Part B and MAI Allocations Report |
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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 |
1. Part B Base Award |
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2. Part B Supplemental Award |
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3. Total Part B Base + Base Supplemental Awards |
$0 |
4. Part B ADAP Earmark Award |
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Section A: Identifying Information |
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5. Part B ADAP Supplemental Award |
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~ Enter Name of Grantee Here ~ |
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6. Total Part B ADAP + ADAP Supplemental Awards |
$0 |
~ Enter Preparer's Name Here ~ |
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7. Part B Emerging Communities Award |
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~ Enter Preparer's Phone Number Here ~ |
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8. Total Part B Funds |
$0 |
~ Enter Preparer's Email Address Here ~ |
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9. Part B MAI Award |
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10. Total Part B + MAI Funds |
$0 |
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Section C: Part B Allocations by Program Component |
1. Base + Supplemental Awards |
2. ADAP + Supplemental Award (ADAP) |
3. Emerging Communities Award (EC) |
4. Total |
Amount |
Percentage |
Amount |
Percentage |
Amount |
Percentage |
Amount |
Percentage |
1. Part B AIDS Drug Assistance Program Subtotal |
$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 |
- - |
4a. Part B HIV Care Consortia/EC services (Provide detail in Section D, Column 1 or 3)1 |
$0 |
- - |
|
|
$0 |
- - |
$0 |
- - |
4b. Part B HIV Care Cosortia/EC Administration2 |
|
- - |
|
|
|
- - |
$0 |
- - |
5. Part B State Direct Services (Provide detail in Section D, Column 2)1 |
$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 |
- - |
10.Total Part B Allocations5 |
$0 |
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Section D: Breakdown for Consortia, State Direct Services and Emerging Communities |
1. Consortia6 |
2. Direct Services |
3. Emerging Communities |
4. Total |
Amount |
Percentage |
Amount |
Percentage |
Amount |
Percentage |
Amount |
Percentage |
1. Core Medical Services Sub-total |
$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 |
- - |
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 |
|
- - |
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- - |
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- - |
$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 |
- - |
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MAI Award |
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Section E: MAI Allocations by Program Component |
Amount |
Percentage |
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1. Education to increase minority participation in ADAP |
|
- - |
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FOR OFFICE USE ONLY: |
2. Outreach to increase minority participation in ADAP |
|
- - |
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o Grantee received waiver for 75% core medical services requirement. |
3. Clinical Quality Management 3 |
|
- - |
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4. Grantee Planning & Evaluation Activities 4 |
|
- - |
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5. Grantee Administration 4 |
|
- - |
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6. Total MAI Allocations 7 |
$0 |
0.00% |
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(1) The total services amounts will automatically be calculated based on the details you provide in Section D, column 1 or 2 or 3. |
(2) Consortia/Emerging Communities Administration, Planning and Evaluation costs may not exceed 10% of their respective total 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) This amount must equal the combined total of the Part B Base, Part B Supplemental, ADAP, ADAP Supplemental, and Emerging Communities awards. |
(6) All services in this column are considered Supprt Services. |
(7) This amount must equal the total of the Part B MAI Award. |
Part B & MAI Allocations Report |
Automatic Calculation of Part B Core Medical & Support Services Allocations |
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~ Enter Name of Grantee Here ~ |
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NOTE: This table is for reference only and is provided for grantees to automatically calculate their total Core Medical Service allocations/percentages across all Part B service dollars. The figures below reflect the amounts entered in the Allocations Report (green tab). |
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Core Medical Services Allocations |
Amount |
Percentage (Amount / Total Service Allocations) |
ADAP (H18) |
$0 |
- - |
Home-and Community-based Health Services (H23) |
$0 |
- - |
Health Insurance Premium & Cost Sharing Assistance (H22) |
$0 |
- - |
State-Direct Services: Core Medical Services (D35) |
$0 |
- - |
Emerging Communities: Core Medical Services (F35) |
$0 |
- - |
Total Core Medical Services Allocations |
$0 |
- - |
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Support Services Allocations |
Amount |
Percent |
Consortia Services (B24) + Consortia/EC Administration (H25) |
$0 |
- - |
State-Direct Services: Support Services (D49) |
$0 |
- - |
Emerging Communities: Support Services (F49) |
$0 |
- - |
MAI Allocations for Education + Outreach Services (B70 + B71) |
$0 |
- - |
Total Support Services Allocations |
$0 |
- - |
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Total Part B + MAI Services Allocations |
$0 |
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Kelley Weld:
Are they required to spend their total MAI Award?
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