Form Data Sheet Data Sheet Data Sheet

OMB Number: 0915-XXXX Expiration Date: XX/XX/XXXX

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 control number.  The OMB control number for this project is 0915-xxxx.  Public reporting burden for this collection of information is estimated to average xx hours per respondent annually, including 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 regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland, 20857.

Factor Replacement Product (FRP) Data Sheet

For HRSA Funded Hemophilia Treatment Centers (HTCs) Having FPR Sales Programs

1	Name of HTC
2	Reporting period
3	Patient Data
4	Non-Medicaid Patients receiving 340B FRP from HTC
5	Medicaid patients receiving 340B FRP from HTC
6	Medicaid patients receiving non-340B FRP from HTC
7	Total number of patients receiving FRP from HTC
8	Financial Data
9	Balance at start of reporting period
10	(Add) Total FRP Program revenue
11	From 340B FRP sales
12	From non-340B sales to HTC patients
13	(Subtract) Total FRP Program operating costs
14	Cost of FRP at 340B price
15	Cost of FRP at non-340B price
16	Cost of pharmacy staff
17	Cost of contractual services
18	Other direct costs
19	FRP Program Net Income
20	Subtract Use of FRP Program Net Income
21	HTC staff costs
22	Indirect Costs
23	Other HTC Costs
24	Balance at End of Reporting Period