| Part B & MAI Expenditures Report | |||||||||||||
| Detailed instructions for completing and submitting this report can be found in the Electronic Handbooks and download from the web: https://grants.hrsa.gov/webexternal/Login.asp |
Section B: Reporting Year Award Information | Award Amount | Prior Year Carryover | Total Avail. Funds | |||||||||
| 1. Part B Base Award | $0 | ||||||||||||
| 2. Part B ADAP Earmark Award | $0 | ||||||||||||
| 3. Part B ADAP Supplemental Award | $0 | ||||||||||||
| Section A: Identifying Information | 4. Total Part B Base + ADAP + ADAP Supplemental Funds | $0 | $0 | $0 | |||||||||
| ~ Enter Name of Grantee Here ~ | 5. Part B Emerging Communities Award | $0 | |||||||||||
| ~ Enter Preparer's Name Here ~ | 6. Part B Supplemental Award | $0 | |||||||||||
| ~ Enter Preparer's Phone Number Here ~ | 6. Total Part B Funds | $0 | $0 | $0 | |||||||||
| ~ Enter Preparer's Email Address Here ~ | 7. Part B MAI Award | $0 | |||||||||||
| 8. Total Part B + MAI Funds | $0 | $0 | $0 | ||||||||||
| Section C: Part B Expenditures by Program Component | 1. Base Award | 2. ADAP Earmark + Supplemental | 3. Emerging Communities Award | 4. Total Prior Year Carryover | 5. Total | ||||||||
| Award | Carryover | Percent* | Award | Carryover | Percent* | Award | Carryover | Percent* | Amount | Percent | Amount | Percent | |
| 1. Part B AIDS Drug Assistance Program Subtotal | $0 | - - | $0 | - - | $0 | - - | $0 | - - | $0 | - - | |||
| a. ADAP Services | - - | - - | - - | - - | $0 | - - | |||||||
| b. Health Insurance to Provide Medications | - - | - - | - - | - - | $0 | - - | |||||||
| c. ADAP Access/Adherence/Monitoring Services | - - | - - | - - | - - | $0 | - - | |||||||
| 2. Part B Health Insurance Premium & Cost Sharing Assistance | - - | - - | - - | $0 | - - | ||||||||
| 3. Part B Home and Community-based Health Services | - - | - - | - - | $0 | - - | ||||||||
| 4. Part B HIV Care Consortia (Provide service detail in Sec. D, Column 1 & 4) 1 | $0 | $0 | - - | - - | - - | $0 | - - | ||||||
| 4a. Part B HIV Care Consortia Administration, Planning & Evaluation2 | |||||||||||||
| 5. Part B State Direct Services (Provide detail in Sec. D, Column 2 & 4)1 | $0 | $0 | - - | - - | - - | $0 | - - | ||||||
| 6. Part B Clinical Quality Management3 | - - | - - | - - | - - | $0 | - - | |||||||
| 7. Part B Grantee Planning & Evaluation Activities4 | - - | - - | - - | - - | $0 | - - | |||||||
| 8. Grantee Administration 4 | - - | - - | - - | - - | $0 | - - | |||||||
| 9. Column Totals | $0 | - - | $0 | - - | $0 | - - | $0 | - - | $0 | - - | |||
| 10.Total Part B Expenditures | $0 | ||||||||||||
| Section D: Breakdown for Consortia, State Direct Services and Emerging Communities | 1. Consortia5 | 2. Direct Services | 3. Emerging Communities 6 | 4. Prior Year Carryover | 5. Total | ||||||||
| Award | Percent | Award | Percent | Award | Percent | Amount | Percent | Amount | Percent | ||||
| 1. Core Medical Services Sub-total | $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. 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 (including Treatment Adherence) | - - | - - | - - | - - | $0 | - - | |||||||
| m. Substance Abuse Services–outpatient | - - | - - | - - | - - | $0 | - - | |||||||
| 2. Support Services Sub-total | $0 | - - | $0 | - - | $0 | - - | $0 | - - | $0 | - - | |||
| 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 Residential Services | - - | - - | - - | - - | $0 | - - | |||||||
| p. Treatment Adherence Counseling | - - | - - | - - | - - | $0 | - - | |||||||
| 3. Total | $0 | - - | $0 | $0 | $0 | - - | $0 | - - | |||||
| MAI AWARD | |||||||||||||
| REPORTING YEAR AWARD | PRIOR FY CARRYOVER | TOTAL | |||||||||||
| Section E: MAI Expenditures by Program Component | Amount | Percent | Amount | Percent | Amount | Percent | |||||||
| 1. Education to increase minority participation in ADAP | - - | - - | - - | ||||||||||
| 2. Outreach to increase minority participation in ADAP | - - | - - | - - | ||||||||||
| 3. Clinical Quality Management 3 | - - | - - | - - | ||||||||||
| 4. Grantee Planning & Evaluation Activities 4 | - - | - - | - - | ||||||||||
| 5. Grantee Administration 4 | - - | - - | - - | ||||||||||
| 6. Total MAI Expenditures | $0 | 0.00% | $0 | 0.00% | $0 | 0.00% | |||||||
| * Percentage is calculated on the combined total of the current Fiscal Year award plus prior year carryover amount. | |||||||||||||
| (1) In the Base Award column ONLY, this cell will automatically calculate based on the detail you provide in Section D. | |||||||||||||
| (2) Administration expenditures for first-line entities is capped at 10% of the aggregate amount allocated for services. Therefore, Consortia Administration, Planning and Evaluation may not exceed 10% of Consortia funds. | |||||||||||||
| (3) May not exceed 5% of the Part B award, or 3 million, whichever amount is smaller. | |||||||||||||
| (4) May not exceed 10% of the Part B award for either Planning & Evaluation or Grantee Admin. Additionally, the combined costs for these two categories may not exceed 15% of the Part B award. | |||||||||||||
| (5) All services in this column are considered Supprt Services. | |||||||||||||
| (6) In the Emerging Communities Column ONLY, the Total Allocations should equal the combined total of Rows 4 + 5 in Section C, Column 3. | |||||||||||||
| FOR OFFICE USE ONLY: | |||||||||||||
| o Grantee received waiver for 75% core medical services requirement. | |||||||||||||
| File Type | application/vnd.ms-excel |
| Author | HRSA |
| Last Modified By | KWeld1 |
| File Modified | 2010-12-16 |
| File Created | 2007-05-07 |