FY 2008 Part A & MAI Allocations Report | ||||||
Section A: Identifying Information | Detailed instructions for completing and submitting this report can be found in the Electronic Handbooks and downloaded from the web at https://grants.hrsa.gov/webexternal/Login.asp |
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~ Enter Name of Grantee Here ~ | ||||||
~ Enter Preparer's Name Here ~ | ||||||
~ Enter Preparer's Phone Number Here ~ | ||||||
~ Enter Preparer's Email Address Here ~ | ||||||
Section B: FY 2008 Award Information | ||||||
1. Part A Grant Award Amount | ||||||
2. MAI Grant Request / Award Amount | ||||||
3. Total Part A Funds | $0 | |||||
Section C: Allocation Categories | 1. Part A Award | 2. MAI Award | 3. Combined Total | |||
Amount | Percentage | Amount | Percentage | Amount | Percentage | |
1. Core Medical Services Subtotal1 (see CHECKLIST) | $0 | 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 (incl. Treatment Adherence) | - - | - - | $0 | - - | ||
m. Substance Abuse Services - outpatient | - - | - - | $0 | - - | ||
2. Support Services Subtotal | $0 | 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 Services - residential | - - | - - | $0 | - - | ||
p. Treatment Adherence Counseling | - - | - - | $0 | - - | ||
3. Total Service Allocations | $0 | - - | $0 | - - | $0 | - - |
4. Non-services Subtotal | $0 | - - | $0 | - - | $0 | - - |
a. Clinical Quality Management2 (see CHECKLIST) | - - | - - | $0 | - - | ||
b. Grantee Administration 3 (see CHECKLIST) | - - | - - | $0 | - - | ||
5. Total Allocations (Service + Non-service)4 (see CHECKLIST) | $0 | - - | $0 | - - | $0 | - - |
FOR OFFICE USE ONLY: | ||||||
o Grantee received waiver for 75% core medical services requirement. | ||||||
FY 2008 Part A & MAI Allocations Report CHECKLIST | ||||
OMB No. 0915-xxxx Expiration Date: | ||||
~ Enter Name of Grantee Here ~ | ||||
Please check the following before submitting your report! | Part A Award | MAI Grant Request / Award |
Total | |
1 | 75% of your combined awards must be spent on core medical services. When reporting Core Medical Services allocations, the percentages for the Part A Award (Row 1, Column 1) and the MAI Award (Row 1, Column 2) do not necessarily need to be 75% as long as the COMBINED Total (Row 1, Column 3) meets the required minimum 75%. If the percentage to the right is less than 75%, you must adjust your allocations so that at least 75% of your combined award amounts (Part A Award + MAI Award) are allocated for Core Medical Services. The exception to this requirment is only for those grantees that requested, and were approved by HRSA, for an FY 2008 Part A Core Medical Services Waiver. |
0.0% | ||
2 | You may not spend more than 5% or 3 million dollars (whichever is smaller) on clinical quality management. If either of these percentages is more than 5% or the amounts is more than $3,000,000 you must go back and adjust your report accordingly. |
0.0% | 0.0% | |
$0 | $0 | |||
3 | You may not spend more than 10% on grantee administration. If either of these percentages is more than 10%, you must adjust your report accordingly. |
0.0% | 0.0% | |
4 | You must allocate your entire award. The total allocations in Section C (Row 5, Column 3) should equal the total amount of funds expected to be available as shown in Section B. |
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Detailed instructions for completing and submitting this report can be found in the Electronic Handbooks and downloaded from the web at https://grants.hrsa.gov/webexternal/Login.asp |
File Type | application/vnd.ms-excel |
Author | Melanie K. Wieland |
Last Modified By | HRSA |
File Modified | 2007-12-31 |
File Created | 2007-05-15 |