Form 1 Title 1

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Overview

Service Categories
Summary
Medical-Black
Medical-Hispanic
Grantee-Auto
Math Check-Auto
All Services-Auto
Award-Auto

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Sheet 1: Service Categories

The categories listed here are consistent with CARE Act Data Report service categories that are allowed under Title I. Grantees may use ONLY these approved categories. TITLE I APPROVED ALLOCATION CATEGORIES
PRIMARY HEALTH CARE SERVICES
Ambulatory/Outpatient Medical Care (Primary & Specialty Care)
Early Intervention Services (Added in 2002)
Health Insurance Continuation
Home Health Care (Select from the 3 options below)
Home Health Care – Professional Care
Home Health Care – Paraprofessional Care
Home Health Care- Specialized Care
Hospice Services (In-home & Residential)
Inpatient Personnel Costs
Local Title I Pharmacy Assistance/Medications Program
Mental Health Services
Nutrition Counseling (Formerly nutritional services)
Oral Health Care (Formerly Dental Care)
Rehabilitation Services (Formerly Rehabilitation Care)
State Title II AIDS Drug Assistance Program Contribution
Substance Abuse Treatment (Select from the 2 options below)
Substance Abuse – Residential Services
Substance Abuse - Outpatient Services
Treatment Adherence Services
CASE MANAGEMENT
SUPPORT SERVICES
Buddy/Companion Services
Child Care Services
Child Welfare Services
Client Advocacy
Day or Respite Care for Adults
Developmental Assessment Services
Emergency Financial Assistance
Food Bank/Home Delivered Meals
Health Education/Risk Reduction
Housing Related Services
Housing Services
Legal Services
Outreach Services
Psychosocial Support Services
Referral to Health Care/Supportive Services
Service Related Capacity Development
Transportation
Other Support Service: (Define on the web-form)
PROGRAM SUPPORT ACTIVITIES
Capacity-Development (Not related to a specific service)
Program/Services Evaluation
Program/Services Planning
Other Program Support: (Define activity on MAI Report Format)

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Sheet 2: Summary

GRANTEE IDENTIFYING INFORMATION
Grantee Name:	Denver, CO (*)		Prepared by:		John Doe (*)	E-Mail Address:	[email protected] (*)
Report Date:	8/29/2006 (*)		Title:		Ryan White Program Director (*)	Telephone:	123-555-6780 (*)
Section I: Title I MAI FUNDING						Summary-Page 1
Fiscal year:	2007 (*)	Available Funds
1. FY Title I MAI Award (*):		$200,000.00
2.MAI $$ Approved for Carryover from Prior Fiscal Year (*):		$10,000.00
3.Total Title I MAI Funds Available for use this FY (*):		$210,000.00
4. FY MAI funds to be used for grantee administration (*)		$10,000.00	5.00%	Note: Calculated automatically (amount of FY award used for grantee administration divided by the FY MAI Award Amount excluding carryover), with internal check to insure the percentage does not exceed the legislatively mandated cap.
Section II: PLANNED MAI-FUNDED SERVICES & ACTIVITIES
5. Activity/Service Category		6a.Funds Budgeted for the service	6b. Percent Budgeted	a	7. Communities of Color To Be Served	8.Amount Budgeted for Each Group
5A. Medical		$200,000.00	95.24%		Asian
					American Indian or Alaskan Native
				x	Black or African American	$120,000.00
				x	Hispanic or Latino(a)	$80,000.00
					NativeHawaiian/Other Pacific Islander
					More than one race
					Unreported
Note: The Web- form will allow grantee users to enter as many services that will be (or were) funded for the fiscal year being reported. It will also generate percents and validate that amounts budgeted across all services add up to the total amount of MAI funds available that year. 5b.					Asian
					American Indian or Alaskan Native
					Black or African American
					Hispanic or Latino(a)
					NativeHawaiian/Other Pacific Islander
					More than one race
					Unreported
9-Total Budget for Services/Activities		$200,000.00	95.24%
10a.Total Budget (Services + Grantee Admin)		$210,000.00	100.00%		10b. Total Budget for All Services to All Client Groups (Less Grantee Admin)	$200,000.00
(*) denotes information pulled from the web form

