Form 1 Form and Instructions for THCGME FTE Chart

Eligible Resident/Fellow FTE Chart and Instructions

Program Name:

NUMBER OF ELIGIBLE RESIDENT/FELLOW FTEs IN PROGRAM
Academic Years	Funding Year	Number of Resident/Fellow FTEs					Aggregate Number of FTEs in the Program	Aggregate Number of THC FTEs
PGY-1	PGY-2	PGY-3	PGY-4	PGY-5
7/1/20xx-6/30/20xx
7/1/20xx-6/30/20xx
7/1/20xx-6/30/20xx
7/1/20xx-6/30/20xx
7/1/20xx-6/30/20xx	Year 1
7/1/20xx-6/30/20xx	Year 2
7/1/20xx-6/30/20xx	Year 3
7/1/20xx-6/30/20xx	Year 4
7/1/20xx-6/30/20xx	Year 5

OMB 0915-0367 Expiration Date: XX/XX/20XX

Instructions for completing the THCGME Eligible Resident/Fellow FTE Chart:

NUMBER OF ELIGIBLE RESIDENT/FELLOW FTEs IN PROGRAM
Academic Years	Funding Year	Number of Resident/Fellowship FTEs					Aggregate Number of FTEs in the Program	Aggregate Number of THC FTEs
		PGY- 1	PGY-2	PGY-3	PGY-4	PGY- 5
7/1/20xx-6/30/20xx
7/1/20xx-6/30/20xx
7/1/20xx-6/30/20xx
7/1/20xx-6/30/20xx	Baseline Year
7/1/20xx-6/30/20xx	Year 1
7/1/20xx-6/30/20xx	Year 2
7/1/20xx-6/30/20xx	Year 3
7/1/20xx-6/30/20xx	Year 4
7/1/20xx-6/30/20xx	Year 5

OMB 0915-0367 Expiration Date: XX/XX/20XX

1. In the columns labeled as “Number of Resident/Fellow FTEs,” list the number of PGY-1, PGY-2, PGY-3, PGY-4 and PGY-5 FTEs enrolled in the residency program during the indicated academic years. Also include the number of resident FTEs enrolled during baseline academic year. If the residency program is three years, input zeros (0) in the PGY-4 and PGY-5 column. If the residency program is a geriatric fellowship, input the fellowship FTE as PGY-4 or PGY-5. If applicable, include any THCGME-supported FTEs funded by HRSA during the indicated academic years.

2. In the columns labeled as “Number of Resident/Fellow FTEs,” list the number of

PGY-1, PGY-2, PGY-3, PGY-4 and PGY-5 FTEs you plan to train over the next five academic years. If the residency program is three years, input zeros (0) in the PGY-4 and PGY-5 column. If the residency program is a geriatric fellowship, input the fellowship FTE as PGY-4 or PGY-5. These columns should include any planned THCGME-supported FTEs during the indicated academic years.

3. In the column labeled as “Aggregate Number of FTEs in the Program” document the aggregate number of resident FTEs that were enrolled, or that you plan to enroll, in the program during each of the listed academic years. This column should be equal to the number listed in the “Number of Resident/Fellowship FTEs” PGY columns and should include resident FTEs supported by all funding sources.

4. In the column labeled as “Aggregate Number of THC FTEs,” document the aggregate number of THCGME-supported resident FTEs that were enrolled, or that you plan to enroll, in the program during each of the listed academic years.

Please note that your projections do not guarantee funding.

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

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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 0915-0367. Public reporting burden for this collection of information is estimated to average 1 hour 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 14N39, Rockville, Maryland, 20857.