supporting statement a

Supporting Statement A Title of the Data Collection

OMB Control No. 0906-XXXX

Terms of Clearance: None.

1. Justification

1. Circumstances Making the Collection of Information Necessary

Section 5508 of the Patient Protection and Affordable Care Act of 2010 (ACA) established the Teaching Health Center Graduate Medical Education (THCGME) program under Title III of the Public Health Service Act. This program aims to increase the number of new primary care physicians and dentists, who are also more likely to continue to practice in rural and underserved setting after completing residency. The THCGME program provides Graduate Medical Education (GME) funding to community based settings to train primary care and dentistry residents in order to address primary care access issues, particularly in underserved settings. This program is significantly different than traditional Medicare GME, in which funding to support residency training is provided directly to inpatient settings - making it difficult for training to occur in community based settings. Providing GME funding directly to the THCs allows these health centers to train future primary care physicians, recruit their trainees and offers primary care and dentistry residents the ability to train in a setting they are likely to practice in after graduation – ultimately increasing their abilities and competencies to provide high quality primary care.

The THCGME program pays both direct and indirect GME payments directly to the THCs – set at an interim $150,000 per resident per year, until the Secretary defines an indirect payment formula for the program. The George Washington University (GW), through a competitive process, was awarded the Evaluation and Initial Assessment of HRSA Teaching Health Centers contract. The purpose of this contract is to conduct an assessment over a five year period to better understand this model of community-based residency training, including specifically examining the costs to train a resident in this model of GME training in order to assist HRSA and the Secretary identify the appropriate indirect payment formula for the THC program.

2. Purpose and Use of Information Collection

The Teaching Health Center Costing Instrument addresses the following evaluation research questions of the GW THC evaluation contract:

• What are the direct and indirect costs of training primary care physicians and dentists in THCs?

• How do these costs compare to costs in traditional GME settings?

• What are the impacts of these costs on the THC's community-based setting, teaching hospitals, and other teaching sites?

• Are there financial benefits that help to offset any costs of training primary care physicians and dentists in THCs?

• Is the THC a financially-sustainable model?

• In what ways, shall so-called "opportunity costs" (e.g., time spent teaching vs. patient care by THC providers/faculty members) be considered in the cost analysis?

• Are there indirect effects on costs and revenues created by the presence of a teaching program at a THC? If so, can these be characterized and/or quantified? (e.g., recruitment costs for providers at a THC may be decreased compared to a similar site without a teaching program)

The Teaching Health Center Costing Instrument (attached in Appendix A) will be administered once to all the THC residency programs. The information gathered in the standardized Teaching Health Center Costing Instrument will include, but is not limited to, resident salaries and medical malpractice insurance, educational costs, administrative support costs, consortium costs, faculty salaries and costs, and patient care costs and clinical revenue generated by the residents. The financial data collected in the Teaching Health Center Costing Instrument will allow GW to advise HRSA on future funding opportunities for the program.

3. Use of Improved Information Technology and Burden Reduction

GW has developed the Teaching Health Center Costing Instrument so that it utilizes technology to administer, collect, and analyze the data collected. The Teaching Health Center Costing Instrument will be implemented using fillable excel forms. All of the responses (100%) will be collected and submitted electronically.

4. Efforts to Identify Duplication and Use of Similar Information

The Teaching Health Center Costing Instrument has been developed to collect standardized costing information from THC residency programs. Implementation of a standardized instrument with all THC programs will be critical to establish a reasonable and reliable estimate of the cost per resident for THC residency programs, and to fully determine the areas and degrees of variation between programs. While all residency programs keep accounts of their expenses and revenues, no standardized method for categorizing expenses and revenues specific to residency programs currently exists. There is no duplication of this effort anywhere in the field. The Teaching Health Center Costing Instrument will ultimately be made available to the individual THC programs to continue collecting relevant costing information and to add to it as needed.

5. Impact on Small Businesses or Other Small Entities

The majority of programs fall under the category of small entities. For example, many of the THC programs 501c (3) operations are newly formed small non-profits, with fewer than 30 employees. Wherever possible, the Teaching Health Center Costing Instrument has been designed to capture information collected as part of the financial management of the organization. We have developed guidance that facilitates completion of the Teaching Health Center Costing Instrument, and are providing assistance to support the programs. The Teaching Health Center Costing Instrument focuses on specific costs that focus on day-to-day operations of the program.

All the organizations have someone who is responsible for financial management and operations, and the survey was designed to be completed by personnel already available within small residency programs.

6. Consequences of Collecting the Information Less Frequently

Because this information has never been collected before, it is necessary to implement the Teaching Health Center Costing Instrument to gather information about the financial picture of the programs.

7. Special Circumstances Relating to the Guidelines of 5 CFR 1320.5

In this request, all guidelines are met and this request fully complies with the regulation. No special circumstances are related to the evaluation.

8. Comments in Response to the Federal Register Notice/Outside Consultation

Section 8A:

A 60-day Federal Register Notice was published in the Federal Register on Thursday, November 13, 2014 Vol. 79, No. 219 pp. 67439 - 67440 (see Appendix B). There were no public comments.

Section 8B:

The Teaching Health Center Costing Instrument was developed from three detailed costing site visits to THCs to clarify costs and cost off-sets, both explicit and implicit, and to better understand the reasonable cost ranges and factors that contribute to variation.

The GW team consulted with a Financial Analysis Expert Panel to provide external informed review of the findings from the detailed costing site visits and the standardized Teaching Health Center Costing Instrument for appropriate content and format, and specifically to examine the issue of direct versus indirect THCGME costs. Four members of the expert panel were representatives of THCs. They included Neil Calman, MD of the Institute for Family Health, John Felton, MPH, MBA, FACHE of the Riverstone Health, Jeff Hackler, JD, MBA of the Oklahoma State University Center for Health Sciences, Stephen McKernan, DO, ND FAAFP of the Lone Star Community Health Center. Four additional panel members were selected due to their expertise in graduate medical education (GME) research and policy. They included Alfred Berg, MD, MPH of the University of Washington, Robert Phillips, MD, MSPH of the American Board of Family Medicine, Eugene Rich, MD, of Mathematica, and Barbara Wynn, MA, of RAND.

9. Explanation of any Payment/Gift to Respondents

No payments or gifts will be given to the respondents.

10. Assurance of Confidentiality Provided to Respondents

The Teaching Health Center Costing Instrument will be implemented once with all HRSA-funded THCs. As noted above, the Teaching Health Center Costing Instrument collects financial and budget data on the residency program and will be implemented as a fillable excel form delivered via e-mail to the THC primary contact person.

Completed instruments will be exported to a database. All data will be stored on password protected secure computers in locked offices. Data reported back to HRSA will be reported on an individual THC program basis. However, if any publicly available documents are written all THC program financial data will be aggregated and therefore, by nature, be de-identified. Publicly available data will include the mean, range and standard deviation of costs to train a resident across all THC programs.

