Children's Hospital Graduate Medical Eduction Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1 HRSA 99-1 (Supplemental FTE Resident Assessment)	Form	New	Available
Form 1 HRSA 99-1 (Reconciliation)	Form	New	Available
Form Exhibit S (Residen Exhibit S (Resident FTE Assessment)	Form	Unchanged	Available
Form Exhibit P (Residen Exhibit P (Resident FTE Assessment)	Form	Unchanged	Available
Form Exhibit O(2) (Resi Exhibit O(2) (Resident FTE Assessment)	Form	Unchanged	Available
Form Exhibit O(1) (Resi Exhibit O(1) (Resident FTE Assessment)	Form	Unchanged	Available
Form Exhibit N (Residen Exhibit N (Resident FTE Assessment)	Form	Unchanged	Available
Form Exhibit C (Residen Exhibit C (Resident FTE Assessment)	Form	Unchanged	Available
Form Conversation Recor Conversation Record (Resident FTE Assessment)	Form	Unchanged	Available
Form 1 HRSA 99-5 (Initial and Reconciliation).docx	Form	Modified	Available
Form HRSA 99-4 HRSA 99-4	Form	Unchanged	Available
Form HRSA 99-2 HRSA 99-2	Form	Unchanged	Available
Form 1 HRSA 99-1 (Initial)	Form	Modified	Available
Form 99 HRSA 99	Form	Unchanged	Available
Legislation.docx	Supplementary Document	Uploaded 2016-12-23	Available
Guidance Document.docx	Supplementary Document	Uploaded 2016-12-23	Available
FINALSupporting Statement.docx	Supporting Statement A	Uploaded 2016-12-23	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
224952	HRSA 99-1 Supplemental (FTE Resident Assessment)	Form	New	HRSA 99-1 (Supplemental FTE Resident Assessment)
224950	HRSA 99-1 Reconcilliation	Form	New	HRSA 99-1 (Reconciliation)
211283	Exhibit S (Resident FTE Assessment)	Form	Unchanged	Exhibit S (Resident FTE Assessment)
211282	Exhibit P (Resident FTE Assessment)	Form	Unchanged	Exhibit P (Resident FTE Assessment)
211281	Exhibit O(2) (Resident FTE Assessment)	Form	Unchanged	Exhibit O(2) (Resident FTE Assessment)
211280	Exhibit O(1) (Resident FTE Assessment)	Form	Unchanged	Exhibit O(1) (Resident FTE Assessment)
211279	Exhibit N (Resident FTE Assessment)	Form	Unchanged	Exhibit N (Resident FTE Assessment)
211278	Exhibit C (Resident FTE Assessment)	Form	Unchanged	Exhibit C (Resident FTE Assessment)
211277	Conversation Record (Resident FTE Assessment)	Form	Unchanged	Conversation Record (Resident FTE Assessment)
211276	Exhibit 1 (Resident FTE Assessment)	Instruction	Unchanged
211275	Exhibit 2 (Initial, Resident FTE Assessment, Reconciliation)	Instruction	Unchanged
211274	Exhibit 3 (Initial, Resident FTE Assessment, Reconciliation)	Instruction	Unchanged
211273	Exhibit 4 (Initial, Resident FTE Assessment, Reconciliation)	Instruction	Unchanged
211272	Exhibit F (Resident FTE Assessment)	Instruction	Unchanged
211271	Exhibit P(2) (Resident FTE Assessment)	Instruction	Unchanged
211270	Exhibit T (Resident FTE Assessment)	Instruction	Unchanged
211269	Exhibit T(1) (Resident FTE Assessment)	Instruction	Unchanged
211268	FTE Assessment Letter (Resident FTE Assessment)	Instruction	Unchanged
211222	CFO Cover Letter	Instruction	Unchanged
211221	Application Cover Letter	Instruction	Unchanged
211220	HRSA 99-5 (Initial and Reconciliation)	Form	Modified	HRSA 99-5 (Initial and Reconciliation).docx
211219	HRSA 99-4	Form	Unchanged	HRSA 99-4
211217	HRSA 99-2	Form	Unchanged	HRSA 99-2
211216	HRSA 99-1	Form	Modified	HRSA 99-1 (Initial)
211215	HRSA 99	Form	Unchanged	HRSA 99

