5a Part C Allocations Report and Checklist

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Overview

Allocations Report
CHECKLIST

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Sheet 1: Allocations Report

Part C Allocations Report
Section A: Identifying Information
~ 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: Reporting FY Award Information
1. Part C Grant Award Amount
Section C: Allocations Categories	Amount	Percent
1. Core Medical Services Subtotal1 (see CHECKLIST)	$0	0%
a. Outpatient /Ambulatory Health Services		- -
b. AIDS Drug Assistance Program (ADAP) Treatments		- -
c. AIDS Pharmaceutical Assistance (local)		- -
d. Oral Health Care		- -
e. Health Insurance Premium & Cost Sharing Assistance		- -
f. Home Health Care		- -
g. Home and Community-based Health Services		- -
h. Hospice Services		- -
i. Mental Health Services		- -
j. Medical Nutrition Therapy		- -
k. Medical Case Management (including Treatment Adherence)		- -
l. Substance Abuse Services - outpatient		- -
2. Support Services Subtotal	$0	0%
a. Case Management (non-Medical)		- -
b. Health Education/Risk Reduction		- -
c. Linguistics Services		- -
d. Medical Transportation Services		- -
e. Outreach Services		- -
f. Psychosocial Support Services		- -
g. Referral for Health Care/Supportive Services		- -
h. Rehabilitation Services		- -
i. Respite Care		- -
j. Treatment Adherence Counseling		- -
3. Total Service Allocations	$0	- -
4. Non-services Subtotal	$0	- -
a. Clinical Quality Management Activities2 (see CHECKLIST)		- -
b. Grantee Administration3 (see CHECKLIST)		- -
5. Total Allocations (Service + Non-service)4 (see CHECKLIST)	$0	- -
FOR OFFICE USE ONLY:
o Grantee received waiver for 75% core medical services requirement.
NOTE: Detailed instructions for completing and submitting your report can be downloaded from the HRSA Electronic Handbook: https://grants.hrsa.gov/webexternal/Login.asp
PUBLIC BURDEN STATEMENT: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB number. The OMB control number for this project is 0915-0318. Public reporting burden for this collection of information is estimated to be 7 hours per response. These estimates include the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments to HRSA Reports Clearance Officer, Health Resources and Services Administration, Room 10-33, 5600 Fishers Lane, Rockville, MD. 20857.

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Sheet 2: CHECKLIST

Part C Allocations Report Checklist
	Please check the following before submitting your report!
1	75% of your award must be spent on core medical services. After meeting the requirements below, if this percentage is less than 75%, you must adjust your report so that at least 75% of your grant award is allocated to core medical services.	0.0%
2	Clinical quality management must be at a reasonable level.	0.0%
3	You may not spend more than 10% on grantee administration. If this percentage is more than 10%, you must adjust your report accordingly.	0.0%
4	You must allocate your entire award. This amount will equal zero if you allocated the entire amount listed in Section B. The amount in Section B must match the amount on your NGA. If this amount does not equal zero, you must adjust your report accordingly.	$0
	NOTE: Detailed instructions for completing and submitting your report can be downloaded from the HRSA Electronic Handbook: https://grants.hrsa.gov/webexternal/Login.asp