Children's Hospital Graduate Medical Eduction Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1-2 Children's Hospital Graduate Medical Eduction Payment Program	Form and Instruction	Removed	Repair queued
Form Exhibit S (Residen Exhibit S (Resident FTE Assessment)	Form	New	Available
Form Exhibit P (Residen Exhibit P (Resident FTE Assessment)	Form	New	Available
Form Exhibit O(2) (Resi Exhibit O(2) (Resident FTE Assessment)	Form	New	Available
Form Exhibit O(1) (Resi Exhibit O(1) (Resident FTE Assessment)	Form	New	Available
Form Exhibit N (Residen Exhibit N (Resident FTE Assessment)	Form	New	Available
Form Exhibit C (Residen Exhibit C (Resident FTE Assessment)	Form	New	Available
Form Conversation Recor Conversation Record (Resident FTE Assessment)	Form	New	Available
Form HRSA 99-5 HRSA 99-5	Form	New	Available
Form HRSA 99-4 HRSA 99-4	Form	New	Available
Form HRSA 99-2 HRSA 99-2	Form	New	Available
Form HRSA 99-1 HRSA 99-1	Form	New	Available
Form 99 HRSA 99	Form	New	Available
Supporting Statement.docx	Supporting Statement A	Uploaded 2014-05-28	Available
CHGME_HRSA_99_3_FY2014(CERTIFICATION_DOES NOT NEED OMB CLEARANCE).docx	Supplementary Document	Uploaded 2014-04-10	Available
CHGME Guidance Document.docx	Supplementary Document	Uploaded 2014-04-10	Available
PLAW-109publ307.pdf	Supplementary Document	Uploaded 2014-04-10	Available
PLAW-108publ490.pdf	Supplementary Document	Uploaded 2014-04-10	Available
PLAW-106publ310.pdf	Supplementary Document	Uploaded 2014-04-10	Available
PLAW-106publ129.pdf	Supplementary Document	Uploaded 2014-04-10	Available
FRN-68vol204.pdf	Supplementary Document	Uploaded 2014-04-10	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
6495	Children's Hospital Graduate Medical Eduction Payment Program	Form and Instruction	Removed
211283	Exhibit S (Resident FTE Assessment)	Form	New
211282	Exhibit P (Resident FTE Assessment)	Form	New
211281	Exhibit O(2) (Resident FTE Assessment)	Form	New
211280	Exhibit O(1) (Resident FTE Assessment)	Form	New
211279	Exhibit N (Resident FTE Assessment)	Form	New
211278	Exhibit C (Resident FTE Assessment)	Form	New
211277	Conversation Record (Resident FTE Assessment)	Form	New
211276	Exhibit 1 (Resident FTE Assessment)	Instruction	New
211275	Exhibit 2 (Initial, Resident FTE Assessment, Reconciliation)	Instruction	New
211274	Exhibit 3 (Initial, Resident FTE Assessment, Reconciliation)	Instruction	New
211273	Exhibit 4 (Initial, Resident FTE Assessment, Reconciliation)	Instruction	New
211272	Exhibit F (Resident FTE Assessment)	Instruction	New
211271	Exhibit P(2) (Resident FTE Assessment)	Instruction	New
211270	Exhibit T (Resident FTE Assessment)	Instruction	New
211269	Exhibit T(1) (Resident FTE Assessment)	Instruction	New
211268	FTE Assessment Letter (Resident FTE Assessment)	Instruction	New
211222	CFO Cover Letter	Instruction	New
211221	Application Cover Letter	Instruction	New
211220	HRSA 99-5	Form	New
211219	HRSA 99-4	Form	New
211217	HRSA 99-2	Form	New
211216	HRSA 99-1	Form	New
211215	HRSA 99	Form	New

ICR Details

OMB Control No: 0915-0247	ICR Reference No: 201404-0915-005
Status: Historical Active	Previous ICR Reference No: 201103-0915-001
Agency/Subagency: HHS/HSA	Agency Tracking No:
Title: Children's Hospital Graduate Medical Eduction Program
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/03/2014
	Date Received in OIRA: 04/23/2014
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2017	36 Months From Approved	06/30/2014
Responses	1,470	0	60
Time Burden (Hours)	5,905	0	3,730
Cost Burden (Dollars)	0	0	0

---

Abstract: The Children's Hospitals Graduate Medical Education (CHGME) Payment Program was enacted by Public Law 106-129 to provide federal support for graduate medical education (GME) to freestanding children's hospitals. This legislation attempts to provide support for GME comparable to the level of Medicare GME support received by other, non-children's hospitals. The legislation requires that eligible children's hospitals receive payments for both direct and indirect medical education expenses. Payments for direct expenses offset the expenses associated with operating approved graduate medical residency training programs, and payments for indirect expenses compensate hospitals for expenses associated with the treatment of more severely ill patients and the additional costs relating to teaching residents in such programs. The Centers for Medicare and Medicaid Services (CMS) issued a final rule in the Federal Register regarding Sections 5503, 5504, 5505 and 5506 of the Affordable Care Act of 2010, Public Law 111-148, on Wednesday, November 24, 2010. This final rule included policy changes on counting resident time in non-provider settings, counting resident time for didactic training and the redistribution of resident caps, which required modification of the data collection forms within the CHGME Payment Program application. The necessary modifications were made and received OMB clearance on June 30, 2012. In addition, on September 30, 2013, CMS published revised cost report forms on their Web site, specifically form CMS 2552-10, Worksheet E-4, requiring modification of the data collection forms in the CHGME Payment Program application. Furthermore, the inclusion of forms and documentation requests used to collect data from the fiscal intermediaries that audit the children's hospitals as part of a contract with the CHGME program. These changes require OMB approval.