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Sheet 3: Medical-Black

Title I FY 2006: MAI Report #1
	Grantee Name:	Denver, CO (*)
Identifying Information	Report Date:	8/29/2006 (*)
	Report prepared by:	John Doe (*)
	Phone:	123-555-6780 (*)
	E-mail address:	[email protected] (*)
Service Information
1.Service or Activity:	Medical (*)
2.ETHNIC or RACIAL COMMUNITY TO RECEIVE THIS SERVICE (Select only ONE minority community. If more than one minority community will receive this service, prepare a separate report for each of those communities.)			Black (*)
3. New, Continuing, or Expanded Effort			Continued (*)
Budget and Expenditure Information
			Budgeted:	4D. Spent
4A. FY MAI funds budgeted for this service to this client group:			$113,000	Below, enter amount spent this FY:
4B. MAI carryover budgeted for this service to this client group:			$7,000
4C. Total MAI funds budgeted or spent for this service to this client group:			$120,000	$119,200
Service Units
5. Service Unit Name and Definition	One visit - Professional, diagnostic and therapeutic services rendered by MD, PA, or NP in office based setting
6. Record of service units provided			Planned	Actual
			600	596
Record of Clients Served
			Planned	Actual
7A. Total Unduplicated Number of Clients			150	155
7B. Total Unduplicated Number of Women			50	48
7C. Total Unduplicated Number of Infants			0	0
7D. Total Unduplicated Number of Children			2	2
7E. Total Unduplicated Number of Youth			15	12
Planned Outcomes
8A. PLANNED CLIENT LEVEL OUTCOMES: Define from one to three planned outcomes measures to be tracked for this service. (Reminder: outcome measures should be consistent with HRSA guidance on selecting outcomes and indicators summarized and cited in the MAI Reporting Instructions)						Target Percent
Planned Outcome #1 and Indicator(s): At a minimum, 70 percent of clients served will achieve improved or stable CD4 counts by the end of the reporting period.						70
Planned Outcome #2 and Indicator(s):
Planned Outcome #3 and Indicator(s):
8B. REVISED PLANNED CLIENT LEVEL OUTCOMES: If any planned outcome measures were redefined during the year, enter the revised outcome measure definitions. (Reminder: outcome measures should be consistent with HRSA guidance on selecting outcomes and indicators summarized and cited in the MAI Reporting Instructions)						Target Percent
Planned Outcome #1 and Indicator(s):
Planned Outcome #2 and Indicator(s):
Planned Outcome #3 and Indicator(s):
Year-End Outcome Results
9A. Narrative Description of Outcomes Achieved			Documented Evidence for Target Population
			9B. No. of Clients Served in Target Population	9C. No. of Clients Achieving Outcome	9D. Percent	9E. Was Outcome Met, Exceeded, Not Met?
Narrative Description for, Outcome #1: Of 155 clients served with more than one CD4 count during the reporting period, 85 (55%) had improved CD4 counts, 33 (21%) maintained stable CD4 counts, and 37 (24%) had a decline in their CD4 count. This was an improvement over last year when 35% of clients had improved CD4 counts and another 40% had stable CD4 counts.			155	118	76%	Exceeded
Narrative Description for Outcome #2:
Narrative Description for Outcome #3:

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Sheet 4: Medical-Hispanic

Title I FY 2006: MAI Report #2
	Grantee Name:	Denver, CO (*)
Identifying Information	Report Date:	8/29/2006 (*)
	Report prepared by:	John Doe (*)
	Phone:	123-555-6780 (*)
	E-mail address:	[email protected] (*)
Service Information
1.Service or Activity:	Medical (*)
2.ETHNIC or RACIAL COMMUNITY TO RECEIVE THIS SERVICE (Select only ONE minority community. If more than one minority community will receive this service, prepare a separate report for each of those communities.)			Hispanic (*)
3. New, Continuing, or Expanded Effort			Continued (*)
Budget and Expenditure Information
			Budgeted:	4D. Spent
4A. FY MAI funds budgeted for this service to this client group:			$77,000	Below, enter amount spent this FY:
4B. MAI carryover budgeted for this service to this client group:			$3,000
4C. Total MAI funds budgeted or spent for this service to this client group:			$80,000	$80,000
Service Units
5. Service Unit Name and Definition	One visit - Professional, diagnostic and therapeutic services rendered by MD, PA, or NP in office based setting
6. Record of service units provided			Planned	Actual
			400	402
Record of Clients Served
			Planned	Actual
7A. Total Unduplicated Number of Clients			100	105
7B. Total Unduplicated Number of Women			20	21
7C. Total Unduplicated Number of Infants			0	0
7D. Total Unduplicated Number of Children			4	3
7E. Total Unduplicated Number of Youth			10	11
Planned Outcomes
8A. PLANNED CLIENT LEVEL OUTCOMES: Define from one to three planned outcomes measures to be tracked for this service. (Reminder: outcome measures should be consistent with HRSA guidance on selecting outcomes and indicators summarized and cited in the MAI Reporting Instructions)						Target Percent
Planned Outcome #1 and Indicator(s): At a minimum, 70 percent of clients served will achieve improved or stable CD4 counts by the end of the reporting period.						70
Planned Outcome #2 and Indicator(s):
Planned Outcome #3 and Indicator(s):
8B. REVISED PLANNED CLIENT LEVEL OUTCOMES: If any planned outcome measures were redefined during the year, enter the revised outcome measure definitions. (Reminder: outcome measures should be consistent with HRSA guidance on selecting outcomes and indicators summarized and cited in the MAI Reporting Instructions)						Target Percent
Planned Outcome #1 and Indicator(s):
Planned Outcome #2 and Indicator(s):
Planned Outcome #3 and Indicator(s):
Year-End Outcome Results
9A. Narrative Description of Outcomes Achieved			Documented Evidence for Target Population
			9B. No. of Clients Served in Target Population	9C. No. of Clients Achieving Outcome	9D. Percent	9E. Was Outcome Met, Exceeded, Not Met?
Narrative Description for, Outcome #1: Of 105 clients served with more than one CD4 count during the reporting period, 68 (65%) had improved CD4 counts, 13 (12%) maintained stable CD4 counts, and 24 (23%) had a decline in their CD4 count. This was an improvement over last year when 20% of clients had improved CD4 counts and another 40% had stable CD4 counts.			105	81	77%	Exceeded
Narrative Description for Outcome #2:
Narrative Description for Outcome #3:

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Sheet 5: Grantee-Auto

Grantee Name:	Denver, CO (*)
Fiscal Year:	2007 (*)
Report Date:	8/29/2006 (*)
Prepared by:	John Doe (*)
Title:	Ryan White Program Director (*)
E-mail Address:	[email protected] (*)
Telephone:	123-555-6780 (*)
FY Title I MAI Award:	200,000.00
MAI $$ Approved for Carryover from prior Fiscal Year:	10,000.00
FY MAI funds to be used for grantee administration:	10,000.00
(*) denotes information pulled from the web form

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Sheet 6: Math Check-Auto

1.Name of EMA:	Denver, CO (*)
2. Report Date:	8/29/2006 (*)		Fiscal Year:	2007 (*)
3. Report prepared by:	John Doe (*)
4 E-mail address:	[email protected] (*)		Telephone:	123-555-6780 (*)
5. Total Funds Available:	$210,000.00
6. Grantee Administration:	$10,000.00
7. Funds for Services:	$200,000.00
Funds Budgeted on Each Report Format				Funds Spent	Percent of Funds	Number Clients Served
Report #	Report Name	Service/Allocation Category	Budgeted Amount
#1	Medical-Black	Medical (*)	$120,000.00	$119,200.00	99.33%	155
#2	Medical-Hispanic	Medical (*)	$80,000.00	$80,000.00	100.00%	105
Total Budget & Expenditures for ALL Services			$200,000.00	$199,200.00	99.60%	260
(*) denotes information pulled from the web form

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Sheet 7: All Services-Auto

Report#

Report Name

Service or Activity

Effort (New, Continue, Expanded)