ICR Details

OMB Control No: 0915-0247	ICR Reference No: 201612-0915-004
Status: Historical Active	Previous ICR Reference No: 201404-0915-005
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 without change	Conclusion Date: 02/06/2017
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/23/2016
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/29/2020	36 Months From Approved	06/30/2017
Responses	1,500	0	1,470
Time Burden (Hours)	6,161	0	5,905
Cost Burden (Dollars)	0	0	0

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Abstract: The Children’s Hospitals Graduate Medical Education (CHGME) Payment Program was enacted by Public Law 106-129, and reauthorized by the CHGME Support Reauthorization Act of 2013 (Pub. L. 113–98) to provide Federal support for graduate medical education (GME) to freestanding children’s hospitals. The legislation indicates that eligible children’s hospitals will receive payments for both direct and indirect medical education. The CHGME Payment Program application and full-time equivalent (FTE) resident assessment forms received OMB clearance on June 30, 2014. The CHGME Support Reauthorization Act of 2013 included a provision to allow certain newly qualified children’s hospitals to apply for CHGME Payment Program funding. The CHGME Payment Program application forms have been revised to accommodate the new statute. In addition, a payment question included in the CHGME Payment Program application forms has been removed, since the participating children’s hospitals are now required to electronically communicate their financial information to the Payment Management System through the Electronic Handbook. The form changes are only applicable to the HRSA 99-1 (also known as Exhibit O(2)) and the HRSA 99-5. All other hospital and auditor forms are the same as currently approved. The changes to the HRSA 99-1 and HRSA 99-5 forms require OMB approval.

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Authorizing Statute(s): PL: Pub.L. 113 - 98 0 Name of Law: CHGME Support Reauthorization Act of 2013
  

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 40320	06/21/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 89114	12/09/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 25

table that charts list of burden

IC Title	Form No.	Form Name
Application Cover Letter
CFO Cover Letter
Conversation Record (Resident FTE Assessment)	Conversation Record (Resident FTE Assessment)	Conversation Record (Resident FTE Assessment)
Exhibit 1 (Resident FTE Assessment)
Exhibit 2 (Initial, Resident FTE Assessment, Reconciliation)
Exhibit 3 (Initial, Resident FTE Assessment, Reconciliation)
Exhibit 4 (Initial, Resident FTE Assessment, Reconciliation)
Exhibit C (Resident FTE Assessment)	Exhibit C (Resident FTE Assessment)	Exhibit C (Resident FTE Assessment)
Exhibit F (Resident FTE Assessment)
Exhibit N (Resident FTE Assessment)	Exhibit N (Resident FTE Assessment)	Exhibit N (Resident FTE Assessment)
Exhibit O(1) (Resident FTE Assessment)	Exhibit O(1) (Resident FTE Assessment)	Exhibit O(1) (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 S (Resident FTE Assessment)	Exhibit S (Resident FTE Assessment)	Exhibit S (Resident FTE Assessment)
Exhibit T (Resident FTE Assessment)
Exhibit T(1) (Resident FTE Assessment)
FTE Assessment Letter (Resident FTE Assessment)
HRSA 99	99	HRSA 99
HRSA 99-1	1	HRSA 99-1 (Initial)
HRSA 99-1 Reconcilliation	1	HRSA 99-1 (Reconciliation)
HRSA 99-1 Supplemental (FTE Resident Assessment)	1	HRSA 99-1 (Supplemental FTE Resident Assessment)
HRSA 99-2	HRSA 99-2	HRSA 99-2
HRSA 99-4	HRSA 99-4	HRSA 99-4
HRSA 99-5 (Initial and Reconciliation)	1	HRSA 99-5 (Initial and Reconciliation).docx

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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	1,500	1,470	0	30	0	0
Annual Time Burden (Hours)	6,161	5,905	0	256	0	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Two forms have been added to the original package, 99-1 Reconciliation and the 99-1 Supplemental, that would cause an increase in the number of responses and burden. There was no reduction.

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Annual Cost to Federal Government: $20,815

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]? No

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

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Common Form ICR:  No

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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: 12/23/2016

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