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					Total Number of FTEs in the Program	Total Number of HRSA-Approved THCGME FTEs	Total Number of New THCGME FTEs Requested with this NOFO Application
			PGY-1	PGY-2	PGY-3	PGY-4	PGY-5			t
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 No: 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					Total Number of FTEs in the Program	Total Number of HRSA-Approved THCGME FTEs	Total Number of New THCGME FTEs Requested with this NOFO Application
		PGY- 1	PGY-2	PGY-3	PGY-4	PGY- 5
7/1/20xx-6/30/20xx		A	A	A	A	A	C	D	E
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	B	B	B	B	B
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 “Total Number of FTEs in the Program” document the total 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/fellow FTEs supported by all funding sources.

4. In the column labeled as “Total Number of HRSA-Approved THCGME FTEs,” document the total number of THCGME-supported resident/fellow FTEs that were enrolled in the program during each of the listed academic years. For example, if you are a program that does not receive THCGME funding this number should be “0.”

5. In the column labeled as “Total Number of New THCGME FTEs Requested with this NOFO Application,” document the total number of new requested THCGME-supported resident/fellow FTEs that you plan to enroll in the program during each of the listed academic years with this NOFO application.

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: The purpose of this information collection is to obtain performance data for the following: HRSA program participants, programs and applications. In addition, these data will facilitate the ability to demonstrate alignment between BHW Programs and the THCGME Program Eligible Resident/Fellow FTE Chart. 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 0915-0367 and it is valid until xx/xx/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 14NWH04, Rockville, Maryland, 20857