11. Justification for Sensitive Questions

The Teaching Health Center Costing Instrument asks programs to report their financial information, which can be considered sensitive. Evaluating the cost of training a resident in a community-based setting is essential to determine if the THCGME program is funded at the correct amount, and make adjustments to the program, if needed. Additionally, completion of the Teaching Health Center Costing Instrument is voluntary; if certain financial information is not available then programs are not required to provide it.

12. Estimates of Annualized Hour and Cost Burden

This section summarizes the total burden hours for this information collection in addition to the costs associated with those hours.

Type of Respondent	Form Name	Number of Respondents	Number of Responses per Respondent	Average Burden per Response (in hours)	Total Burden Hours
THC Program Directors and/or Financial Officers	Teaching Health Center Costing Instrument	60	1	10	600
Total	--	60	1	10	600

Type of Respondent	Total Burden Hours	Hourly Wage Rate	Total Respondent Costs
THC Program Directors and/or Financial Officers	600	$90.001	$54,000
Total	600	$90.00	$54,000

12A. Estimated Annualized Burden Hours:

12B. Estimated Annualized Burden Costs:Type of Respondent ^Form Name

¹ Program directors of residency programs are required to be physicians as part of the residency program academic accreditation. Therefore, we used the average hourly wage of physicians provided by the Bureau of Labor and Statistics to calculate the total respondent costs in the table above. The link to the hourly wage information can be found here: http://www.bls.gov/oes/current/oes291069.htm

13. Estimates of other Total Annual Cost Burden to Respondents or Recordkeepers/Capital Costs

Other than their time, there is no cost to respondents.

14. Annualized Cost to Federal Government

The systems used to collect the data will be at GWU. It is estimated that the amount of staff time needed for the contract representative and review and approval of reports is 2 FTEs both at 100% at the GS-13 step 1 level—for a total of $181,646. Collectively the estimated annualized cost to the government in staff time is estimated to be $181,646.

15. Explanation for Program Changes or Adjustments

This is new data collection.

16. Plans for Tabulation, Publication, and Project Time Schedule

Data collected through the Teaching Health Center Costing Instrument serve a number of important purposes including strengthening program performance, responding to federal reporting requirements, and responding to congressional inquiries. Since programs are publicly- funded, data collected may be showcased in peer-reviewed articles, conferences, and/or reports published through and/or sponsored by HRSA. In the case of publication, all THC program identifiable information will be aggregated and de-identified.

The process for cleaning, analyzing, and reporting data will consist of the following steps:

Step 1: Data cleaning. Data will be cleaned using a series of predetermined analytic rules within 30 days of receipt. Errors or discrepancies in data will be flagged and followed up with THC programs where appropriate.

Step 2: Analysis. Analysis of all data will be conducted under the THC Evaluation contract at the George Washington University during years 3 and 4 of the contract.

Step 3: Reporting. GW will provide HRSA with data on all THC programs individually identified. However, in the case of publication, all THC program identifiable information will be aggregated and de-identified.

17. Reason(s) Display of OMB Expiration Date is Inappropriate

The OMB number and Expiration date will be displayed on every page of every form/instrument.

18. Exceptions to Certification for Paperwork Reduction Act Submissions

There are no exceptions to the certification.

Appendix A: Teaching Health Center Costing Instrument

Please Enter:
Name of Residency Program you are providing information on in this workbook: THC Program Specialty: Residency Accreditation: Please indicate the type of Sponsoring Institution for the Residency Program: How many residency continuity clinic sites do you have? Please indicate the licensure(s) for the residency continuity clinic that you are providing financial information on in this workbook (please specify if other or list multiple): Time Period (Day/Month/Year - Day/Month/Year): New or Expansion Program Under THC Grant: Accredited Class Size per Year (if expansion, put THC and non-THC residents) Contact Person: Contact Person's E-mail: Contact Person's Telephone: Reviewer(s)/Contributor(s) Signatories
Thank you for your assistance in completing this residency program costing instrument. The information gathered here will be important to inform your THCGME program officers better understand the costs of residency training programs and natural variations that occur between THC programs.
General Instructions (Detailed Instructions on Each Page): Enter data only into cells shaded gray. Other cells have been locked to prevent accidental changes. Please enter data for your most recent completed full academic or fiscal year (fill in above), based on your organization's accounting practices. Please fill out the following worksheets: Visits, Revenue, Fac Salaries Benefits, Precepting Contracts, Residents Salaries Benefits, ResidencyAdmin, ClinicOperations, ClinicAdmin, Staffing, and StartUp. There are no cells to fill in on the Summary worksheet. It will auto-populate based on the other worksheets. However, we recommend you review the Summary worksheet prior to submitting the instrument. Please be consistent in the sites, departments, and clinical service lines you report on, according to the following guidelines: For patient visits, revenue, faculty and provider FTE, clinic operations and administration, please match your reports across these areas. For example, report patient revenues and clinic operations/administration expenses for the total visits reported in the Visits worksheet. Please report for the resident continuity clinic and inpatient service lines to the smallest units possible given your organization's accounting practices. For example, if it is possible to report clinic operations/administration expenses, visits, and patient revenue for the residency specialty clinic service in the resident continuity clinic site only, excluding other service lines (such as other specialties, pharmacy, lab, x- ray, etc.), then please report to this level of detail. If certain expenses are shared across more than one residency program, please report on only the proportion of the cost/revenue that can be estimated to be attributable to the residency program that you cite above. Please also only restrict your revenues to the proportion that are attributable to the site for which you are reporting. We understand accounting lines may differ between THC programs. Please use your best judgment on where to enter expenses. Do not enter an expense more than once. For example, if you report an expense in the residency administration worksheet (such as malpractice insurance), do not include that expense when reporting similar expenses in other worksheets.

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 0906‐XXXX. 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 10C‐03I, Rockville, Maryland, 20857.

OMB Number 0906-XXXX and Expiration date XX/XX/201X Basic Info Page 1

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Name of Program:

THC Program Specialty: Time Period:

Summary Page - This page will be autopopulated by your answers in the following worksheets.

Resident and Faculty FTE's:

Total

Faculty Practice (ambulatory, not precepted)

Resident Clinic (Precepted Ambulatory Visits)

Resident Inpatient

Service Residency

Resident FTE 0.00 N/A N/A N/A 0.00

Faculty FTE 0.00 0.00 0.00 0.00 0.00

Visits:

Clinic Visits 0 0 0 N/A N/A

Inpatient Visits 0 N/A N/A N/A

Clinic Sessions 0 0 0 N/A N/A

Revenue:

Net Clinic Pt Revenue Net Inpatient Pt Revenue FQHC Grant

$ - #DIV/0! #DIV/0! N/A N/A

$ - N/A N/A #VALUE! N/A

$ - #DIV/0! #DIV/0! N/A N/A

Other Patient Service Grants #DIV/0! #DIV/0! #VALUE! N/A

Hospital Residency Funding THC Grant

Medicaid GME

Other Residency Support

Total Revenue

$ - N/A N/A N/A $ -

$ - N/A N/A N/A $ -

$ - N/A N/A N/A $ -

$ - N/A N/A N/A $ -

$ - #DIV/0! #DIV/0! #VALUE! $ -

Program Expenses: Personnel Expenses: Faculty Salaries/Benefits

$ - #DIV/0! #DIV/0! $

- $ -

Precepting Contracts #REF! N/A N/A N/A #REF!

