Yes	Fillable Fileable
Form and Instruction	HRSA_CHGME_99-3	HRSA_CHGME_99-3	hrsaform993_1-12-11.pdf	http://bhpr.hrsa.gov/childrenshospitalgme/apply.htm	Yes	Yes	Fillable Fileable
Form and Instruction	HRSA_CHGME_99-5	HRSA_CHGME_99-5	hrsaform995_1-12-11.pdf	http://bhpr.hrsa.gov/childrenshospitalgme/apply.htm	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 60

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to New Statute	Previously Approved
Annual Number of Responses for this IC	60	0	60
Annual IC Time Burden (Hours)	3,730	230	3,500
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Application Guidance, Instructions and Forms	CHGME Guidance Document for OMB Clearance Package FY2011.doc	06/10/2011

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.