Children's Hospital Graduate Medical Eduction Program

Forms and Documents

Document Name	Status
Form 99-2 R HRSA 99-2 (Reconcilliation) Form	New
Form 99-1 S HRSA 99-1 Supplemental (FTE Resident Assessment) Form	Modified
Form 99-1 R HRSA 99-1 (Reconcilliation) Form	Modified
Form S Exhibit S (Resident FTE Assessment) Form	Modified
Form P Exhibit P (Resident FTE Assessment) Form	Modified
Form O2 Exhibit O(2) (Resident FTE Assessment) Form	Modified
Form O(1) Exhibit O(1) (Resident FTE Assessment) Form	Modified
Form N Exhibit N (Resident FTE Assessment) Form	Modified
Form C Exhibit C (Resident FTE Assessment) Form	Modified
Form CR Conversation Record (Resident FTE Assessment) Form	Modified
Form 99-5 I & R HRSA 99-5 (Initial and Reconciliation) Form	Modified
Form 99-4 R HRSA 99-4 (Reconciliation) Form	Modified
Form 99-2 I HRSA 99-2 (Initial) Form	Modified
Form 99-1 I HRSA 99-1 (Initial) Form	Modified
Form 99 I and R HRSA 99 (Initial and Reconcilation) Form	Modified
FY 2019 Guidance Document.docx Supplementary Document	2019-10-03
Supporting Statement A.docx Supporting Statement A	2019-12-05

IC Document Collections

IC ID	Document Title	Status
237997	Exhibit 4 (FTE Resident Assessment) Other-no form-provided by grantee	New
237996	Exhibit 3 (FTE Resident Assessment) Other-no form-provided by grantee	New
237995	Exhibit 2 (FTE Resident Assessment) Other-no form-provided by grantee	New
237994	Exhibit P(2) (FTE Resident Assessment) Other-no form-provided by grantee	New
237993	Application Cover Letter (Reconciiation) Other-no form-provided by grantee	New
237991	HRSA 99-2 (Reconcilliation) Form	New
224952	HRSA 99-1 Supplemental (FTE Resident Assessment) Form	Modified
224950	HRSA 99-1 (Reconcilliation) Form	Modified
211283	Exhibit S (Resident FTE Assessment) Form	Modified
211282	Exhibit P (Resident FTE Assessment) Form	Modified
211281	Exhibit O(2) (Resident FTE Assessment) Form	Modified
211280	Exhibit O(1) (Resident FTE Assessment) Form	Modified
211279	Exhibit N (Resident FTE Assessment) Form	Modified
211278	Exhibit C (Resident FTE Assessment) Form	Modified
211277	Conversation Record (Resident FTE Assessment) Form	Modified
211276	Exhibit 1 (Resident FTE Assessment) Other-no form-provided by grantee	Modified
211275	Exhibit 2 (Initial and Reconciliation) Other-no form-provided by grantee	Modified
211274	Exhibit 3 (Initial and Reconciliation) Other-no form-provided by grantee	Modified
211273	Exhibit 4 (Initial and Reconciliation) Other-no form-provided by grantee	Modified
211272	Exhibit F (Resident FTE Assessment) Other-no form-provided by grantee	Modified
211271	Exhibit P(2) (Resident FTE Assessment) Instruction	Removed
211270	Exhibit T (Resident FTE Assessment) Other-no form-provided by grantee	Modified
211269	Exhibit T(1) (Resident FTE Assessment) Other-no form-provided by grantee	Modified
211268	FTE Assessment Letter (Resident FTE Assessment) Other-no form-provided by grantee	Modified
211222	CFO Cover Letter (Initial and Reconciliation) Other-no form-provided by grantee	Modified
211221	Application Cover Letter (initial) Other-provided by grantee	Modified
211220	HRSA 99-5 (Initial and Reconciliation) Form	Modified
211219	HRSA 99-4 (Reconciliation) Form	Modified
211217	HRSA 99-2 (Initial) Form	Modified
211216	HRSA 99-1 (Initial) Form	Modified
211215	HRSA 99 (Initial and Reconcilation) Form	Modified