Race/Ethnicity

Planned Budget Info

Planned FY MAI funds budgeted for this service to this client group

Planned MAI carryover budgeted for this service to this client group

Planned Total MAI funds budgeted for this service to this client group

Amount Spent

Amount spent in FY

Service Unit Name and Definition

Planned record of service units provided

Actual record of service units provided

Planned Total Unduplicated Number of Clients

Planned Total Unduplicated Number of Women

Planned Total Unduplicated Number of Infants

Planned Total Unduplicated Number of Children

Planned Total Unduplicated Number of Youth

Final Total Unduplicated Number of Clients

Final Total Unduplicated Number of Women

Final Total Unduplicated Number of Infants

Final Total Unduplicated Number of Children

Final Total Unduplicated Number of Youth

Planned Outcome #1 and Indicator(s)

Target Percent #1

Planned Outcome #2 and Indicator(s)

Target Percent #2

Planned Outcome #3 and Indicator(s)

Target Percent #3

Revised Planned Outcome #1 and Indicator(s)

Revised Target Percent #1

Revised Planned Outcome #2 and Indicator(s)

Revised Target Percent #2

Revised Planned Outcome #3 and Indicator(s)

Revised Target Percent #3

Narrative Valueription for Outcome #1

No. of Clients Served in Target Population

No. of Clients Achieving Outcome

Percent

Was Outcome Met, Exceeded, Not Met?

Narrative Valueription for Outcome #2

No. of Clients Served in Target Population

No. of Clients Achieving Outcome

Percent

Was Outcome Met, Exceeded, Not Met?

Narrative Valueription for Outcome #3

No. of Clients Served in Target Population

No. of Clients Achieving Outcome

Percent

Was Outcome Met, Exceeded, Not Met?

#1

Medical-Black

Medical (*)

Continued (*)

Black (*)

113000

7000

120000

119200

One visit - Professional, diagnostic and therapeutic services rendered by MD, PA, or NP in office based setting

600

596

150

50

0

2

15

155

48

0

2

12

Planned Outcome #1 and Indicator(s): At a minimum, 70 percent of clients served will achieve improved or stable CD4 counts by the end of the reporting period.

70

Planned Outcome #2 and Indicator(s):

Planned Outcome #3 and Indicator(s):

Planned Outcome #1 and Indicator(s):

Planned Outcome #2 and Indicator(s):

Planned Outcome #3 and Indicator(s):

Narrative Description for, Outcome #1: Of 155 clients served with more than one CD4 count during the reporting period, 85 (55%) had improved CD4 counts, 33 (21%) maintained stable CD4 counts, and 37 (24%) had a decline in their CD4 count. This was an improvement over last year when 35% of clients had improved CD4 counts and another 40% had stable CD4 counts.

155

118

0.761290322580645

Exceeded

Narrative Description for Outcome #2:

Narrative Description for Outcome #3:

#2

Medical-Hispanic

Medical (*)

Continued (*)

Hispanic (*)

77000

3000

80000

80000

One visit - Professional, diagnostic and therapeutic services rendered by MD, PA, or NP in office based setting

400

402

100

20

0

4

10

105

21

0

3

11

Planned Outcome #1 and Indicator(s): At a minimum, 70 percent of clients served will achieve improved or stable CD4 counts by the end of the reporting period.

70

Planned Outcome #2 and Indicator(s):

Planned Outcome #3 and Indicator(s):

Planned Outcome #1 and Indicator(s):

Planned Outcome #2 and Indicator(s):

Planned Outcome #3 and Indicator(s):

Narrative Description for, Outcome #1: Of 105 clients served with more than one CD4 count during the reporting period, 68 (65%) had improved CD4 counts, 13 (12%) maintained stable CD4 counts, and 24 (23%) had a decline in their CD4 count. This was an improvement over last year when 20% of clients had improved CD4 counts and another 40% had stable CD4 counts.

105

81

0.771428571428571

Exceeded

Narrative Description for Outcome #2:

Narrative Description for Outcome #3:

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Sheet 8: Award-Auto

1. FY 2006 Title I MAI Award:	2.MAI $$ Approved for Carryover from Prior Fiscal Year:	3.Total Title I MAI Funds Available for use in FY:	FY 2006MAI Funds to be Used for Grantee Administration	Percent of FY 2006 MAI Funds to be Used for Grantee Administration
200000	10000	210000	10000	5.00%