Resident Salaries/Benefits

$ - N/A N/A N/A $ -

Sub-Total #REF! #DIV/0! #DIV/0! $

- #REF!

Residency Program Administration: Residency Administrative Personnel Education Costs

$ - N/A N/A N/A -

Resident Education Stipends $

Resident Required Training $

Simulation Center Costs $

Education Supplies $

Medical/Dental School or OPTI fees $

Inpatient Service Costs $

Licensing and Certification Fees

Licensing Examination Fees $

In-Service Examination Fees $

Board Certification Fees $

Licensing Fees $

Program Fees and Costs

Accreditation Fees $

NRMP/Match Participation Fees $

Recruitment Costs $

Graduation Costs $

Faculty/Staff Development $

Travel $

General Liability Insurance $

Malpractice Insurance $

Legal and Accounting $

Consortium Expenses (if applicable) $

Rent/Occupancy $

Supplies

Mobile Communications Devices $

IT Costs $

White Coats/Uniforms $

Office Supplies $

Other $

• N/A N/A N/A $ -

• N/A N/A N/A $ -

• N/A N/A N/A $ -

• N/A N/A N/A $ -

• N/A N/A N/A $ -

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• N/A N/A N/A $ -

• N/A N/A N/A $ -

• N/A N/A N/A $ -

Sub-Total

$ - $ - $

- $ - $ -

Clinic Operations Expenses:

Clinical Support Personnel Salaries/Benefits $

Purchased Medical Services $

Medical Supplies $

Medical Equipment $

Licensing Fees $

Malpractice Insurance $

EHR licenses/maintenance $

Uniforms $

Occupancy $

Depreciation $

Other $

• #DIV/0! #DIV/0! N/A N/A

• #DIV/0! #DIV/0! N/A N/A

• #DIV/0! #DIV/0! N/A N/A

• #DIV/0! #DIV/0! N/A N/A

• #DIV/0! #DIV/0! N/A N/A

• #DIV/0! #DIV/0! N/A N/A

• #DIV/0! #DIV/0! N/A N/A

• #DIV/0! #DIV/0! N/A N/A

- #DIV/0! #DIV/0! N/A #DIV/0!

• #DIV/0! #DIV/0! N/A N/A

• #DIV/0! #DIV/0! N/A N/A

Sub-Total

$ - #DIV/0! #DIV/0! $

- $ -

Clinic Administration Expenses:

Administrative Personnel Salaries/Benefits $

Purchased Admin Services $

Office Supplies $

Recruitment $

Staff Development $

Travel $

IT Infrastructure $

Other $

Sub-Total $

- #DIV/0! #DIV/0! $

- #DIV/0! #DIV/0! $

- #DIV/0! #DIV/0! $

- #DIV/0! #DIV/0! $

- #DIV/0! #DIV/0! $

- #DIV/0! #DIV/0! $

- #DIV/0! #DIV/0! $

- #DIV/0! #DIV/0! $

- #DIV/0! #DIV/0! $

• N/A

• N/A

• N/A

• N/A

• N/A

• N/A

• N/A

• N/A

- $ -

Total Program Expense #REF! #DIV/0! #DIV/0! $

- #REF!

Overall Profit/Loss #REF! #DIV/0! #DIV/0! #VALUE! #REF!

Residency Overhead

$ - N/A N/A N/A $ -

Clinical Overhead

$ - #DIV/0! #DIV/0! N/A N/A

Total Overhead

$ - #DIV/0! #DIV/0! N/A $ -

Excluding Overhead:

Residency Program Cost * ** #DIV/0!

Cost per Resident #DIV/0!

Including Overhead:

Residency Program Cost * ** #DIV/0!

Cost per Resident #DIV/0!

*Residency program cost and cost per resident exclude explicit residency program funding

** Faculty Practice revenue and expense, non precepted, is not included in the Cost per Resident calculations

OMB Number 0906-XXXX and Expiration date XX/XX/201X Summary Page 2

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Name of Program:

THC Program Specialty: Time Period:

Patient Visits Instructions:

Report for the resident continuity clinic and inpatient service lines to the smallest units possible given your organization's accounting practices.

• For example, if it is possible to report clinic operations/administration expenses, visits, and patient revenue for the residency specialty clinic service in the resident continuity clinic site only, excluding other service lines (such as other specialties, pharmacy, lab, x-ray, etc.), then please report to this level of detail.

Enter the total number of clinical sessions matched to the reported visits. A session can be a morning, afternoon, or evening session. Sessions should be reported for all relevant providers.

• For example, if 4 providers are working during a morning session, the total sessions would equal 4.

For the Inpatient Service, enter the total patient visits for all revenue generating services where residents provide care on a continuous basis Faculty Practice visits should include patient visits for faculty in the THC residency program specialty in the residency continuity clinic sites.

• For example, if your THC program is a family medicine program, only enter patient visits for family medicine faculty when they are not precepting.

	Numbers of Patient Visits/Sessions in the Reporting Year
		Ambulatory Visits in the Resident Continuity Clinic									Resident Inpatient Service (if applicable)
		Non-Precepted			Residency Faculty Precepted
Visits	Total Medical or Dental	Residency Faculty Practice	Non-Faculty Providers	(Please enter the specialty of non-faculty providers below)	PGY-1 PGY-2 PGY-3 PGY-4 Residents Residents Residents Residents Chief Residents					Resident Total (All PGYs + Chiefs)
Clinic										0	N/A
Inpatient					N/A	N/A	N/A	N/A	N/A	N/A
Clinic Sessions										0	N/A

Payer Mix:

	Resident Site(s) Percent of Visits
	Outpatient Service	Inpatient Service	Notes
Total Medicaid
Total Medicare
Dual Eligible (Medicaid & Medicare)
Charity Care
Sliding Scale
Workman’s comp
Military Tri-Care
Number Written Off as Bad Debt
Other Public
Total Private
Self-Pay
Total	-	-

OMB Number 0906-XXXX and Expiration date XX/XX/201X Visits Page 3

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Name of Program:

THC Program Specialty: Time Period:

Patient Revenue

Outpatient Resident Clinic and Inpatient Revenue Instructions:

For Outpatient Revenue, enter the patient revenue generated in the residency continuity clinic site matched to the site listed in the first page, and used for the total medical or dental visits and clinical operations and administration expenses reported.

