Form 1 Hospital Fianance Staff HRSA 100-1

---

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
.
..

---

Sheet 1: Cover Page

Department of Health and Human Services						OMB No. 0915-0313
Health Resources and Services Administration						Expiration Date: 11/30/2013
	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 9.2 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.

---

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: 11/30/2013
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	FY2013
Relevant academic year for application	July 1, 2011 - June 30, 2012
Year your hospital first received CHGME funding
Submission Date of Annual Report
Indicate years in which hospital received any CHGME funding :
	0%
	0%
	0%
	0%
	0%
	0%
	0%
	0%
	0%
	0%
	0
	0
	0
Type of Application	1

---

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: 11/30/2013
Children's Hospitals Graduate Medical Education Payment Program
HRSA 100-1-B: Children’s Hospital GME Training Program Status and Change
Hospital Name:	0
Medicare Provider Number:	00-0000
Date of Report:	12/30/99
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, including programs without residents actively rotating during the relevant academic year. (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. Only indicate a program has been added if it has been newly accredited since the previous academic year. Only indicate a program has been dropped if it has voluntarily or involuntarily lost accreditation since the previous academic year. 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 2011-2012				PROGRAM CHANGE SINCE 2010-2011
	Sponsoring Program	Major Participating Institution or Rotation Site/Other Participating Institution	Not Offered		Program Added Since 2010-2011	Program Dropped Since 2010-2011	No Change
Primary Care Programs
Family Medicine
Pediatrics
Combined Programs
Internal Medicine /Pediatrics
Pediatrics/Dermatology
Pediatrics/Emergency Medicine
Pediatrics/Medical Genetics
Pediatrics/Physical Medicine and Rehab
Pediatrics/Psychiatry/Child & Adolescent Psych
Pediatric Medical Subspecialties
Adolescent Medicine Pediatrics
Child Abuse Pediatrics
Developmental Behavioral Pediatrics
Hospice and Palliative Medicine
Medical Toxicology
Neonatal-Perinatal Medicine
Neurodevelopmental Disabilities
Pediatric Cardiology
Pediatric Critical Care Medicine
Pediatric Emergency Medicine
Pediatric Endocrinology
Pediatric Gastroenterology
Pediatric Hematology/Oncology
Pediatric Infectious Disease
Pediatric Nephrology
Pediatric Pulmonology
Pediatric Rheumatology
Pediatric Transplant Hepatology
Pediatric Sports Medicine
Pediatric Surgical Subspecialties
Pediatric Cardiothoracic Surgery
Pediatric Neurosurgery
Pediatric Ophthalmology
Pediatric Orthopedics
Pediatric Otolaryngology
Pediatric Surgery
Pediatric Urology
Other Specialties
Child and Adolescent Psychiatry
Child Neurology
Emergency Medicine (Pediatric)a
Pediatric Anesthesiology
Pediatric Dermatology
Pediatric Pathology
Pediatric Radiology
Pediatric Rehabilitation Medicine
General (Non-pediatric) Specialties
Anesthesiology
Colon & Rectal Surgery
Dermatology
Emergency Medicine
Medical Genetics
Neurological Surgery
Neurology
Nuclear Medicine
Obstetrics and Gynecology
Ophthalmology
Orthopedic Surgery
Otolaryngology
Pathology
Physical Medicine & Rehabilitation
Plastic Surgery
Preventive Medicine
Psychiatry
Radiology
Surgery
Thoracic Surgery
Urology
Allergy Immunology
Pediatric Sleep Medicine
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
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.

---

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: 11/30/2013
Children's Hospitals Graduate Medical Education Payment Program
HRSA 100-1-C: Number of FTE Trainees - Sponsoring Institution
Hospital Name:	0
Medicare Provider Number:	00-0000
Date of Report:	12/30/99
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 assigned to sponsoring institutions only 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 (2011-2012)	Number of Recruited Positions (2011-2012)	Number of Positions Filled for the Total Program (2011-2012)	Number of Residents in FTE Training Positions (2011-2012)
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
N/A
N/A
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
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
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
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
N/A
N/A
N/A
N/A
N/A
N/A
N/A
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.

