| FY 2008 Part A & MAI Expenditures 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 | Current FY | Carryover | Total | |||||||||||
| 1. Part A Grant Award Amount | $0 | |||||||||||||
| 2. MAI Grant Award Amount | $0 | |||||||||||||
| 3. Total Part A Funds | $0 | $0 | $0 | |||||||||||
| PART A AWARD | MAI AWARD | 3. COMBINED TOTAL |
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| Section C: Expenditure Categories | CURRENT FY | PRIOR FY CARRYOVER | TOTAL | CURRENT FY | PRIOR FY CARRYOVER | TOTAL | ||||||||
| Amount | Percentage | Amount | Percentage | Amount | Percentage | Amount | Percentage | Amount | Percentage | Amount | Percentage | Amount | Percentage | |
| 1. Core Medical Services Subtotal1 (see CHECKLIST) | $0 | 0% | $0 | 0% | $0 | 0% | $0 | 0% | $0 | 0% | $0 | 0% | $0 | 0% |
| a. Outpatient /Ambulatory Health Services | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| b. AIDS Drug Assistance Program (ADAP) Treatments | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| c. AIDS Pharmaceutical Assistance (local) | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| d. Oral Health Care | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| e. Early Intervention Services | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| f. Health Insurance Premium & Cost Sharing Assistance | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| g. Home Health Care | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| h. Home and Community-based Health Services | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| i. Hospice Services | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| j. Mental Health Services | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| k. Medical Nutrition Therapy | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| l. Medical Case Management (incl. Treatment Adherence) | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| m. Substance Abuse Services - outpatient | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| 2. Support Services Subtotal | $0 | 0% | $0 | 0% | $0 | 0% | $0 | 0% | $0 | 0% | $0 | 0% | $0 | 0% |
| a. Case Management (non-Medical) | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| b. Child Care Services | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| c. Emergency Financial Assistance | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| d. Food Bank/Home-Delivered Meals | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| e. Health Education/Risk Reduction | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| f. Housing Services | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| g. Legal Services | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| h. Linguistics Services | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| i. Medical Transportation Services | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| j. Outreach Services | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| k. Psychosocial Support Services | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| l. Referral for Health Care/Supportive Services | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| m. Rehabilitation Services | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| n. Respite Care | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| o. Substance Abuse Services - residential | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| p. Treatment Adherence Counseling | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| 3. Total Service Expenditures | $0 | - - | $0 | - - | $0 | - - | $0 | - - | $0 | - - | $0 | - - | $0 | - - |
| 4. Non-services Subtotal | $0 | - - | $0 | - - | $0 | - - | $0 | - - | $0 | - - | $0 | - - | $0 | - - |
| a. Clinical Quality Management2 (see CHECKLIST) | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| b. Grantee Administration 3 (see CHECKLIST) | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| 5. Total Expenditures | $0 | - - | $0 | - - | $0 | - - | $0 | - - | $0 | - - | $0 | - - | $0 | - - |
| FOR OFFICE USE ONLY: | ||||||||||||||
| o Grantee received waiver for 75% core medical services requirement. | ||||||||||||||
| FY 2008 Part A & MAI Expenditures 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 Award | Combined Total | |
| 1 | 75% of your combined awards must be spent on core medical services. When reporting Core Medical Services, the percentages in Section C, Row 1 under PART A AWARD and MAI AWARD columns do not necessarily need to be 75% as long as the COMBINED TOTAL column percentage meets the required minimum 75%. 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. Use the percentages and figures to the right to help determine if this requirement is met. |
0.0% | 0.0% | |
| $0 | $0 | |||
| 3 | You may not spend more than 10% on grantee administration. These percentages should not be more than 10%. |
0.0% | 0.0% | |
| 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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| File Type | application/vnd.ms-excel |
| Author | Melanie K. Wieland |
| Last Modified By | HRSA |
| File Modified | 2007-12-31 |
| File Created | 2007-05-15 |