FY 2008 Part B & MAI Expenditures Report OMB No. 0915-xxxx Expiration Date: | |||||||||||||
Detailed instructions for completing and submitting this report can be found in the Electronic Handbooks and download from the web: https://grants.hrsa.gov/webexternal/Login.asp |
Section B: FY 2008 Award Information | Award Amount | Prior Year Carryover | Total Avail. Funds | |||||||||
1. Part B Base Award | |||||||||||||
2. Part B ADAP Earmark Award | |||||||||||||
3. Part B Supplemental Award | |||||||||||||
Section A: Identifying Information | 4. Total Part B ADAP + Supplemental Award | $0 | $0 | $0 | |||||||||
~ Enter Name of Grantee Here ~ | 5. Part B Emerging Communities Award | ||||||||||||
~ Enter Preparer's Name Here ~ | 6. Total Part B Award | $0 | $0 | $0 | |||||||||
~ Enter Preparer's Phone Number Here ~ | 7. Part B MAI Award | ||||||||||||
~ Enter Preparer's Email Address Here ~ | 8. Total Part B + MAI Award | $0 | $0 | $0 | |||||||||
Section C: Part B Expenditures by Program Component | 1. Base Award | 2. ADAP Earmark + Supplemental | 3. Emerging Communities Award | 4. Total Prior Year Carryover | 5. Total | ||||||||
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 | - - | |||
a. ADAP Services | - - | - - | - - | - - | $0 | - - | |||||||
b. Health Insurance to Provide Medications | - - | - - | - - | - - | $0 | - - | |||||||
c. ADAP Access/Adherence/Monitoring Services | - - | - - | - - | - - | $0 | - - | |||||||
2. Part B Health Insurance Premium & Cost Sharing Assistance | - - | - - | - - | $0 | - - | ||||||||
3. Part B Home and Community-based Health Services | - - | - - | - - | $0 | - - | ||||||||
4. Part B HIV Care Consortia Services (Provide detail in Sec. D, Column 1 & 4) 1 | $0 | $0 | - - | - - | - - | $0 | - - | ||||||
5. Part B State Direct Services (Provide detail in Sec. D, Column 2 & 4)1 | $0 | $0 | - - | - - | - - | $0 | - - | ||||||
6. Part B Clinical Quality Management2 | - - | - - | - - | - - | $0 | - - | |||||||
7. Part B Grantee Planning & Evaluation Activities3 | - - | - - | - - | - - | $0 | - - | |||||||
8. Grantee Administration 3 | - - | - - | - - | - - | $0 | - - | |||||||
9. Column Totals | $0 | - - | $0 | - - | $0 | - - | $0 | - - | $0 | - - | |||
10.Total Part B Expenditures | $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 | ||||||||
Award | Percent | Award | Percent | Award | Percent | Amount | Percent | Amount | Percent | ||||
1. Core Medical Services Sub-total7 | $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 | |||||||||||||
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 | - - | - - | - - | ||||||||||
2. Outreach to increase minority participation in ADAP | - - | - - | - - | ||||||||||
3. Clinical Quality Management 2 | - - | - - | - - | ||||||||||
4. Grantee Planning & Evaluation Activities 3 | - - | - - | - - | ||||||||||
5. Grantee Administration 3 | - - | - - | - - | ||||||||||
6. Total MAI Expenditures | $0 | 0% | $0 | 0% | $0 | 0% | |||||||
* 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) May not exceed 5% of the Part B award, or 3 million, whichever amount is smaller. | |||||||||||||
(3) 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. | |||||||||||||
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 | HRSA |
File Modified | 2007-12-31 |
File Created | 2007-05-07 |