| FY08 Part D Expenditures Report OMB No. 0915-xxxx Expiration Date: |
|
|
|
|
|
| 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 D Grant Award Amount |
|
|
|
|
|
|
|
|
|
|
|
|
CURRENT FY |
PRIOR FY CARRYOVER |
TOTAL |
| Section C: Expenditure Categories |
Amount |
Percent |
Amount |
Percent |
Amount |
Percent |
| 1. Medical Services Subtotal |
$0 |
0% |
$0 |
0% |
$0 |
0% |
| a. Outpatient /Ambulatory Health Services |
|
- - |
|
- - |
|
- - |
| b. AIDS Pharmaceutical Assistance (local) |
|
- - |
|
- - |
|
- - |
| c. Oral Health Care |
|
- - |
|
- - |
|
- - |
| d. Home Health Care |
|
- - |
|
- - |
|
- - |
| e. Home and Community-based Health Services |
|
- - |
|
- - |
|
- - |
| f. Hospice Services |
|
- - |
|
- - |
|
- - |
| g. Mental Health Services |
|
- - |
|
- - |
|
- - |
| h. Medical Nutrition Therapy |
|
- - |
|
- - |
|
- - |
| i. Medical Case Management (including Treatment Adherence) |
|
- - |
|
- - |
|
- - |
| j. Substance Abuse Services - outpatient |
|
- - |
|
- - |
|
- - |
| 2. Support Services Sub-total |
$0 |
0% |
$0 |
0% |
$0 |
0% |
| a. Case Management (non-Medical) |
|
- - |
|
- - |
|
- - |
| b. Child Care Services |
|
- - |
|
- - |
|
- - |
| c. Pediatric Developmental Assessment / Early Intervention Services |
|
- - |
|
- - |
|
- - |
| d. Emergency Financial Assistance |
|
- - |
|
- - |
|
- - |
| e. Food Bank/Home-Delivered Meals |
|
- - |
|
- - |
|
- - |
| f. Health Education/Risk Reduction |
|
- - |
|
- - |
|
- - |
| g. Legal Services |
|
- - |
|
- - |
|
- - |
| h. Linguistics Services |
|
- - |
|
- - |
|
- - |
| i. Medical Transportation Services |
|
- - |
|
- - |
|
- - |
| j. Outreach Services |
|
- - |
|
- - |
|
- - |
| k. Permanency Planning |
|
- - |
|
- - |
|
- - |
| l. Psychosocial Support Services |
|
- - |
|
- - |
|
- - |
| m. Referral for Health Care/Supportive Services |
|
- - |
|
- - |
|
- - |
| n. Rehabilitation Services |
|
- - |
|
- - |
|
- - |
| o. Respite Care |
|
- - |
|
- - |
|
- - |
| p. Treatment Adherence Counseling |
|
- - |
|
- - |
|
- - |
| 3. Total Service Expenditures |
$0 |
- - |
$0 |
- - |
$0 |
- - |
| 4. Non-services Subtotal |
$0 |
- - |
$0 |
- - |
$0 |
- - |
| a. Clinical Quality Management Activities |
|
- - |
|
- - |
|
- - |
| b. Grantee Administration1 |
|
- - |
|
- - |
|
- - |
| c. Indirect Costs |
|
- - |
|
- - |
|
- - |
| 5. Total Expenditures |
$0 |
- - |
$0 |
- - |
$0 |
- - |
|
|
|
|
|
|
|
| (1) May not exceed 10% of Part D award. |
|
|
|
|
|
|