| FY14 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 Award | 2. ADAP + ADAP Supplemental Award | 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 | |||||||
| 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 | (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. |
|||||||
| Section E: MAI Allocations by Program Component | Amount | Percentage | ||||||
| 1. Education to increase minority participation in ADAP | - - | |||||||
| 2. Outreach to increase minority participation in ADAP | - - | |||||||
| 3. Clinical Quality Management 3 | - - | |||||||
| 4. Grantee Planning & Evaluation Activities 4 | - - | |||||||
| 5. Grantee Administration 4 | - - | |||||||
| 6. Total MAI Allocations 7 | $0 | 0.00% | ||||||
| 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 12 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. | ||||||||
| FOR OFFICE USE ONLY: | ||||||||
| o Grantee received waiver for 75% core medical services requirement. | ||||||||
| File Type | application/vnd.ms-excel |
| Author | HRSA |
| Last Modified By | ifua |
| File Modified | 2014-01-22 |
| File Created | 2007-05-07 |