Document
THCGME Reconciliation Tool Form
ICR 202509-0915-002 · OMB 0915-0342 · Object 162622701.
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Document Metadata
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
|---|---|
| File Title | THCGME Reconciliation Tool Form |
| Author | Aswini Balasubramanian |
| Last Modified By | Writer |
| File Modified | 2025-08-11 |
| File Created | 2026-10-24 |
| Conversion State | complete |
Extracted Text
Attachment 1
Reconciliation Report
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Resources and Services Administration
BUREAU OF HEALTH WORKFORCE
FOR HRSA USE ONLY
Institution:
Program: Teaching Health Center Graduate Medical Education (THCGME) Payment Program
Submission Tracking Number:
Grant Number:
Reporting Period: xx/xx/xxxx – xx/xx/xxxx
FTE Data for Academic Year 202x – 202x
Resident Position Identifier
(1)
FTE paid by THC
(2)
FTE paid by Other Sources
(3)
Did the resident in this position rotate at a hospital below its Medicare resident cap?
(4)
Explain any changes or deviations from the number of FTE(s) funded on your last NOA?
(5)
If there are any changes or deviations from the number of FTE(s) funded on your last NOA, please indicate the dates that the resident was absent during the reporting period.
(6)
Total
OMB Approval Number: 0915-0342
Expiration Date: xx/xx/202x
Public Burden Statement: This data collection instrument will gather information relating to the number of resident full-time equivalents (FTEs) in Teaching Health Centers (THC) training programs in order to reconcile payments for both direct and indirect expenses. 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 information collection is 0915-0342 and it is valid until XX/XX/202X. This information collection is mandatory (Section 340H(e) of the PHS Act [42 U.S.C. 256h(e)]. Public reporting burden for this collection of information is estimated to average xx hours per response, including the time for reviewing instructions, searching existing data sources, 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 14NWH04, Rockville, Maryland, 20857.