---

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: 11/30/2013
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:	00-0000
Date of Report:	12/30/99
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 assigned to major participating institutions only, the number of positions recruited to fill in the most recent academic year (2011-2012), 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 more than 75 percent of their training time training under your hospital's supervision. Do not submit the number of approved positions assigned to the resident's sponsoring institution. 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 (2011-2012)	Number of Recruited Positions (2011-2012)	Number of Approved Positions Filled (2011-2012)	Number of Residents Rotating through Programs (2011-2012)	Number of Trainees Spending ³ 75% under Children’s Hospital Supervision (2011-2012)
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
N/A
N/A
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
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
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
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
N/A
N/A
N/A
N/A
N/A
N/A
N/A
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.

---

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: 11/30/2013
	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:	00-0000
	Date of Report:	12/30/99
	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.
1	N/A	0
2	N/A	0
3	N/A	0
4	N/A	0
5	N/A	0
6	N/A	0
7	N/A	0
8	N/A	0
9	N/A	0
10	N/A	0
11	N/A	0
12	N/A	0
13	N/A	0
14	N/A	0
15	N/A	0
16	N/A	0
17	N/A	0
18	N/A	0
19	N/A	0
20		0
21	N/A	0
22	N/A	0
23	N/A	0
24	N/A	0
25	N/A	0
26	N/A	0
27	N/A	0
28	N/A	0
29	N/A	0
30	N/A	0
31	N/A	0
32	N/A	0
33		0
34	N/A	0
35	N/A	0
36	N/A	0
37	N/A	0
38	N/A	0
39	N/A	0
40	N/A	0
41		0
42	N/A	0
43	N/A	0
44	N/A	0
45	N/A	0
46	N/A	0
47	N/A	0
48	N/A	0
49	N/A	0
50	N/A	0
51	N/A	0
52	N/A	0
53	N/A	0
54	N/A	0
55	N/A	0
56	N/A	0
57	N/A	0
58	N/A	0
59	N/A	0
60	N/A	0
61	N/A	0
62	N/A	0
63	N/A	0
64	N/A	0
65	N/A	0
66	N/A	0
67	N/A	0
68	N/A	0
69	N/A	0
70	N/A	0
71	N/A	0
72	N/A	0
73	N/A	0
74	N/A	0
75	N/A	0
76	N/A	0
77	N/A	0
78	N/A	0
79	N/A	0
80	N/A	0
81	N/A	0
82	N/A	0
83	N/A	0
84	N/A	0
85	N/A	0
86	N/A	0
87	N/A	0
88	N/A	0
89	N/A	0
90	N/A	0
91	N/A	0
92	N/A	0
93	N/A	0
94	N/A	0
95	N/A	0

---

Sheet 7: .

Initial completion of annual report

Data missing from initial application

---

Sheet 8: ..