• Full Charges should reflect the total full charges for services rendered to patients

• Amount Collected should reflect the gross receipts for the period on a cash basis, regardless of the period in which the paid for services were rendered

For the Inpatient Revenue, enter the total patient revenue matched to residency inpatient service visits reported Outpatient Resident Clinic and Resident Inpatient Service

	Outpatient Resident Clinic Revenue		Inpatient Resident Service Revenue
Payer	Full Charges This Period	Amount Collected This Period	Full Charges This Period	Amount Collected This Period	Space for THC to describe if categories are combined, or other explanations.
Total Medicaid Total Medicare Dual Eligible (Medicaid & Medicare) Charity Care Sliding Scale Workman’s comp Military Tri-Care Amount Written Off as Bad Debt Other Public Total Private Self-Pay
Subtotals	$ -	$ -	$ -	$ -
Retroactive Settlements, Receipts, Paybacks: Collections of Retroactive Payments Penalty/Payback
Total Adjusted Revenue		$ -		$ -
FQHC Grant
Other Patient Service Grants: Source Source Source Source Source Total Patient Service Grants					End Date of Grant/Renewable or Non-renewable
		$ -		$ -

.

Residency Program Funding Instructions:

For Residency Program Funding, include only funding that explicitly supports resident training or other activities. For example, if your organization receives a "PCMH" grant explicitly to support resident training in PCMH, include that grant here. If the PCMH grant supports clinical service in the site for which this workbook is covering, include the grant in Other Patient Service Grants above.

Residency Program Funding	Total Amount
Hospital Residency Funding THCGME Payment Medicaid GME
Grants:			End Date of Grant	Renewable or Non-renewable
Source
Source
Source
Source
Source
Sub-Total Grants	$	-
Donations
Other: Meaningful Use Incentives Source Source Sub-Total Other Total Grants & Other Residency Support			End Date of Grant	Renewable or Non-renewable
	$	-
	$	-

Medical Student Funding

	Total Amount
Medical Student Funding

OMB Number 0906-XXXX and Expiration date XX/XX/201X Revenue Page 4

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Name of Program:

THC Program Specialty: Time Period:

Faculty Salary and Benefits Instructions:

To determine FTE allocation, please use actual data of time spent in the different areas from your most recently completed academic year

• In general, 1 session per week or 48 sessions per year is 0.1 FTE. Sessions can be a morning, afternoon or evening session, and are often approximately 4 hours. For Total FTE, report the total time the individual works, matched to the Total Salary and Benefits reported.

• For example, if the individual works for the health center 0.5 FTE, enter 0.5 and the total salary and benefits correlated to that 0.5 FTE.

If there is insufficient space for core, part time, or other faculty, list additional faculty positions below. Totals will auto-populate the Additional Faculty line.

For Other Providers - Non-Teaching, report the total FTE for all non-teaching providers in the residency continuity clinic site related to the number of visits and revenue reported in the Visits and Revenue worksheets. Include other specialty faculty in Residency Faculty FTE Allocations only if they have dedicated residency program time. Otherwise include in Other Providers - Non-Teaching if appropriate.

• For example, for a family medicine residency, include OB-Gyn, internal medicine, or pediatrics faculty only if they are covering resident inpatient services (including OB) or have dedicated residency teaching, curriculum, or administrative time If benefit payments are reported separately from salary, report in the "Total Benefits" column. Otherwise include in the "Total Salary" column.

		Residency Faculty FTE Allocations								Cost
Faculty Salaries and Benefits Specialty	Total FTE	Faculty Practice Resident Clinic (Ambulatory, (Precepted Not Ambulatory Precepting) Visits)		Resident Inpatient Service Clinic Admin		Residency Other Grants Description of (Non- Residency Activities Residency)				Total Salary Total Benefits				Faculty Practice (Ambulatory, Not Precepting)			Resident Clinic (Precepted Ambulatory Visits)			Resident Inpatient Service			Clinic Admin		Residency			Other Grants (Non-Residency)
Example - Core Faculty Internal Medicine	1.00	0.10	0.20	0.10	0.10	0.50		0.00		$ 165,000		$ 39,600		$	20,460		$	40,920		$	20,460		$	20,460	$	102,300		$	-
Program Director Associate Program Director Core Faculty Core Faculty Core Faculty Core Faculty Core Faculty Core Faculty Core Faculty Core Faculty Core Faculty Part time faculty Part time faculty Part time faculty Part time faculty Behaviorist (if applicable) Director of Research (if applicable) Additional Faculty (See below) Providers - Non-Teaching (e.g. MA, PA) Total	0.00													$	-		$	-		$	-		$	-	$	-		$	-
	0.00													$		-	$		-	$		-	$	-	$		-	$	-
	0.00													$		-	$		-	$		-	$	-	$		-	$	-
	0.00													$		-	$		-	$		-	$	-	$		-	$	-
	0.00													$		-	#VALUE!			$		-	$	-	$		-	$	-
	0.00													$		-	$		-	$		-	$	-	$		-	$	-
	0.00													$		-	$		-	$		-	$	-	$		-	$	-
	0.00													#VALUE!			#VALUE!			#VALUE!			$	-	#VALUE!			$	-
	0.00													$		-	$		-	$		-	$	-	$		-	$	-
	0.00													$		-	$		-	$		-	$	-	$		-	$	-
	0.00													#VALUE!			#VALUE!			#VALUE!			$	-	#VALUE!			$	-
	0.00													$		-	#VALUE!			#VALUE!			$	-	#VALUE!			$	-
	0.00													$		-	$		-	$		-	$	-	$		-	$	-
	0.00													$		-	$		-	$		-	$	-	$		-	$	-
	0.00													$		-	$		-	$		-	$	-	$		-	$	-
	0.00													$		-	$		-	$		-	$	-	$		-	$	-
	0.00													$		-	$		-	$		-	$	-	$		-	$	-
	0.00	0.00	0.00	0.00	0.00	0.00		0.00		$	-	$	-	$		-	$		-	$		-	$	-	$		-	$	-
	0.00		N/A			N/A								$		-	#VALUE!			$		-			#VALUE!			$	-
	0.00	0.00	0.00	0.00	0.00	0.00		0.00		$	-	$	-	$	-		$	-		$	-		$	-	$	-		$	-

Additional Faculty Positions:		Total FTE	Faculty Practice Resident Clinic (Ambulatory, (Precepted Not Ambulatory Precepting) Visits)		Inpatient Service Clinic Admin		Residency	Residency Notes	Other Grants (Non- Residency)		Total Salary Total Benefits				Faculty Practice (Ambulatory, Not Precepting)		Resident Clinic (Precepted Ambulatory Visits)		Inpatient Service		Clinic Admin		Residency		Other G	rants
		0.00													$	-	$	-	$	-	$	-	$	-	$	-
		0.00													$	-	$	-	$	-			$	-	$	-
		0.00													$	-	$	-	$	-			$	-	$	-
		0.00													$	-	$	-	$	-			$	-	$	-
		0.00													$	-	$	-	$	-			$	-	$	-
		0.00													$	-	$	-	$	-			$	-	$	-
		0.00													$	-	$	-	$	-			$	-	$	-
		0.00													$	-	$	-	$	-			$	-	$	-
		0.00													$	-	$	-	$	-			$	-	$	-
		0.00													$	-	$	-	$	-			$	-	$	-
		0.00													$	-	$	-	$	-			$	-	$	-
		0.00													$	-	$	-	$	-			$	-	$	-
		0.00													$	-	$	-	$	-			$	-	$	-
		0.00													$	-	$	-	$	-			$	-	$	-
		0.00													$	-	$	-	$	-			$	-	$	-
Total		0.00	0.00	0.00	0.00	0.00	0.00		0.00		$	-	$	-	$	-	$	-	$	-	$	-	$	-	$	-

OMB Number 0906-XXXX and Expiration date XX/XX/201X Faculty Salaries Page 5

0

Name of Program:

THC Program Specialty: Time Period:

Residency Program Precepting Contracts Instructions:

Report the amount paid by the residency under "Total Amount for Contracts Paid by the Residency", and the amounts paid by the hospital under "Total Amount for Contracts Paid by the Hospital". Enter the amount of any contracts with hospital or community preceptors to provide training experiences for your residents that are paid for by the residency.