ICR Details

OMB Control No: 0915-0247	ICR Reference No: 201910-0915-001
Status: Active	Previous ICR Reference No: 201612-0915-004
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: 01/06/2020
	Date Received in OIRA: 10/07/2019
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2023	36 Months From Approved	02/29/2020
Responses	2,160	0	1,500
Time Burden (Hours)	8,200	0	6,161
Cost Burden (Dollars)	0	0	0

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Abstract: The Children’s Hospitals Graduate Medical Education (CHGME) Payment Program provides Federal support for graduate medical education to freestanding children’s hospitals. Eligible children’s hospitals receive payments for both direct and indirect medical education. Data are collected on the number of resident FTEs in applicant children’s hospitals’ training programs to determine the amount of direct and indirect medical education payments to be distributed to participating children’s hospitals. If this data is not collected, HRSA will have no means to monitor grantees, verify grantee reporting, or determine grantee eligibility for CHGME funding.

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Authorizing Statute(s): PL: Pub.L. 115 - 241 340E 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:
	84 FR 133	07/11/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 53160	10/04/2019
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 30

IC Title	Form No.	Form Name
Exhibit 3 (Initial and Reconciliation)
Exhibit F (Resident FTE Assessment)
Exhibit 4 (Initial and Reconciliation)
Exhibit 2 (FTE Resident Assessment)
Exhibit 2 (Initial and Reconciliation)
Exhibit 1 (Resident FTE Assessment)
Conversation Record (Resident FTE Assessment)	CR	Conversation Record (FTE Resident Assessment)
Exhibit C (Resident FTE Assessment)	C	Exhibit C (FTE Resident Assessment)
Exhibit O(1) (Resident FTE Assessment)	O(1)	Exhibit O(1) (FTE Resident Assessment)
FTE Assessment Letter (Resident FTE Assessment)
Exhibit T(1) (Resident FTE Assessment)
Exhibit T (Resident FTE Assessment)
Exhibit N (Resident FTE Assessment)	N	Exhibit N (FTE Resident Assessment)
Exhibit O(2) (Resident FTE Assessment)	O2	Exhibit O(2) (FTE Resident Assessment)
Exhibit P (Resident FTE Assessment)	P	Exhibit P (FTE Resident Assessment)
Exhibit S (Resident FTE Assessment)	S	Exhibit S (FTE Resident Assessment)
Application Cover Letter (Reconciiation)
Exhibit 3 (FTE Resident Assessment)
HRSA 99-2 (Initial)	99-2 I	HRSA 99-2 (Initial)
HRSA 99-4 (Reconciliation)	99-4 R	HRSA 99-4 (Reconciliation)
CFO Cover Letter (Initial and Reconciliation)
HRSA 99 (Initial and Reconcilation)	99 I and R	HRSA 99 (Initial and Reconciliation)
HRSA 99-1 (Initial)	99-1 I	HRSA 99-1 (Initial)
HRSA 99-5 (Initial and Reconciliation)	99-5 I & R	HRSA 99-5 (Initial and Reconciliation)
Application Cover Letter (initial)
HRSA 99-1 Supplemental (FTE Resident Assessment)	99-1 S	HRSA 99-1 (Supplemental FTE Resident Assessment)
HRSA 99-1 (Reconcilliation)	99-1 R	HRSA 99-1 (Reconciliation)
Exhibit P(2) (FTE Resident Assessment)
Exhibit 4 (FTE Resident Assessment)
Exhibit P(2) (Resident FTE Assessment)
HRSA 99-2 (Reconcilliation)	99-2 R	HRSA 99-2 (Reconciliation)

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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	2,160	1,500	0	30	630	0
Annual Time Burden (Hours)	8,200	6,161	0	-90	2,129	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: The current burden inventory is 6161 hours and this request is for 8197.80 hours. (rounded up by ROCIS to 8,200 hours) The burden inventory for 2016 was entered incorrectly, the burden estimate should have been 8,164.80 hours. The burden estimate will increase 33 hours for this request. Some of the ICs do not have forms associated with them as they are documents provided by the grantees.

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Annual Cost to Federal Government: $22,281

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: 10/07/2019

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