Form 1 THCGME Reconciliation Tool Form 2020 F

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: 07/01/2019-6/30/2020
FTE Data for Academic Year 2019 - 2020
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: 07/31/2020

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 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 14N136B, Rockville, Maryland, 20857 or paperwork@hrsa.gov.