Form 1 Reconciliation Tool for the Teaching Health Center Gradu

Attachment 1

Reconciliation Report
DEPARTMENT OF HEALTH AND HUMAN SERVICES Health Resources and Services Administration BUREAU OF HEALTH PROFESSIONS		FOR HRSA USE ONLY
		Institution:				Program: Affordable Care Act Teaching Health Center (THC) Graduate Medical Education (GME) Payment Program
		Submission Tracking Number:		Grant Number:		Reporting Period: 10/1/2012 - 9/30/2013
FTE Data for Academic Year 2013 - 2014
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 NGA? (5)	If there are any changes or deviations from the number of FTE(s) funded on your last NGA, please indicate the dates that the resident was absent during the reporting period. (6)
Total

FTE Data for Academic Year 2012 - 2013
Resident Position Identifier	FTE paid by THC	FTE paid by Other Sources	Did the resident in this position rotate at a hospital below its medicare resident cap?	Explain any changes or deviations from the number of FTE(s) funded on your last NGA?	If there are any changes or deviations from the number of FTE(s) funded on your last NGA, please indicate the dates that the resident was absent during the reporting period.
Total

OMB Approval Number: 0915-0342
Expiration Date: XX/XX/XXXX

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 0915-0342.  Public reporting burden for this collection of information is estimated to average 2 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.