| Part A & MAI Allocations Table | ||||||
| Section A: Identifying Information | Detailed instructions for completing and submitting this report can be found in the Electronic Handbooks and downloaded from the web at https://grants.hrsa.gov/webexternal/Login.asp |
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| ~ Enter Name of Grantee Here ~ | ||||||
| ~ Enter Preparer's Name Here ~ | ||||||
| ~ Enter Preparer's Phone Number Here ~ | ||||||
| ~ Enter Preparer's Email Address Here ~ | ||||||
| Section B: Reporting Year Award Information | ||||||
| 1. Part A Grant Award Amount | ||||||
| 2. MAI Grant Request / Award Amount | ||||||
| 3. Total Part A Funds | $0 | |||||
| Section C: Allocation Categories | 1. Part A Award | 2. MAI Award | 3. Combined Total | |||
| Amount | Percentage | Amount | Percentage | Amount | Percentage | |
| 1. Core Medical Services Subtotal1 (see CHECKLIST) | $0 | 0.00% | $0 | 0.00% | $0 | 0.00% |
| 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 (incl. Treatment Adherence) | - - | - - | $0 | - - | ||
| m. Substance Abuse Services - outpatient | - - | - - | $0 | - - | ||
| 2. Support Services Subtotal | $0 | 0.00% | $0 | 0.00% | $0 | 0.00% |
| 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 Services - residential | - - | - - | $0 | - - | ||
| p. Treatment Adherence Counseling | - - | - - | $0 | - - | ||
| 3. Total Service Allocations | $0 | - - | $0 | - - | $0 | - - |
| 4. Non-services Subtotal | $0 | - - | $0 | - - | $0 | - - |
| a. Clinical Quality Management2 (see CHECKLIST) | - - | - - | $0 | - - | ||
| b. Grantee Administration 3 (see CHECKLIST) | - - | - - | $0 | - - | ||
| 5. Total Allocations (Service + Non-service)4 (see CHECKLIST) | $0 | - - | $0 | - - | $0 | - - |
| FOR OFFICE USE ONLY: | ||||||
| o Grantee received waiver for 75% core medical services requirement. | ||||||
| Part A & MAI Allocations Report CHECKLIST | ||||
| ~ Enter Name of Grantee Here ~ | ||||
| Please check the following before submitting your report! | Part A Award | MAI Grant Request / Award |
Total | |
| 1 | 75% of your combined awards must be spent on core medical services. When reporting Core Medical Services allocations, the percentages for the Part A Award (Row 1, Column 1) and the MAI Award (Row 1, Column 2) do not necessarily need to be 75% as long as the COMBINED Total (Row 1, Column 3) meets the required minimum 75%. If the percentage to the right is less than 75%, you must adjust your allocations so that at least 75% of your combined award amounts (Part A Award + MAI Award) are allocated for Core Medical Services. The exception to this requirment is only for those grantees that requested, and were approved by HRSA, for an FY 2009 Part A Core Medical Services Waiver. |
0.0% | ||
| 2 | You may not spend more than 5% or 3 million dollars (whichever is smaller) on clinical quality management. If either of these percentages is more than 5% or the amounts is more than $3,000,000 you must go back and adjust your report accordingly. |
- - | - - | |
| $0 | $0 | |||
| 3 | You may not spend more than 10% on grantee administration. If either of these percentages is more than 10%, you must adjust your report accordingly. |
0.0% | 0.0% | |
| 4 | You must allocate your entire award. The total allocations in Section C (Row 5, Column 3) should equal the total amount of funds expected to be available as shown in Section B. |
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| Detailed instructions for completing and submitting this report can be found in the Electronic Handbooks and downloaded from the web at https://grants.hrsa.gov/webexternal/Login.asp |
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| File Type | application/vnd.ms-excel |
| Author | Melanie K. Wieland |
| Last Modified By | KWeld1 |
| File Modified | 2010-12-16 |
| File Created | 2007-05-15 |