---

Authorizing Statute(s): PL: Pub.L. 106 - 310 2001 Name of Law: Graduate Medical Education Programs in Children's Hospitals
   PL: Pub.L. 106 - 129 4 Name of Law: Healthcare Research and Quality Act of 1999
   PL: Pub.L. 108 - 490 2 Name of Law: Children's Hospital GME Support Reauthorization Act of 2006
   PL: Pub.L. 106 - 310 2001 Name of Law: Children's Health Act of 2000
   PL: Pub.L. 111 - 148 5503, 5504 Name of Law: Patient Protection and Affordable Care Act
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 5503, 5504 Name of Law: Patient Protection and Affordable Care Act

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 8194	02/11/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 22502	04/22/2014
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 23

table that charts list of burden

IC Title	Form No.	Form Name
Exhibit 2 (Initial, Resident FTE Assessment, Reconciliation)
Exhibit 1 (Resident FTE Assessment)
Conversation Record (Resident FTE Assessment)	Conversation Record (Resident FTE Assessment)	Conversation Record (Resident FTE Assessment)
Exhibit C (Resident FTE Assessment)	Exhibit C (Resident FTE Assessment)	Exhibit C (Resident FTE Assessment)
Exhibit O(1) (Resident FTE Assessment)	Exhibit O(1) (Resident FTE Assessment)	Exhibit O(1) (Resident FTE Assessment)
FTE Assessment Letter (Resident FTE Assessment)
Exhibit T(1) (Resident FTE Assessment)
Exhibit T (Resident FTE Assessment)
Exhibit N (Resident FTE Assessment)	Exhibit N (Resident FTE Assessment)	Exhibit N (Resident FTE Assessment)
Exhibit O(2) (Resident FTE Assessment)	Exhibit O(2) (Resident FTE Assessment)	Exhibit O(2) (Resident FTE Assessment)
Exhibit P (Resident FTE Assessment)	Exhibit P (Resident FTE Assessment)	Exhibit P (Resident FTE Assessment)
Exhibit P(2) (Resident FTE Assessment)
Exhibit F (Resident FTE Assessment)
Exhibit 4 (Initial, Resident FTE Assessment, Reconciliation)
Exhibit 3 (Initial, Resident FTE Assessment, Reconciliation)
Exhibit S (Resident FTE Assessment)	Exhibit S (Resident FTE Assessment)	Exhibit S (Resident FTE Assessment)
Children's Hospital Graduate Medical Eduction Payment Program	HRSA_CHGME_99, HRSA_CHGME_99-3, HRSA_CHGME_99-5, 1-2, 4	HRSA_CHGME_99-1-2 ,   HRSA_CHGME_99-4 ,   HRSA_CHGME_99 ,   HRSA_CHGME_99-3 ,   HRSA_CHGME_99-5
HRSA 99-2	HRSA 99-2	HRSA 99-2
HRSA 99-4	HRSA 99-4	HRSA 99-4
CFO Cover Letter
HRSA 99	99	HRSA 99
HRSA 99-1	HRSA 99-1	HRSA 99-1
HRSA 99-5	HRSA 99-5	HRSA 99-5
Application Cover Letter

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,470	60	0	1,470	-60	0
Annual Time Burden (Hours)	5,905	3,730	0	5,905	-3,730	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: In the previous information collection request there was an estimated total of 3,729.6 burden hours. We are now requesting a total of 5,903.4 hours, which is an increase of 2173.8 burden hours. The increase in total burden hours results from minor revisions made to the CHGME Payment Program application forms to accommodate changes required by the Affordable Care Act, in particular revisions implemented related to the CMS Form 2552-10, which is used as part of the CHGME Payment Program application. In addition, increase in total burden hours results from the addition of the forms and documentation used to collect data from the fiscal intermediaries that audit the children's hospitals as part of a contract the CHGME program currently has to assess the FTE resident counts reported by the children's hospitals and used to calculate payment. The information requested in not a new requirement for the fiscal intermediaries and has been a part of the CHGME application process, particularly with reconciliation requirements, for over ten years. However the CHGME program now understands although the data is a deliverable within the contract approval is needed to collect the data. Furthermore, the CHGME application is integrated with HRSA's EHB system which requires adjustments to certain data fields to comply with system requirements and HRSA's standards for all grant programs functioning within the EHB.

---

Annual Cost to Federal Government: $8,566

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 04/23/2014

---