| FY 2008 Part C Expenditures Report | ||||||
| Section A: Identifying Information | NOTE: Detailed instructions for completing and submitting your report can be downloaded from the HRSA Electronic Handbook: https://grants.hrsa.gov/webexternal/Login.asp | |||||
| ~ 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 | ||||||
| CURRENT FY | PRIOR FY CARRYOVER | TOTAL | ||||
| Section C: Expenditure Categories | Amount | Percent | Amount | Percent | Amount | Percent |
| 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. Health Insurance Premium & Cost Sharing Assistance | - - | - - | $0 | - - | ||
| f. Home Health Care | - - | - - | $0 | - - | ||
| g. Home and Community-based Health Services | - - | - - | $0 | - - | ||
| h. Hospice Services | - - | - - | $0 | - - | ||
| i. Mental Health Services | - - | - - | $0 | - - | ||
| j. Medical Nutrition Therapy | - - | - - | $0 | - - | ||
| k. Medical Case Management (including Treatment Adherence) | - - | - - | $0 | - - | ||
| l. Substance Abuse Services - outpatient | - - | - - | $0 | - - | ||
| 2. Support Services Subtotal | $0 | 0% | $0 | 0% | $0 | 0% |
| a. Case Management (non-Medical) | - - | - - | $0 | - - | ||
| b. Health Education/Risk Reduction | - - | - - | $0 | - - | ||
| c. Linguistics Services | - - | - - | $0 | - - | ||
| d. Medical Transportation Services | - - | - - | $0 | - - | ||
| e. Outreach Services | - - | - - | $0 | - - | ||
| f. Psychosocial Support Services | - - | - - | $0 | - - | ||
| g. Referral for Health Care/Supportive Services | - - | - - | $0 | - - | ||
| h. Rehabilitation Services | - - | - - | $0 | - - | ||
| i. Respite Care | - - | - - | $0 | - - | ||
| j. Treatment Adherence Counseling | - - | - - | $0 | - - | ||
| 3. Total Service Expenditures | $0 | - - | $0 | - - | $0 | - - |
| 4. Non-services Subtotal | $0 | - - | $0 | - - | $0 | - - |
| a. Clinical Quality Management Activities1 (see CHECKLIST) | - - | - - | $0 | - - | ||
| b. Grantee Administration2 (see CHECKLIST) | - - | - - | $0 | - - | ||
| 5. Total Expenditures (Service + Non-service) | $0 | - - | $0 | - - | $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. | ||||||
| FY 2008 Part C Expenditures 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, this percentage should not be less than 75%. |
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. This percentage should not be more than 10%. |
0.0% |
| 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 |