Form 1 The Teaching Health Center Graduate Medical Education (T

Instructions for completing the Eligible Resident/FTE Chart (Attachment 1):

NUMBER OF ELIGIBLE RESIDENTS/FTEs IN PROGRAM
Academic Years		Number of Residents				Aggregate Number of THC FTEs	Aggregate Number of Residents in Program
		PGY-1	PGY-2	PGY-3	PGY-4
7/1/2010-6/30/2011
7/1/2011-6/30/2012
7/1/2012-6/30/2013
7/1/2013-6/30/2014	Baseline
7/1/2014-6/30/2015	Year 1
7/1/2015-6/30/2016	Year 2

OMB 0915-XXXX Expiration Date: XX/XX/201X

1. List the number of PGY-1, PGY-2, PGY-3, and PGY-4 residents enrolled in the residency program during academic years 7/1/2010-6/30/2011, 7/1/2011-6/30/2012, and 7/1/2012-6/30/2013. Also include the number of residents enrolled during the 7/1/2013-6/30/2014 baseline academic year.

1. For existing THCs applying for an expansion, list the number of previously approved THC FTEs for the baseline academic year.

2. List the number of PGY-1, PGY-2, PGY-3, and PGY-4 residents you plan to train over the next two academic years. Please be sure to include in this section any THCGME residents funded by HRSA during Fiscal Years 2011, 2012 and 2013. These residents should not be included in the “Addition to Base Number” column (Section C) as they are not considered “new” residents and would not constitute an expansion of the program.

3. List the number of expanded THC FTEs you plan to add to your program over the next two academic years. The data should accurately reflect the program’s plans to expand; however, please note that these projections do not guarantee funding beyond FY2014.

4. Include the aggregate number of residents that were enrolled, or that you plan to enroll, in the program during each of the listed academic years.

Failure to provide sufficiently clear and documented evidence of FTEs may jeopardize or decrease GME funding.

Public Burden Statement:  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 project is 0915-XXXX.  Public reporting burden for this collection of information is estimated to average 0.5 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 10-29, Rockville, Maryland, 20857.