Children's Hospital GME Annual Report Program Information

Department of Health and Human Services
Health Resources and Services Administration

OMB No.: 0915-0313
Expiration Date: 11/30/2010

Children’s Hospitals Graduate Medical Education Payment Program
Annual Report Checklist
ANNUAL REPORT FORM HRSA 100-5

Name of Children’s Hospital:

Address:

City:

State:

Zip Code:

Date of Report:

Medicare Provider Number:
Federal fiscal year for application:
Year the hospital first received CHGME funding:

Annual Report Forms

This Column to be
Completed by the
Applicant Hospital

This Column to
be Completed by
the CHGME PP

Is the Listed Item Completed and
Attached?

HRSA 100-1

Yes No

Yes No

HRSA 100-2

Yes No

Yes No

HRSA 100-3

Yes No

Yes No

HRSA 100-4

Yes No

Yes No

HRSA 100-5

Yes No

Yes No

Computer Disk with Zip Code Data

Yes No

Yes No

One (1) hard copy and (1) electronic copy of the completed Annual Report including
relevant forms and the zip code file.

Yes No

Yes No

HRSA 100-5 Page 1 of 1

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