In some situations, these fees are paid by the hospital rather than the residency program.

If this is the case for your program, please include the hospital payments under the "Total Amount for Contracts Paid by the Hospital" for contracts where the hospital makes the payments.

Preceptorships	Total Amount for Contracts Paid by the	Total Amount for Contracts Paid by the
Assistant Program Director
Medical Student Clerkship Director
Simulation Lead
Clinic Director
Behavioral Health
Community Preceptors
Critical Care
Emergency Medicine
Family Medicine
General Adult Medicine/Internal Medicine
General Pediatrics
General Surgery
Geriatrics
Gynecology
Hospitalist
Neurology
OB/GYN
Obstetrics
Psychiatry
Radiology
Additional Preceptorships Internal Medicine
Additional Preceptorships Internal Medicine
Additional Preceptorships Internal Medicine
Additional Preceptorships Internal Medicine
Additional Preceptorships Internal Medicine
Additional Preceptorships Internal Medicine
Additional Preceptorships Pediatrics
Additional Preceptorships Pediatrics
Additional Preceptorships Pediatrics
Additional Preceptorships Pediatrics
Additional Preceptorships Dentistry
Additional Preceptorships Dentistry
Type/Field
Type/Field
	$ -	$ -

OMB Number 0906-XXXX and Expiration date XX/XX/201X PreceptingContracts Page 6

0

Name of Program:

THC Program Specialty: Time Period:

Residents Salaries and Benefits Instructions:

Use actual numbers for your fiscal year reported. Average Annual Salary per FTE refers to the average annual salary for each residency year in the event that residents within each year are paid differently.

If benefit payments are reported separately from salary, report in the "Average Annual Benefits per FTE" column. Otherwise include in the "Average Annual Salary per FTE" column.

Report partial salaries as full amount for the period you are reporting for (i.e. if reporting for one year report annual amounts).

For "Chief Residents" row, report FTE, salaries & benefits for Chief Residents that are beyond the final year of training here. For example, if your Chief Residents are in PGY-3, report their salaries as a PGY-3, leaving the "Chief Residents" row blank.

Add rows if you have more than 7 residents for any given PGY.

Year of Residency	FTE per resident	Average Annual Salary per FTE			Average Annual Benefits per FTE	Total
PGY-1						$	-
PGY-1						$	-
PGY-1						$	-
PGY-1						$	-
PGY-1						$	-
PGY-1						$	-
PGY-1						$	-
PGY-2						$	-
PGY-2						$	-
PGY-2						$	-
PGY-2						$	-
PGY-2						$	-
PGY-2						$	-
PGY-2						$	-
PGY-3						$	-
PGY-3						$	-
PGY-3						$	-
PGY-3						$	-
PGY-3						$	-
PGY-3						$	-
PGY-3						$	-
PGY-4						$	-
PGY-4						$	-
PGY-4						$	-
PGY-4						$	-
PGY-4						$	-
PGY-4						$	-
PGY-4						$	-
PGY-4						$	-
PGY-4						$	-
Chief Resident(s)						$	-
Chief Resident(s)						$	-
Chief Resident(s)						$	-
Total	0.00	$	-	$	-	$	-

OMB Number 0906-XXXX and Expiration date XX/XX/201X ResidSalaries Page 7

0

Name of Program:

THC Program Specialty: Time Period:

Residency Program Administration Expenses

Residency Administrative Personnel Instructions:

For Total FTE, include only time that is dedicated to the residency program

For Total Salary and Total Benefits enter the total salary and benefits received by the individual

If benefit payments are reported separately from salary, report in the Total Benefits column. Otherwise include in the Total Salary column.

Cost
Admin Support Salaries	Total FTE Total Salary			Total Benefits		Residency Program Cost
Provide Title and Role						$	-
Provide Title and Role						$	-
Provide Title and Role						$	-
Provide Title and Role						$	-
Provide Title and Role						$	-
Provide Title and Role						$	-
Provide Title and Role						$	-
Provide Title and Role						$	-
Total	0.00	$	-	$	-	$	-

Residency Program Explicit Expenses Instructions:

Please report only those expenses charged directly to the residency program for which this costing instrument applies. In any cases where the residency program is not explicitly charged, please enter "0"

* Do not include expenses reported in other spreadsheets, such as faculty development included in faculty benefits costs or insurance or licensing fees included in clinical operations costs.

Additional Instructions

Total Residency Square Footage Please insert the square footage of the space allocated for the residency educational functions

	Total Am	ount
Education Costs:
Resident Education Stipends Resident Required Training Simulation Center Costs Education Supplies Medical/Dental School or OPTI fees General Educational Allowance Inpatient Service Costs
Licensing/Certification Fees:
Licensing Examination Fees In-Service Examination Fees Board Certification Fees Board Preparation Costs Licensing Fees
Program Fees and Costs:
Accreditation Fees NRMP/Match Participation Fees Recruitment Costs Graduation Costs Faculty/Staff Development Travel Away Rotation Housing General Liability Insurance Malpractice Insurance Legal and Accounting Consortium Expenses (if applicable) Rent/Occupancy
Supplies:
Mobile Communications Devices IT Costs White Coats/Uniforms Printing and Postage Office Supplies
Other:
Other Expense Type
Other Expense Type
Other Expense Type
Other Expense Type
Other Expense Type
Other Expense Type
Other Expense Type
Other Expense Type
Total Other	$	-
Total	$	-
Overhead:
Expense Type
Expense Type
Expense Type
Expense Type
Expense Type
Total Overhead	$	-

Include fees paid for any resident required training programs, such as ACLS/PALS etc.

Include any costs associated with simulation exercises. These may include cost of simulation equipment, related supplies, or fees to access simulation centers Educational supplies may include costs associated with library resources, textbooks, journal subscriptions, scholarly association fees, software

Report any fees associated with medical school, dental school or OPTI affiliations

Lump sum amount given to residents for their own purchase of educational supplies and materials

Report any additional inpatient service payments. Do not include any precepting contracts reported in the "Precepting Contracts" spreadsheet.

Include any fees paid for resident licensing exams, such as USMLE fees

Include any fees paid for residents for Board certification exams or training

Include any practice licensing fees paid for residents (not faculty: faculty licenses should be listed under ClinicOps row 18)

Include per program annual assessments and per resident fees for use of any accreditation services Include any fees paid for participation in the NRMP, AOA, or other match programs

Include any costs associated with recruitment, such as candidate travel, give-a-ways, meals, brochures, etc Include cost of graduation such as venue, food, entertainment, certificates, etc

Include faculty development costs such as NIPPD, and staff development costs such as conferences, association dues, etc, STFM dues, etc.

