| FY14 Part B & MAI Expenditures Report | |||||||||||||
| Detailed instructions for completing and submitting your report can be downloaded from the HRSA Electronic Handbook: https://grants.hrsa.gov/webexternal/Login.asp |
Section B: Reporting Year Award Information | Award Amount | Prior Year Carryover | Total Avail. Funds | |||||||||
| 1. Part B Base Award | $0 | ||||||||||||
| 2. Part B ADAP Earmark Award | $0 | ||||||||||||
| 3. Part B ADAP Supplemental Award | $0 | ||||||||||||
| Section A: Identifying Information | 4. Total Part B Base + ADAP + ADAP Supplemental Funds | $0 | $0 | $0 | |||||||||
| ~ Enter Name of Grantee Here ~ | 5. Part B Emerging Communities Award | $0 | |||||||||||
| ~ Enter Preparer's Name Here ~ | 6. Part B Supplemental Award | $0 | |||||||||||
| ~ Enter Preparer's Phone Number Here ~ | 7. Total Part B Funds | $0 | $0 | $0 | |||||||||
| ~ Enter Preparer's Email Address Here ~ | 8. Part B MAI Award | $0 | |||||||||||
| 9. Total Part B + MAI Funds | $0 | $0 | $0 | ||||||||||
| Section C: Part B Expenditures by Program Component | 1. Base Award | 2. ADAP Earmark + ADAP Supplemental | 3. Emerging Communities Award | 4. Total Prior Year Carryover | 5. Total (including carryover) | ||||||||
| Award | Carryover | Percent* | Award | Carryover | Percent* | Award | Carryover | Percent* | Amount | Percent | Amount | Percent | |
| 1. Part B AIDS Drug Assistance Program Subtotal | $0 | $0 | - - | $0 | $0 | - - | $0 | - - | $0 | - - | $0 | - - | |
| a. ADAP Services | - - | - - | - - | $0 | - - | $0 | - - | ||||||
| b. Health Insurance to Provide Medications | - - | - - | - - | $0 | - - | $0 | - - | ||||||
| c. ADAP Access/Adherence/Monitoring Services | - - | - - | - - | $0 | - - | $0 | - - | ||||||
| 2. Part B Health Insurance Premium & Cost Sharing Assistance | - - | - - | $0 | - - | $0 | - - | |||||||
| 3. Part B Home and Community-based Health Services | - - | - - | $0 | - - | $0 | - - | |||||||
| 4. Part B HIV Care Consortia (Provide service detail in Sec. D, Column 1 & 4) 1 | $0 | $0 | - - | - - | $0 | - - | $0 | - - | |||||
| 4a. Part B HIV Care Consortia Administration, Planning & Evaluation2 | - - | - - | $0 | - - | $0 | - - | |||||||
| 5. Part B State Direct Services (Provide detail in Sec. D, Column 2 & 4)1 | $0 | $0 | - - | - - | $0 | - - | $0 | - - | |||||
| 6. Part B Clinical Quality Management3 | - - | - - | - - | $0 | - - | $0 | - - | ||||||
| 7. Part B Grantee Planning & Evaluation Activities4 | - - | - - | - - | $0 | - - | $0 | - - | ||||||
| 8. Grantee Administration 4 | - - | - - | - - | $0 | - - | $0 | - - | ||||||
| 9. Column Totals | $0 | $0 | - - | $0 | $0 | - - | $0 | $0 | - - | $0 | - - | $0 | - - |
| 10.Total Part B Expenditures (excluding carryover) | $0 | ||||||||||||
| Section D: Breakdown for Consortia, State Direct Services and Emerging Communities | 1. Consortia5 | 2. Direct Services | 3. Emerging Communities 6 | 4. Prior Year Carryover | 5. Total (including carryover) | ||||||||
| Award | Percent | Award | Percent | Award | Percent | Amount | Percent | Amount | Percent | ||||
| 1. Core Medical Services Sub-total | $0 | - - | $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 | - - | $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 | - - | $0 | - - | |||
| MAI AWARD | * Percentage is calculated on the combined total of the current Fiscal Year award plus prior year carryover amount. (1) In the Base Award column ONLY, this cell will automatically calculate based on the detail you provide in Section D. (2) Administration expenditures for first-line entities is capped at 10% of the aggregate amount allocated for services. Therefore, Consortia Administration, Planning and Evaluation may not exceed 10% of Consortia 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) All services in this column are considered Supprt Services. (6) In the Emerging Communities Column ONLY, the Total Allocations should equal the combined total of Rows 4 + 5 in Section C, Column 3. |
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| REPORTING YEAR AWARD | PRIOR FY CARRYOVER | TOTAL | |||||||||||
| Section E: MAI Expenditures by Program Component | Amount | Percent | Amount | Percent | Amount | Percent | |||||||
| 1. Education to increase minority participation in ADAP | - - | - - | $0 | - - | |||||||||
| 2. Outreach to increase minority participation in ADAP | - - | - - | $0 | - - | |||||||||
| 3. Clinical Quality Management 3 | - - | - - | $0 | - - | |||||||||
| 4. Grantee Planning & Evaluation Activities 4 | - - | - - | $0 | - - | |||||||||
| 5. Grantee Administration 4 | - - | - - | $0 | - - | |||||||||
| 6. Total MAI Expenditures | $0 | 0.00% | $0 | 0.00% | $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 |