CHGME Payment Program HRSA 100-2 and HRSA 100-3 Annual Report Forms

Department of Health and Human Services
Health Resources and Services Administration

OMB No. 0915-0313
Expiration Date: 11/30/2013

CHILDREN’S HOSPITALS GRADUATE MEDICAL
EDUCATION PAYMENT PROGRAM
ANNUAL REPORT FORM HRSA 100-5

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 1 hour 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 10-33, Rockville,
Maryland, 20857.

Department of Health and Human Services
Health Resources and Services Administration

OMB No.: 0915-0313
Expiration Date: 11/30/2013

Children’s Hospitals Graduate Medical Education Payment Program
Annual Report Checklist
ANNUAL REPORT FORM HRSA 100-5

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 100-5 Page 1 of 1

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