| Part B and MAI Allocations Report |
|
| Detailed instructions for completing and submitting this report can be
found in the Electronic Handbooks and download from the web:
https://grants.hrsa.gov/webexternal/Login.asp |
Section B: Reporting Year Award Information |
| 1. Part B Base Award |
|
| 2. Part B Supplemental Award |
|
| 3. Total Part B Base + Base Supplemental Awards |
$0 |
| 4. Part B ADAP Earmark Award |
|
| Section A: Identifying Information |
|
5. Part B ADAP Supplemental Award |
|
| ~ Enter Name of Grantee Here ~ |
|
6. Total Part B ADAP + ADAP Supplemental Awards |
$0 |
| ~ Enter Preparer's Name Here ~ |
|
|
7. Part B Emerging Communities Award |
|
| ~ Enter Preparer's Phone Number Here ~ |
|
|
8. Total Part B Funds |
$0 |
| ~ Enter Preparer's Email Address Here ~ |
|
9. Part B MAI Award |
|
|
|
10. Total Part B + MAI Funds |
$0 |
|
| Section C: Part B Allocations by Program Component |
1. Base + Supplemental Awards |
2. ADAP + Supplemental Award (ADAP) |
3. Emerging Communities Award (EC) |
4. Total |
| Amount |
Percentage |
Amount |
Percentage |
Amount |
Percentage |
Amount |
Percentage |
| 1. Part B AIDS Drug Assistance Program Subtotal |
$0 |
- - |
$0 |
- - |
$0 |
- - |
$0 |
- - |
| a. ADAP Services |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| b. Health Insurance to Provide Medications |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| c. ADAP Access/Adherence/Monitoring Services |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| 2. Part B Health Insurance Premium & Cost Sharing Assistance |
|
- - |
|
|
|
- - |
$0 |
- - |
| 3. Part B Home and Community-based Health Services |
|
- - |
|
|
|
- - |
$0 |
- - |
| 4a. Part B HIV Care Consortia/EC services (Provide detail in Section D, Column 1 or 3)1 |
$0 |
- - |
|
|
$0 |
- - |
$0 |
- - |
| 4b. Part B HIV Care Cosortia/EC Administration2 |
|
- - |
|
|
|
- - |
$0 |
- - |
| 5. Part B State Direct Services (Provide detail in Section D, Column 2)1 |
$0 |
- - |
|
|
|
- - |
$0 |
- - |
| 6. Part B Clinical Quality Management3 |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| 7. Part B Grantee Planning & Evaluation Activities4 |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| 8. Grantee Administration 4 |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| 9. Column Totals |
$0 |
- - |
$0 |
- - |
$0 |
- - |
$0 |
- - |
| 10.Total Part B Allocations5 |
$0 |
|
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| Section D: Breakdown for Consortia, State Direct Services and Emerging Communities |
1. Consortia6 |
2. Direct Services |
3. Emerging Communities |
4. Total |
| Amount |
Percentage |
Amount |
Percentage |
Amount |
Percentage |
Amount |
Percentage |
| 1. Core Medical Services Sub-total |
$0 |
- - |
$0 |
- - |
$0 |
- - |
$0 |
- - |
| a. Outpatient /Ambulatory Health Services |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| b. AIDS Drug Assistance Program (ADAP) Treatments |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| c. AIDS Pharmaceutical Assistance (local) |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| d. Oral Health Care |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| e. Early Intervention Services |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| f. Health Insurance Premium & Cost Sharing Assistance |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| g. Home Health Care |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| h. Home and Community-based Health Services |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| i. Hospice Services |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| j. Mental Health Services |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| k. Medical Nutrition Therapy |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| l. Medical Case Management (including Treatment Adherence) |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| m. Substance Abuse Services–outpatient |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| 2. Support Services Sub-total |
$0 |
- - |
$0 |
- - |
$0 |
- - |
$0 |
- - |
| a. Case Management (non-Medical) |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| b. Child Care Services |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| c. Emergency Financial Assistance |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| d. Food Bank/Home-Delivered Meals |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| e. Health Education/Risk Reduction |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| f. Housing Services |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| g. Legal Services |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| h. Linguistics Services |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| i. Medical Transportation Services |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| j. Outreach Services |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| k. Psychosocial Support Services |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| l. Referral for Health Care/Supportive Services |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| m. Rehabilitation Services |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| n. Respite Care |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| o. Substance Abuse Residential Services |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| p. Treatment Adherence Counseling |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| 3. Total |
$0 |
- - |
$0 |
- - |
$0 |
- - |
$0 |
- - |
|
|
MAI Award |
|
| Section E: MAI Allocations by Program Component |
Amount |
Percentage |
|
| 1. Education to increase minority participation in ADAP |
|
- - |
|
FOR OFFICE USE ONLY: |
| 2. Outreach to increase minority participation in ADAP |
|
- - |
|
o Grantee received waiver for 75% core medical services requirement. |
| 3. Clinical Quality Management 3 |
|
- - |
|
| 4. Grantee Planning & Evaluation Activities 4 |
|
- - |
|
| 5. Grantee Administration 4 |
|
- - |
|
| 6. Total MAI Allocations 7 |
$0 |
0.00% |
|
| (1) The total services amounts will automatically be calculated based on the details you provide in Section D, column 1 or 2 or 3. |
| (2) Consortia/Emerging Communities Administration, Planning and Evaluation costs may not exceed 10% of their respective total funds. |
| (3) May not exceed 5% of the Part B award, or 3 million, whichever amount is smaller. |
| (4) May not exceed 10% of the Part B award for either Planning & Evaluation or Grantee Admin. Additionally, the combined costs for these two categories may not exceed 15% of the Part B award. |
| (5) This amount must equal the combined total of the Part B Base, Part B Supplemental, ADAP, ADAP Supplemental, and Emerging Communities awards. |
| (6) All services in this column are considered Supprt Services. |
| (7) This amount must equal the total of the Part B MAI Award. |
| Part B & MAI Allocations Report |
| Automatic Calculation of Part B Core Medical & Support Services Allocations |
|
| ~ Enter Name of Grantee Here ~ |
|
| NOTE: This table is for reference only and is provided for grantees to automatically calculate their total Core Medical Service allocations/percentages across all Part B service dollars. The figures below reflect the amounts entered in the Allocations Report (green tab). |
|
| Core Medical Services Allocations |
Amount |
Percentage
(Amount / Total Service Allocations) |
| ADAP (H18) |
$0 |
- - |
| Home-and Community-based Health Services (H23) |
$0 |
- - |
| Health Insurance Premium & Cost Sharing Assistance (H22) |
$0 |
- - |
| State-Direct Services: Core Medical Services (D35) |
$0 |
- - |
| Emerging Communities: Core Medical Services (F35) |
$0 |
- - |
| Total Core Medical Services Allocations |
$0 |
- - |
|
|
|
| Support Services Allocations |
Amount |
Percent |
| Consortia Services (B24) + Consortia/EC Administration (H25) |
$0 |
- - |
| State-Direct Services: Support Services (D49) |
$0 |
- - |
| Emerging Communities: Support Services (F49) |
$0 |
- - |
| MAI Allocations for Education + Outreach Services (B70 + B71) |
$0 |
- - |
| Total Support Services Allocations |
$0 |
- - |
|
| Total Part B + MAI Services Allocations |
$0 |
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Kelley Weld:
Are they required to spend their total MAI Award?
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