| Part D Allocations Report |
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| Section A: Identifying Information |
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| ~ Enter Name of Grantee Here ~ |
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| ~ Enter Grant Number Here ~ |
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| ~ Enter Preparer's Name Here ~ |
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| ~ Enter Preparer's Phone Number Here ~ |
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| ~ Enter Preparer's Email Address Here ~ |
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| Section B: Reporting FY Award Information |
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| 1. Part D Grant Award Amount |
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| Section C: Allocations Categories |
Amount |
Percent |
| 1. Medical Services Subtotal |
$0 |
0% |
| a. Outpatient /Ambulatory Health Services |
|
- - |
| b. AIDS Pharmaceutical Assistance (local) |
|
- - |
| c. Oral Health Care |
|
- - |
| d. Home Health Care |
|
- - |
| e. Home and Community-based Health Services |
|
- - |
| f. Hospice Services |
|
- - |
| g. Mental Health Services |
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- - |
| h. Medical Nutrition Therapy |
|
- - |
| i. Medical Case Management (including Treatment Adherence) |
|
- - |
| j. Substance Abuse Services - outpatient |
|
- - |
| 2. Support Services Sub-total |
$0 |
0% |
| a. Case Management (non-Medical) |
|
- - |
| b. Child Care Services |
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- - |
| c. Pediatric Developmental Assessment / Early Intervention Services |
|
- - |
| d. Emergency Financial Assistance |
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- - |
| e. Food Bank/Home-Delivered Meals |
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- - |
| f. Health Education/Risk Reduction |
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- - |
| g. Legal Services |
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- - |
| h. Linguistics Services |
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- - |
| i. Medical Transportation Services |
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- - |
| j. Outreach Services |
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- - |
| k. Permanency Planning |
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- - |
| l. Psychosocial Support Services |
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- - |
| m. Referral for Health Care/Supportive Services |
|
- - |
| n. Rehabilitation Services |
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- - |
| o. Respite Care |
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- - |
| p. Treatment Adherence Counseling |
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- - |
| 3. Total Service Allocations |
$0 |
- - |
| 4. Non-services Subtotal |
$0 |
- - |
| a. Clinical Quality Management Activities |
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- - |
| b. Grantee Administration1 |
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- - |
| c. Indirect Costs |
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- - |
| 5. Total Allocations (Services + Non-services)2 |
$0 |
- - |
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| (1) May not exceed 10% of Part D award. |
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| (2) Must equal the total Part D award. |
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| 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. |