Children’s Hospitals Graduate Medical Education (CHGME) Quality Bonus System (QBS) Initiative Response Form

Forms and Documents

Document Name	Status
Form 1 Children's Hospitals Graduate Medical Education Quality Bonus System (QBS) Initiative Response Form Form and Instruction	New
FINALSupporting Statement B.docx Supporting Statement B	2019-04-04
CHGME Program Quality Bonus Payment System Initiatives Supporting Statement A_4-4-19_CLEAN.docx Supporting Statement A	2019-04-04

IC Document Collections

IC ID	Document Title	Status
234990	Children's Hospitals Graduate Medical Education Quality Bonus System (QBS) Initiative Response Form Form and Instruction	New

ICR Details

OMB Control No: 0906-0041	ICR Reference No: 201902-0906-001
Status: Active	Previous ICR Reference No:
Agency/Subagency: HHS/HRSA	Agency Tracking No:
Title: Children’s Hospitals Graduate Medical Education (CHGME) Quality Bonus System (QBS) Initiative Response Form
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 04/05/2019
	Date Received in OIRA: 02/20/2019
Terms of Clearance: OMB is approving this information collection request for a period of three years during which time HRSA will request approval to extend or revise the collection if HRSA seeks to continue the information collection activity beyond the period approved under this action.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2022	36 Months From Approved
Responses	58	0	0
Time Burden (Hours)	1,880	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Children’s Hospital GME Support Reauthorization Act of 2013states that the Secretary may establish a QBS, whereby the Secretary distributes bonus payments to hospitals participating in the CHGME Payment Program that meet standards specified by the Secretary. In order to qualify for the QBS payment in Fiscal Year (FY) 2019, CHGME award recipients must submit documentation as an attachment in the FY 2019 reconciliation application describing the hospital’s initiatives, resident curriculum, and direct resident involvement in 5 key areas. To demonstrate the fulfillment of such standards, it will be necessary for applicants to complete the QBS Response Initiative form and submit it as an attachment to the FY 2019 reconciliation application.

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Authorizing Statute(s): None

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:
	83 FR 53487	10/23/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 2533	02/07/2019
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Children's Hospitals Graduate Medical Education Quality Bonus System (QBS) Initiative Response Form	1	: CHGME Program Quality Bonus Payment System Initiatives Reporting Form.pdf

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ICR Summary 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	58	0	0	58	0	0
Annual Time Burden (Hours)	1,880	0	0	1,880	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: No

Burden Reduction Due to:

Short Statement: This is a new ICR, so burden increases from zero (0).

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Annual Cost to Federal Government: $8,698

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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: 02/20/2019

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