Form 1-HAB-CL

Health Resources and Services Administration (HRSA)
Ryan White HIV/AIDS Program Client-Level Data Report

GRANTEE FORM

Grantees complete a separate grantee form for each Ryan White HIV/AIDS
Program grant they receive from HRSA — e.g., an agency with only a Part
C grant completes one grantee form; an agency with a Part C and Part D
grant completes two grantee forms, one for its Part C grant and another for
its Part D grant.

Last saved by: Michael J. Dols
Last saved at: 5/14/2008 12:14 PM

Items 1 – 3 (display only): These items show the grantee and user
information stored in the HRSA Electronic Handbooks (EHBs). To edit this
information, grantees must update their agency information and/or user
profile in the EHBs.
Item 4: Select the status of your agency’s clinical quality management
program during this reporting period.

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Health Resources and Services Administration (HRSA)
Ryan White HIV/AIDS Program Client-Level Data Report

GRANTEE FORM

Review the list of service provider contracts that were active during the
given reporting period. (Note: For the initial report, this list will be prepopulated with the provider lists in the current Ryan White Data Report
System.) Add new provider contracts with the ADD PROVIDER
CONTRACT link. Remove any provider contracts by clicking the Remove
icon next to the provider’s name. Edit the provider address (and other
provider information) by clicking the Edit icon. Part C and D grantees
must include its own organization on its provider contracts list.
Update contract information (Note: For the purpose of the Ryan White Data
Report, “contracts” include formal contracts, memorandum of
understanding, or other agreements) by reviewing and editing:
Last saved by: Michael J. Dols
Last saved at: 5/14/2008 12:14 PM

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Contract Reference (optional): Specify a reference for use by your
providers in reporting Ryan White HIV/AIDS Program data associated
with this contract.
Contract Start and End Date: Enter the start date and end date of the
contract for each provider.
Services: This link opens another screen (see pages 4 – 7). Select the
services the agency has been contracted to provide under this
agreement (check all that apply).
Amount: Enter the total amount of funding for the selected contract.

After completing all information for each funded contract, check
“Completed.”
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Health Resources and Services Administration (HRSA)
Ryan White HIV/AIDS Program Client-Level Data Report

GRANTEE FORM

Grantees that contract with an agency to provide fiscal intermediary
services (i.e., grantees that utilize a pass-through agency) must also enter
the list of contracts funded by their grant through the selected fiscal
intermediary (FI) service provider(s).
Select a contract for FI services from the list box. A list of contracts funded
by your grant through the selected FI service provider will be displayed.

Review the service provider contracts under the selected FI provider to
ensure that:
1. All contracts that were active during the given reporting period are
listed; and,
2. The services each agency was contracted to provide under each
agreement have been selected.
After completing all information for each contract, check “Completed.”

Last saved by: Michael J. Dols
Last saved at: 5/14/2008 12:14 PM

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Health Resources and Services Administration (HRSA)
Ryan White HIV/AIDS Program Client-Level Data Report

GRANTEE FORM — SERVICES

If this agency is contracted to provide administrative and technical services, please select the service(s) funded under this agreement. Check all that apply.

Last saved by: Michael J. Dols
Last saved at: 5/14/2008 12:14 PM

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Health Resources and Services Administration (HRSA)
Ryan White HIV/AIDS Program Client-Level Data Report

GRANTEE FORM — SERVICES

If this agency is funded to provide core medical services, please select the service(s) funded under this agreement. Check all that apply.

Last saved by: Michael J. Dols
Last saved at: 5/14/2008 12:14 PM

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Health Resources and Services Administration (HRSA)
Ryan White HIV/AIDS Program Client-Level Data Report

GRANTEE FORM — SERVICES

If this agency is funded to provide support services, please select the service(s) funded under this agreement. Check all that apply.

Last saved by: Michael J. Dols
Last saved at: 5/14/2008 12:14 PM

Page 6 of 7

Health Resources and Services Administration (HRSA)
Ryan White HIV/AIDS Program Client-Level Data Report

GRANTEE FORM — SERVICES

Check the box if the agency is funded to provide HIV counseling and testing services.

Last saved by: Michael J. Dols
Last saved at: 5/14/2008 12:14 PM

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