Include travel to educational courses and conferences, and any other travel that is paid for by the residency program, except "away rotation housing" Lodging costs paid by the residency program for away rotations

Include any general liability insurance purchased for the residency program

Only include malpractice insurance if specifically paid for residents or faculty related to residency program activities Include all legal and accounting fees associated with the residency program

If you have a consortium, include any expenses associated with that consortium that do not appear in any other worksheet Report only rent or occupancy fees specifically charged to the residency program for residency program space

Include any pagers or cell phones purchased for residents or residency program staff

Only include IT costs charged directly to the residency program, such as laptop computers, e-mail service, or residency program management software for residents

List any expenses not detailed above that are associated with the administration of the residency program. Also include the total for the academic year

Report any central administrative overhead costs charged to the residency program; Please indicate what your program includes in "overhead cost"

OMB Number 0906-XXXX and Expiration date XX/XX/201X ResidAdmin Page 8

0

Name of Program:

THC Program Specialty: Time Period:

Residency Program Administration In-Kind Donations

Please include here the value of residency administration costs that you do not have to pay because they are provided for free by other entities.

For example, if your residency is housed for free in a location, please estimate and enter below what you would have to pay for square footage, had the residency been required to pay for the space it occupies.

Residency Program Only In-Kind Donations Instructions:

Please report only those in-kind donations that would have been charged directly to the residency program for which this costing instrument applies. The in-kind donations would be expected to match the "0" items entered in ResidAdmin tab.

Additional Instructions

Total Residency Square Footage Please insert the square footage of the space allocated for the residency educational functions

	Total Am	ount
Education Costs:
Resident Education Stipends Resident Required Training Simulation Center Costs Education Supplies Medical/Dental School or OPTI fees General Educational Allowance Inpatient Service Costs
Licensing/Certification Fees:
Licensing Examination Fees In-Service Examination Fees Board Certification Fees Board Preparation Costs Licensing Fees
Program Fees and Costs:
Accreditation Fees NRMP/Match Participation Fees Recruitment Costs Graduation Costs Faculty/Staff Development Travel Away Rotation Housing General Liability Insurance Malpractice Insurance Legal and Accounting Consortium Expenses (if applicable) Rent/Occupancy
Supplies:
Mobile Communications Devices IT Costs White Coats/Uniforms Printing and Postage Office Supplies
Other:
Other Expense Type
Other Expense Type
Other Expense Type
Other Expense Type
Other Expense Type
Other Expense Type
Other Expense Type
Other Expense Type
Total Other	$	-
Total	$	-
Overhead:
Expense Type
Expense Type
Expense Type
Expense Type
Expense Type
Total Overhead	$	-

Include fees paid for any resident required training programs, such as ACLS/PALS etc.

Include any costs associated with simulation exercises. These may include cost of simulation equipment, related supplies, or fees to access simulation centers Educational supplies may include costs associated with library resources, textbooks, journal subscriptions, scholarly association fees, software

Report any fees associated with medical school, dental school or OPTI affiliations

Lump sum amount given to residents for their own purchase of educational supplies and materials

Report any additional inpatient service payments. Do not include any precepting contracts reported in the "Precepting Contracts" spreadsheet.

Include any fees paid for resident licensing exams, such as USMLE fees

Include any fees paid for residents for Board certification exams or training

Include any practice licensing fees paid for residents (not faculty: faculty licenses should be listed under ClinicOps row 18)

Include per program annual assessments and per resident fees for use of any accreditation services Include any fees paid for participation in the NRMP, AOA, or other match programs

Include any costs associated with recruitment, such as candidate travel, give-a-ways, meals, brochures, etc Include cost of graduation such as venue, food, entertainment, certificates, etc

Include faculty development costs such as NIPPD, and staff development costs such as conferences, association dues, etc, STFM dues, etc.

Include travel to educational courses and conferences, and any other travel that is paid for by the residency program, except "away rotation housing" Lodging costs paid by the residency program for away rotations

Include any general liability insurance purchased for the residency program

Only include malpractice insurance if specifically paid for residents or faculty related to residency program activities Include all legal and accounting fees associated with the residency program

If you have a consortium, include any expenses associated with that consortium that do not appear in any other worksheet Report only rent or occupancy fees specifically charged to the residency program for residency program space

Include any pagers or cell phones purchased for residents or residency program staff

Only include IT costs charged directly to the residency program, such as laptop computers, e-mail service, or residency program management software for residents

List any expenses not detailed above that are associated with the administration of the residency program. Also include the total for the time period this worksheet applies to.

Report any central administrative overhead costs paid by others but would normally be charged to the residency program; Please indicate what your program includes in "overhead cost"

OMB Number 0906-XXXX and Expiration date XX/XX/201X In-kind ResidAdmin Page 9

0

Name of Program:

THC Program Specialty: Time Period:

Clinic Administrative Expenses: Include all clinic administrative costs that are not included as part of the residency admin tab or as part of overhead

Instructions:

Enter expenses matched to the total medical or dental visits, revenue, and clinic operation expenses reported for the resident continuity clinic site Include all clinic administrative costs that are not included as part of the residency admin tab or as part of overhead

Do not include expenses reported in other spreadsheets. For example, do not report here malpractice insurance or licensing fees reported in the residency admin expenses. In the "Inpatient Service" column, report any administrative costs allocated to the inpatient service.

	Costs
	Residency Continuity Clinic Site		Inpatient Service (if applicable)
Administrative Personnel Salaries/Benefits Purchased Admin Services Office Supplies Recruitment Staff Development Travel IT Infrastructure Other Expense Type Other Expense Type Other Expense Type Other Expense Type Other Expense Type
Total Other	$	-	$	-
Total Clinic Admin Expenses	$	-	$	-

Additional Instructions:

Include any contracts for administrative type services for the clinic only Include the cost of clinic office supplies

Include any additional recruitment costs that are separate from the residency recruitment costs Include any non-residency, clinic staff development costs

Include any travel associated with clinical activities

Include any hardware, wiring, servers etc purchased in the last full academic year Include the name and amount of any other expenses that are not duplicative

Overhead
Administrative Overhead Finance and Accounting Overhead Physical Plant IT Overhead Other Expense Type Other Expense Type Other Expense Type			N/A
			N/A
			N/A
			N/A
			N/A
			N/A
			N/A
Total Other	$	-	N/A
Total Overhead	$	-	N/A

Report any additional centralized overhead costs here that were not reported elsewhere This may include your organization's CEO, CFO, COO, CNO, CMO, etc

This may include your organization's finance office, billing office, accounting fees, payroll office, etc

Include any maintenance, mortgage, repairs, etc. that are allocated as overhead to the residency continuity clinic site. Usually includes IT department staff

List the name and amount of any other overhead categories that are allocated to the residency continuity clinic site

OMB Number 0906-XXXX and Expiration date XX/XX/201X ClinicAdmin Page 10

0

Name of Program:

THC Program Specialty: Time Period:

Clinical Operations Expenses: Enter expenses matched to the total medical or dental visits, revenue, and clinic administration expenses reported for the resident continuity clinic site. Instructions:

Enter expenses matched to the total medical or dental visits, revenue, and clinic administration expenses reported for the resident continuity clinic site

Do not include expenses reported in other spreadsheets. For example, do not include malpractice insurance or licensing fees reported in the residency admin expenses.