Program Number	Program Label
1	Other (specify):
2	Other: ABA Alternative Pathway (Anesthesia)
3	Other: Addiction Psychiatry
4	Other: Adolescent Bariatric Surgery
5	Other: Adolescent Medicine
6	Other: Adult Cardiothoracic Anesthesiology
7	Other: Adult Congenital Heart Disease
8	Other: Adult Transplant Hepatology
9	Other: Advanced General Dentistry
10	Other: Advanced Pediatric Hematology/ Oncology Neurooncology
11	Other: Advanced Pediatric Hematology/ Oncology Stem Cell Transplantation
12	Other: Anesthesia/Pain Medicine
13	Other: Anesthesiology/ Critical Care Medicine
14	Other: Body MRI
15	Other: Bone & Marrow Transplantation
16	Other: Cardio DS
17	Other: Cardiology
18	Other: Child Psychology
19	Other: Clinical Cardiac Electrophysiology
20	Other: Clinical Cardiac Electrophysiology (Adult)
21	Other: Clinical Immunodeficiency
22	Other: Clinical Neurophysiology
23	Other: Clinical Pharmacology and Toxicology
24	Other: Congenital Cardiac Surgery
25	Other: Craniofacial Surgery
26	Other: Critical Care Anesthesiology
27	Other: Critical Care Medicine
28	Other: Dentistry
29	Other: Dermapathology
30	Other: Emergency Medicine/ Family Medicine
31	Other: Endocrinology, Diabetes and Metabolism
32	Other: Endodontics
33	Other: Endovascular Surgical Neuroradiology
34	Other: Epilepsy
35	Other: Family Medicine/ Psychiatry
36	Other: Family Medicine/ Sports Medicine
37	Other: Female Pelvic Medicine and Reconstructive Surgery
38	Other: Fetal Cardiology
39	Other: Fetal Surgery
40	Other: Foot and Ankle Orthopedics
41	Other: Gastroenterology
42	Other: General and Community Medicine
43	Other: General Internship (DO)
44	Other: General Pediatrics
45	Other: GI Motility
46	Other: Gynecological Oncology
47	Other: Headache
48	Other: Hematology
49	Other: Hematology/ Oncology
50	Other: Hematopathology
51	Other: Hospice and Palliative Medicine
52	Other: Hospitalist
53	Other: Infectious Disease
54	Other: Internal Medicine
55	Other: Internal Medicine/ Emergency Medicine
56	Other: Internal Medicine/ Hematology/ Oncology Fellowship
57	Other: Internal Medicine/ Infectious Disease
58	Other: International Pediatric Neurosurgery
59	Other: Interventional Cardiology
60	Other: Interventional Radiology
61	Other: Lung Transplant
62	Other: Maternal Fetal Medicine
63	Other: Medical Biochemical Genetics
64	Other: Medical Genetics, Molecular Genetic Pathology
65	Other: Medical Microbiology
66	Other: Molecular Genetic Medicine
67	Other: Movement Disorders
68	Other: Musculoskeletal Oncology
69	Other: Musculoskeletal Radiolology
70	Other: Neonatology
71	Other: Nephrology
72	Other: Neuromuscular Medicine
73	Other: Neuropathology
74	Other: Neuroradiology
75	Other: Nuclear Radiology
76	Other: Oral and Maxillofacial Surgery
77	Other: Oral Surgery
78	Other: Orthopaedic Sports Medicine
79	Other: Orthopedic Hand Surgery
80	Other: Orthopedic Surgery of the Spine
81	Other: Osteopathy
82	Other: Pain Medicine
83	Other: Palliative Care
84	Other: Pathology, Anatomic and Clinical, Dermatopathology
85	Other: Pathology, Anatomic and Clinical, General
86	Other: Pathology, Anatomic and Clinical, Hematology
87	Other: Pathology, Blood Banking/ Transfusion Medicine
88	Other: Pathology/ Medical Microbiology
89	Other: Pediatric Allergy and Immunology
90	Other: Pediatric and Adolescent Gynecology
91	Other: Pediatric Cardiac Imaging
92	Other: Pediatric Clinical Cardiac Electrophysiology
93	Other: Pediatric Clinical Pharmacology
94	Other: Pediatric Colorectal Surgery
95	Other: Pediatric Dentistry
96	Other: Pediatric Diagnotic Radiology
97	Other: Pediatric Environmental Health
98	Other: Pediatric Epilepsy
99	Other: Pediatric Heart Failure Transplant
100	Other: Pediatric Hospital Medicine
101	Other: Pediatric International Surgery
102	Other: Pediatric Inteventional Cardiac Catherization
103	Other: Pediatric Neurocritical Care
104	Other: Pediatric Neuromuscular
105	Other: Pediatric Neuroradiology
106	Other: Pediatric Nutrition
107	Other: Pediatric Optometry
108	Other: Pediatric Orthodontics
109	Other: Pediatric Physical Medicine and Rehabilitation
110	Other: Pediatric Plastic Surgery
111	Other: Pediatric Preventive Cardiology
112	Other: Pediatric Surgical Critical Care
113	Other: Pediatric Transplantation Surgery
114	Other: Pediatric Trauma Surgery
115	Other: Pedodontics
116	Other: Plastic Hand Surgery
117	Other: Plastic Surgery - Integrated
118	Other: Podiatric Medicine and Surgery
119	Other: Preliminary Medicine
120	Other: Preliminary Surgery
121	Other: Preventative Medicine-Medical Toxicology
122	Other: Procedural Dermatology, General
123	Other: Psychosomatic Medicine
124	Other: Pulmonary Disease
125	Other: Pulmonary Medicine/ Critical Care Medicine
126	Other: Pulmonology
127	Other: Quality Scholars in Transforming Health Care
128	Other: Radiation Oncology
129	Other: Reproductive Endocrinology
130	Other: Rheumatology
131	Other: Sleep Medicine
132	Other: Spinal Cord
133	Other: Spinal Cord Injury Medicine
134	Other: Sports Medicine
135	Other: Surgical Critical Care
136	Other: Surgical Scholar
137	Other: Traditional Rotating Internships (Osteopathic)
138	Other: Transitional Year
139	Other: Transplant Medicine
140	Other: Transplant Surgery
141	Other: Vascular and Interventional Radiology
142	Other: Vascular Anomalies Surgery
143	Other: Vascular Neurology
144	Other: Vascular Surgery