| FY14 Part A & MAI Expenditures Report | ||||||||||||||
| Section A: Identifying Information | Detailed instructions for completing and submitting your report can be downloaded from the HRSA Electronic Handbook: https://grants.hrsa.gov/webexternal/Login.asp | |||||||||||||
| ~ 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 | 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 number. The OMB control number for this project is 0915-0318. Public reporting burden for this collection of information is estimated to be 1.5 hours per response. These estimates include the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments to HRSA Reports Clearance Officer, Health Resources and Services Administration, Room 10-33, 5600 Fishers Lane, Rockville, MD. 20857. | ||||||||||
| 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 (includes carryover) |
||||||||||||
| 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 Subtotal (See Legislative Requirements) | $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 Management (See Legislative Requirements) | - - | - - | $0 | - - | - - | $0 | - - | $0 | - - | $0 | - - | |||
| b. Grantee Administration (See Legislative Requirements) | - - | - - | $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 | |||||||||||
| LEGISLATIVE REQUIREMENTS CHECKLIST | |||||
| INSTRUCTIONS: Grantees and Project Officers should use the following table to determine whether or not the following legislative requirements have been met. Unlike the Expenditure Report which shows individual expenditures as a percentage of total expenditures, this table shows expenditures as a percentage of award for specific cateogories as outlined in the Ryan White HIV/AIDS Treatment Extension Act of 2009. | |||||
| REQUIREMENT: 75% of your total award must be spent on core medical services. | |||||
| When reporting Core Medical Services expenses, the Current FY totals in Section C, Row 1 of the Expenditure Report for PART A AWARD and MAI AWARD columns do not necessarily need to be 75% of each individual award as long as the combined total meets the 75% minimum requirement. The exception to this requirment is only for those grantees that requested, and were approved by HRSA, for a Part A Core Medical Services Waiver. To the right in red, is the percentage of your Current Fiscal Year Core Medical Services expenditures divided by your Total Part A Award (B18 + H18) / B12. Please check to make sure this percentage is 75% or greater. |
0.0% | ||||
| REQUIREMENT: No more than 5% of your total award or $3 million (whichever is smaller) can be spent on clinical quality management. | |||||
| When reporting Clinical Quality Management expenses, the Current FY totals in Section C, Row 4a of the Expenditure Report for PART A AWARD and MAI AWARD columns do not necessarily need to be meet this requirement as long as the combined total meets the 5% or $3 million (whichever is smaller) requirement. To the right in red, is the maximum (Capped Amount) you can spend on Clinical Quality Management (the lessor of B12 * .05 or $3 million) as well as the amount of Current Fiscal Year dollars spent (CQM Exepnditures) on Clinical Quality Management (B51 + H51). Please check to make sure your Expenditures do not exceed your Capped Amount. |
$0 | (Capped Amount) | |||
| $0 | (CQM Expenditures) | ||||
| REQUIREMENT: No more than 10% of your total award can be spent on grantee administration. | |||||
| When reporting Grantee Administration expenses, the Current FY totals in Section C, Row 4b of the Expenditure Report for PART A AWARD and MAI AWARD columns do not necessarily need to be meet this requirement as long as the combined total meets the 10% or less requirement. To the right in red, is the percentage of your Current Fiscal Year Grantee Administration expenditures divided by your Total Part A Award (B52 + H52) / B12. Please check to make sure this percentage is not greater than 10%. |
0.0% | ||||
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |