| Part A & MAI Expenditures Report | ||||||||||||||
| Section A: Identifying Information | ||||||||||||||
| ~ Enter Name of Grantee Here ~ | ||||||||||||||
| ~ Enter Preparer's Name Here ~ | ||||||||||||||
| ~ Enter Preparer's Phone Number Here ~ | ||||||||||||||
| ~ Enter Preparer's Email Address Here ~ | ||||||||||||||
| Section B: Award Information | Current FY | Carryover | Total | |||||||||||
| 1. Part A Grant Award Amount | $0 | |||||||||||||
| 2. MAI Grant Award Amount | $0 | |||||||||||||
| 3. Total Part A Funds | $0 | $0 | $0 | |||||||||||
| PART A AWARD | MAI AWARD | PART A + MAI TOTAL AWARD | ||||||||||||
| Section C: Expenditure Categories | CURRENT FY | PRIOR FY CARRYOVER | PART A TOTAL | CURRENT FY | PRIOR FY CARRYOVER | MAI TOTAL | ||||||||
| Amount | Percentage | Amount | Percent | Amount | Percent | Amount | Percentage | Amount | Percent | Amount | Percent | Amount | Percent | |
| 1. Core Medical Services Subtotal1 (see CHECKLIST) | $0 | 0.00% | $0 | 0.00% | $0 | 0.00% | $0 | 0.00% | $0 | 0.00% | $0 | 0.00% | $0 | 0.00% |
| a. Outpatient /Ambulatory Health Services | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| b. AIDS Drug Assistance Program (ADAP) Treatments | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| c. AIDS Pharmaceutical Assistance (local) | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| d. Oral Health Care | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| e. Early Intervention Services | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| f. Health Insurance Premium & Cost Sharing Assistance | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| g. Home Health Care | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| h. Home and Community-based Health Services | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| i. Hospice Services | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| j. Mental Health Services | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| k. Medical Nutrition Therapy | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| l. Medical Case Management (incl. Treatment Adherence) | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| m. Substance Abuse Services - outpatient | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| 2. Support Services Subtotal | $0 | 0.00% | $0 | 0.00% | $0 | 0.00% | $0 | 0.00% | $0 | 0.00% | $0 | 0.00% | $0 | 0.00% |
| a. Case Management (non-Medical) | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| b. Child Care Services | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| c. Emergency Financial Assistance | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| d. Food Bank/Home-Delivered Meals | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| e. Health Education/Risk Reduction | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| f. Housing Services | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| g. Legal Services | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| h. Linguistics Services | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| i. Medical Transportation Services | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| j. Outreach Services | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| k. Psychosocial Support Services | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| l. Referral for Health Care/Supportive Services | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| m. Rehabilitation Services | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| n. Respite Care | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| o. Substance Abuse Services - residential | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| p. Treatment Adherence Counseling | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| 3. Total Service Expenditures | $0 | - - | $0 | - - | $0 | - - | $0 | - - | $0 | - - | $0 | - - | $0 | - - |
| 4. Non-services Subtotal | $0 | - - | $0 | - - | $0 | - - | $0 | - - | $0 | - - | $0 | - - | $0 | - - |
| a. Clinical Quality Management2 (see CHECKLIST) | - - | - - | $0 | - - | - - | $0 | - - | $0 | - - | $0 | - - | |||
| b. Grantee Administration 3 (see CHECKLIST) | - - | - - | $0 | - - | - - | $0 | - - | $0 | - - | $0 | - - | |||
| 5. Total Expenditures | $0 | - - | $0 | - - | $0 | - - | $0 | - - | $0 | - - | $0 | - - | $0 | - - |
| Section D: Award & Expenditure Summary | Award | Expenditure | Balance | |||||||||||
| 1. Part A | $0 | $0 | $0 | FOR OFFICE USE ONLY: | ||||||||||
| 2. Part A MAI | $0 | $0 | $0 | o Grantee received waiver for 75% core medical services requirement. | ||||||||||
| 3. Total | $0 | $0 | $0 | |||||||||||
| Part A & MAI Expenditures Report CHECKLIST | ||||
| ~ Enter Name of Grantee Here ~ | ||||
| Please check the following before submitting your report! | Part A Award | MAI Grant Award | Combined Total | |
| 1 | 75% of your combined awards must be spent on core medical services. When reporting Core Medical Services, the percentages in Section C, Row 1 under PART A AWARD and MAI AWARD columns do not necessarily need to be 75% as long as the COMBINED TOTAL column percentage meets the required minimum 75%. The exception to this requirment is only for those grantees that requested, and were approved by HRSA, for an FY 2010 Part A Core Medical Services Waiver. |
0.0% | ||
| 2 | You may not spend more than 5% or 3 million dollars (whichever is smaller) on clinical quality management. Use the percentages and figures to the right to help determine if this requirement is met. |
- - | - - | |
| $0 | $0 | |||
| 3 | You may not spend more than 10% on grantee administration. These percentages should not be more than 10%. |
0.0% | 0.0% | |
| File Type | application/vnd.ms-excel |
| Author | Melanie K. Wieland |
| Last Modified By | KWeld1 |
| File Modified | 2010-12-13 |
| File Created | 2007-05-15 |