Additional Instructions:

Clinic Square Footage Insert the total Clinic square footage of the Family Medicine Center, NOT including any residency/educational space.

	Total Amount
Clinical Support Personnel Salaries/Benefits Purchased Medical/Dental Services Medical/Dental Supplies Medical/Dental Equipment Licensing Fees Malpractice Insurance EHR licenses/maintenance Uniforms Occupancy Depreciation Other Expense Type Other Expense Type Other Expense Type Other Expense Type Total Other
	$	-
Total	$	-

Purchased medical services are contracted clinical services that are not accounted for in any other category Include any medical/dental supplies for patient care services in the residency continuity clinic

Include any medical/dental equipment purchasing or maintenance costs of that medical equipment Include any licensing fees of the actual clinical site or of faculty, providers and staff working at that site

Include any malpractice costs above and beyond FTCA coverage, if applicable. Please do not duplicate malpractice insurance expenses

provided in ResidAdmin in cell C55

If EHR licenses are a one time fee, just insert maintenance costs here. If licenses are paid annually, include license and maintenance fees Include the cost of staff uniforms, white coats, scrubs, etc

Include any rent, building maintenance, or utilities costs not explicitly reported elsewhere.

Include equipment or facility depreciation for any items not reported in line 17 "Medical/Dental Equipment" above. Report the name and amount of any other expenses not listed above.

OMB Number 0906-XXXX and Expiration date XX/XX/201X ClinicOps Page 11

0

Name of Program:

THC Program Specialty: Time Period:

Residency Start-Up Expenses Instructions:

Please complete this worksheet if your residency program accepted its first class of residents in 2010 or later

Include all costs associated with the start-up phase of your residency program. These are costs expended prior to the start of your residency program. Do not report any costs here that are already reported as expenses in other worksheets in this workbook.

If benefit payments are reported separately from salary, report in the Benefits row. Otherwise include in the Personnel costs.

Start up Expenses	Total Amo	unt
Personnel
Program Director	$	-
Residency Program Coordinator	$	-
Other Expense Type
Other Expense Type
Other Expense Type
Other Expense Type
Other Expense Type
Sub-total	$	-
Benefits
Total	$	-
Contracts Legal Consultants Grantwriter Faculty hours Other Expense Type Other Expense Type Other Expense Type Other Expense Type Other Expense Type
Total Contracts	$	-
Non-Wage Accreditation Application Fee Faculty Recruitment Faculty Development IT Costs Office Supplies Other Expense Type Other Expense Type Other Expense Type Other Expense Type Other Expense Type
Total Non-Wage	$	-
TOTAL
	$	-
Capital Capital Improvements Equipment Furnishings Other Expense Type Other Expense Type Other Expense Type Other Expense Type Other Expense Type
Total Capital	$	-

Additional Instructions

Include any additional faculty recruitment costs above prior provider recruitment costs required to start the residency program Include any initial faculty development costs prior to the start of the residency program

Include any initial IT infrastructure costs to support the new residency program. This may include hardware or software costs.

Include only those capital investments made specifically to support the residency program. For example, renovations for residency offices or teaching space.

OMB Number 0906-XXXX and Expiration date XX/XX/201X StartUp Page 12

Appendix B: 60-day Federal Registrar Notice

Federal Register / Vol. 79, No. 219 / Thursday, November 13, 2014 / Notices

67439

Committee would be held on December 16–17, 2014. The ADDRESSES portion of the document is to read as follows: ADDRESSES: FDA is opening a docket for public comment on this meeting. The

docket will open for public comment on November 13, 2014. The docket will

close on January 15, 2014. Interested persons may submit either electronic comments regarding this meeting to http://www.regulations.gov or written comments to the Division of Dockets Management (HFA–305), Food and Drug Administration, 5630 Fishers Lane, Rm. 1061, Rockville, MD 20852. It is only necessary to send one set of comments. Identify comments with the docket number found in brackets in the heading of this document. Received comments may be seen in the Division of Dockets Management between 9 a.m. and 4 p.m., Monday through Friday, and will be posted to the docket at http:// www.regulations.gov. All comments received will be posted without changes, including any personal information provided. Comments received on or before December 1, 2014, will be provided to the committee before the meeting.

On page 49091, in the second column,

the Agenda portion of the document is changed to read as follows:

Agenda: The committee will discuss

how risk assessments should account for the susceptibility to the effects of a particular chemical exposure because of factors such as genetics, age, sex, and health status and the circumstances under which FDA would decide to conduct a separate risk assessment for these groups.

This notice is issued under the

Federal Advisory Committee Act (5

3. app. 2) and 21 CFR part 14, relating to the advisory committees.

Dated: November 7, 2014.

Jill Hartzler Warner,

Associate Commissioner for Special Medical Programs.

[FR Doc. 2014–26823 Filed 11–12–14; 8:45 am]

BILLING CODE 4164–01–P

ACTION: Notice.

SUMMARY: In compliance with the requirement for opportunity for public comment on proposed data collection projects (Section 3506(c)(2)(A) of the Paperwork Reduction Act of 1995), the Health Resources and Services Administration (HRSA) announces plans to submit an Information Collection Request (ICR), described below, to the Office of Management and Budget (OMB). Prior to submitting the ICR to OMB, HRSA seeks comments from the public regarding the burden estimate, below, or any other aspect of the ICR.

DATES: Comments on this Information Collection Request must be received no later than January 12, 2015.

ADDRESSES: Submit your comments to paperwork@hrsa.gov or mail the HRSA Information Collection Clearance Officer, Room 10C–03, Parklawn Building, 5600 Fishers Lane, Rockville, MD 20857.

FOR FURTHER INFORMATION CONTACT: To

request more information on the proposed project or to obtain a copy of the data collection plans and draft instruments, email paperwork@hrsa.gov or call the HRSA Information Collection Clearance Officer at (301) 443–1984.

SUPPLEMENTARY INFORMATION: When

submitting comments or requesting information, please include the information request collection title for reference.

Information Collection Request Title: Evaluation and Initial Assessment of the HRSA Teaching Health Centers

Graduate Medical Education Program.

OMB No.: 0906–xxxx—New.

Abstract: Section 5508 of the Affordable Care Act of 2010 amended section 340H of the Public Health Service Act to establish the Teaching Health Center Graduate Medical Education (THCGME) program to provide funding support for new and the expansion of existing primary care residency training programs in

amount used to determine the Program’s payment for direct medical expenses (DME). To inform these determinations and to increase understanding of this model of residency training, the George Washington University (GW) is conducting an evaluation of the costs associated with training residents in the Teaching Health Center (THC) model.

