FY 2008 Part C Allocations Report | ||
Section A: Identifying Information | ||
~ Enter Name of Grantee Here ~ | ||
~ Enter Grant Number 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 C Grant Award Amount | ||
Section C: Allocations Categories | Amount | Percent |
1. Core Medical Services Subtotal1 (see CHECKLIST) | $0 | 0% |
a. Outpatient /Ambulatory Health Services | - - | |
b. AIDS Drug Assistance Program (ADAP) Treatments | - - | |
c. AIDS Pharmaceutical Assistance (local) | - - | |
d. Oral Health Care | - - | |
e. Health Insurance Premium & Cost Sharing Assistance | - - | |
f. Home Health Care | - - | |
g. Home and Community-based Health Services | - - | |
h. Hospice Services | - - | |
i. Mental Health Services | - - | |
j. Medical Nutrition Therapy | - - | |
k. Medical Case Management (including Treatment Adherence) | - - | |
l. Substance Abuse Services - outpatient | - - | |
2. Support Services Subtotal | $0 | 0% |
a. Case Management (non-Medical) | - - | |
b. Health Education/Risk Reduction | - - | |
c. Linguistics Services | - - | |
d. Medical Transportation Services | - - | |
e. Outreach Services | - - | |
f. Psychosocial Support Services | - - | |
g. Referral for Health Care/Supportive Services | - - | |
h. Rehabilitation Services | - - | |
i. Respite Care | - - | |
j. Treatment Adherence Counseling | - - | |
3. Total Service Allocations | $0 | - - |
4. Non-services Subtotal | $0 | - - |
a. Clinical Quality Management Activities1 (see CHECKLIST) | - - | |
b. Grantee Administration2 (see CHECKLIST) | - - | |
5. Total Allocations (Service + Non-service)4 (see CHECKLIST) | $0 | - - |
FOR OFFICE USE ONLY: | ||
o Grantee received waiver for 5% clinical quality management activities. | ||
o Grantee received waiver for 75% core medical services requirement. | ||
NOTE: Detailed instructions for completing and submitting your report can be downloaded from the HRSA Electronic Handbook: https://grants.hrsa.gov/webexternal/Login.asp |
FY 2008 Part C Allocations Report Checklist | ||
OMB No. 0915-xxxx Expiration Date: | ||
Please check the following before submitting your report! | ||
1 | 75% of your award must be spent on core medical services. After meeting the requirements below, if this percentage is less than 75%, you must adjust your report so that at least 75% of your grant award is allocated to core medical services. |
0.0% |
2 | You may not spend more than 5% on clinical quality management unless you have received a waiver from the Division of Community Based Programs. If this percentage is more than 5% you must have received a waiver from the Division of Community Based Programs. |
0.0% |
3 | You may not spend more than 10% on grantee administration. If this percentage is more than 10%, you must adjust your report accordingly. |
0.0% |
4 | You must allocate your entire award. This amount will equal zero if you allocated the entire amount listed in Section B. The amount in Section B must match the amount on your NGA. If this amount does not equal zero, you must adjust your report accordingly. |
$0 |
NOTE: Detailed instructions for completing and submitting your report can be downloaded from the HRSA Electronic Handbook: https://grants.hrsa.gov/webexternal/Login.asp |
File Type | application/vnd.ms-excel |
Author | HRSA |
Last Modified By | HRSA |
File Modified | 2007-12-31 |
File Created | 2007-05-08 |