GW has developed a standardized costing instrument to gather data from all THCGME programs. The information gathered in the standardized costing instrument includes, but is not limited to, resident and faculty full-time equivalents, salaries and benefits, residency administration costs, educational costs, residency clinical operations and administrative costs, and patient visits and clinical revenue generated by medical residents.

Need and Proposed Use of the Information: HRSA is collecting costing information related to both DME and IME in an effort to establish a THC’s total cost of running a residency program, to assist the Secretary in determining an appropriate update to the per resident amount used to calculate the payment for DME and an appropriate IME payment. The described data collection activities will serve to inform these statutory requirements for the Secretary in a uniform and consistent manner.

Likely Respondents: THCGME grantees.

Burden Statement: Burden in this context means the time expended by persons to generate, maintain, retain, disclose or provide the information requested. This includes the time needed to review instructions; to develop, acquire, install and utilize technology and systems for the purpose of collecting, validating and verifying information, processing and maintaining information, and disclosing and providing information; to train

community-based settings. The primary

goals of this program is to increase the

personnel and to be able to respond to

a collection of information; to search

DEPARTMENT OF HEALTH AND

HUMAN SERVICES

Health Resources and Services Administration

Agency Information Collection Activities: Proposed Collection: Public Comment Request

AGENCY: Health Resources and Services Administration, HHS.

production of primary care providers who are better prepared to practice in community settings, particularly with underserved populations, and improve the geographic distribution of primary care providers.

Statute requires the Secretary to

determine an appropriate THCGME program payment for indirect medical expenses (IME) as well as to update, as deemed appropriate, the per resident

data sources; to complete and review the collection of information; and to transmit or otherwise disclose the information. The total annual burden hours estimated for this Information Collection Request are summarized in the table below.

The annual estimate of burden is as follows:

67440 Federal Register / Vol. 79, No. 219 / Thursday, November 13, 2014 / Notices

Form name	Number of respondents	Number of responses per respondent	Total responses	Average burden per response (in hours)	Total burden hours
Teaching Health Center Costing Instrument ....................... Total ..............................................................................	60	1	60	10	600
	60	1	60	10	600

HRSA specifically requests comments on (1) the necessity and utility of the proposed information collection for the proper performance of the agency’s functions, (2) the accuracy of the estimated burden, (3) ways to enhance the quality, utility, and clarity of the information to be collected, and (4) the use of automated collection techniques or other forms of information technology to minimize the information collection burden.

Dated: October 31, 2014.

Jackie Painter,

Acting Director, Division of Policy and Information Coordination.

[FR Doc. 2014–26854 Filed 11–12–14; 8:45 am]

BILLING CODE 4165–15–P

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Health Resources and Services Administration

Agency Information Collection Activities: Submission to OMB for Review and Approval; Public Comment Request

AGENCY: Health Resources and Services Administration, HHS.

ACTION: Notice.

SUMMARY: In compliance with Section 3507(a)(1)(D) of the Paperwork Reduction Act of 1995, the Health Resources and Services Administration (HRSA) has submitted an Information Collection Request (ICR) to the Office of Management and Budget (OMB) for review and approval. Comments submitted during the first public review of this ICR will be provided to OMB. OMB will accept further comments from the public during the review and approval period.

DATES: Comments on this ICR should be received no later than December 15, 2014.

ADDRESSES: Submit your comments, including the Information Collection Request Title, to the desk officer for HRSA, either by email to OIRA submission@omb.eop.gov or by fax to 202–395–5806.

FOR FURTHER INFORMATION CONTACT: To

request a copy of the clearance requests

submitted to OMB for review, email the HRSA Information Collection Clearance Officer at paperwork@hrsa.gov or call (301) 443–1984.

SUPPLEMENTARY INFORMATION:

Information Collection Request Title: Title V Maternal and Child Health Services Block Grant to States Program: Guidance and Forms for the Title V Application/Annual Report OMB No. 0915–0172—Revision.

Abstract: The Health Resources and Services Administration (HRSA) is

revising the Title V Maternal and Child Health Services Block Grant to States Program: Guidance and Forms for the Title V Application/Annual Report. The Guidance is used annually by the 50 states and nine jurisdictions in applying for Block Grants under Title V of the Social Security Act and in preparing the required Annual Report. In partnership with the leadership in State Title V Maternal and Child Health (MCH) programs as well as with other national MCH leaders and stakeholders, HRSA’s Maternal and Child Health Bureau (MCHB) has been working over the past year to develop and refine a vision for transforming the MCH Block Grant to States program to better meet current and future challenges facing our nation’s mothers and children, including children with special health care needs (CSHCN) and their families. The proposed revisions to the Application and Annual Reporting requirements and to the data forms that are contained in the revised guidance reflect this transformative vision.

Relative to the state’s submission of a

yearly Application, Annual Report and 5-year Needs Assessment, the aims of the MCH Block Grant to States program transformation are threefold: (1) Reduce burden to states, (2) maintain state flexibility, and (3) improve accountability. Revisions to this edition are intended to enable the state to tell

a more cohesive and comprehensive Title V story and to better reflect on the program’s leadership role and its contributions to the state’s public health system in building improved and expanded systems of care for the MCH population. It is recognized that the full extent of the anticipated burden reduction will be realized over time as states become more familiar with the

new instructions and reporting requirements. The burden estimates presented in the table below are based on previous burden estimates, consultations with a few states on the proposed changes, and comments received during the 60-day public comment period.

Specific changes to this edition of the

Title V Maternal and Child Health Services Block Grant to States Program: Guidance and Forms for the Title V Application/Annual Report include the following:

1. Narrative reporting will be

organized by six population health domains (i.e., Women’s/Maternal Health; Perinatal/Infant’s Health; Child Health; CSHCN; Adolescent Health and Cross-cutting or Life Course); (2) Revised National Performance Measure (NPM) framework will be implemented with states selecting 8 of 15 NPMs for their programmatic focus; (3) state-level program data, such as breakdowns of MCH populations by race/ethnicity, health indicator data, and national performance and outcome measure data will be provided by MCHB, as available, from national data sources, thus, reducing the annual reporting burden for states; (4) Given that most MCH issues are multifactorial, the state will establish evidence based or evidence informed strategies to address each of the selected NPMs and will report on one or more of the Evidence-based or informed Strategy Measures (ESMs) developed for each NPM; (5) Revised instructions and the inclusion of a logic model for the State Title V MCH Block Grant Application/Annual Report process will provide greater emphasis on the need for the state priority needs and national MCH priority areas to drive the state’s reporting on the 5-year (and ongoing) Needs Assessment findings, the selection of eight (8) NPMs which target the state-identified priority needs, the development of evidence based or informed strategies and related ESMs for addressing each of the selected NPMs, and the establishment of between three

(3) and five (5) State Performance Measures (SPMs) which respond to the state’s identified unique needs; (6) State Application/Annual Report will include a 5-year Action Plan for addressing the identified MCH priority areas; (7) An