| FY17 RWHAP Part C Expenditures Report |
|
|
|
|
|
|
|
| Section A: Identifying Information |
|
NOTE: Detailed instructions for completing and submitting your report can be downloaded from the HRSA Electronic Handbook: https://grants.hrsa.gov/webexternal/Login.asp |
| ~ Enter Name of Recipient 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 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
REPORTING FY |
PRIOR FY CARRYOVER |
TOTAL |
| Section C: Expenditure Categories |
Amount |
Percent |
Amount |
Percent |
Amount |
Percent |
| 1. Core Medical Services Subtotal (See Legislative Requirements) |
$0 |
0% |
$0 |
0% |
$0 |
0% |
| a. AIDS Drug Assistance Program (ADAP) Treatments |
|
- - |
|
- - |
$0 |
- - |
| b. AIDS Pharmaceutical Assistance (CPAP) |
|
- - |
|
- - |
$0 |
- - |
| c. Early Intervention Services |
|
- - |
|
- - |
$0 |
- - |
| d. Health Insurance Premium & Cost Sharing Assistance |
|
- - |
|
- - |
$0 |
- - |
| e. Home and Community-based Health Services |
|
- - |
|
- - |
$0 |
- - |
| f. Home Health Care |
|
- - |
|
- - |
$0 |
- - |
| g. Hospice |
|
- - |
|
- - |
$0 |
- - |
| h. Medical Case Management (including Treatment Adherence Services) |
|
- - |
|
- - |
$0 |
- - |
| i. Medical Nutrition Therapy |
|
- - |
|
- - |
$0 |
- - |
| j. Mental Health Services |
|
- - |
|
- - |
$0 |
- - |
| k. Oral Health Care |
|
- - |
|
- - |
$0 |
- - |
| l. Outpatient /Ambulatory Health Services |
|
- - |
|
- - |
$0 |
- - |
| m. Substance Abuse Outpatient Care |
|
- - |
|
- - |
$0 |
- - |
| 2. Support Services Subtotal |
$0 |
0% |
$0 |
0% |
$0 |
0% |
| a. Child Care Services |
|
- - |
|
- - |
$0 |
- - |
| b. Emergency Financial Assistance |
|
- - |
|
- - |
$0 |
- - |
| c. Food Bank/Home-Delivered Meals |
|
- - |
|
- - |
$0 |
- - |
| d. Health Education/Risk Reduction |
|
- - |
|
- - |
$0 |
- - |
| e. Housing |
|
- - |
|
- - |
$0 |
- - |
| f. Linguistics Services |
|
- - |
|
- - |
$0 |
- - |
| g. Medical Transportation |
|
- - |
|
- - |
$0 |
- - |
| h. Non-Medical Case Management Services |
|
- - |
|
- - |
$0 |
- - |
| i. Other Professional Services |
|
- - |
|
- - |
$0 |
- - |
| j. Outreach Services |
|
- - |
|
- - |
$0 |
- - |
| k. Psychosocial Support Services |
|
- - |
|
- - |
$0 |
- - |
| l. Referral for Health Care and Support Services |
|
- - |
|
- - |
$0 |
- - |
| m. Rehabilitation Services |
|
- - |
|
- - |
$0 |
- - |
| n. Respite Care |
|
- - |
|
- - |
$0 |
- - |
| o. Substance Abuse Services - residential |
|
- - |
|
- - |
$0 |
- - |
| 3. Total Service Expenditures |
$0 |
- - |
$0 |
- - |
$0 |
- - |
| 4. Non-services Subtotal |
$0 |
- - |
$0 |
- - |
$0 |
- - |
| a. Clinical Quality Management (see Legislative Requirements) |
|
- - |
|
- - |
$0 |
- - |
| b. Recipient Administration (see Legislative Requirements) |
|
- - |
|
- - |
$0 |
- - |
| 5. Total Expenditures (Service + Non-service) |
$0 |
- - |
$0 |
- - |
$0 |
- - |
|
|
|
|
|
|
|
| FOR OFFICE USE ONLY: |
|
|
|
|
|
|
| o Recipient received waiver for 75% core medical services requirement. |
|
|
|
|
|
|
|
|
|
|
|
|
| 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 5 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. |
| LEGISLATIVE REQUIREMENTS CHECKLIST |
|
|
| INSTRUCTIONS: Recipients and Project Officers should use the following table to determine whether or not the following legislative requirements have been met. Unlike the Expenditure Report which shows individual expenditures as a percentage of total expenditures, this table shows expenditures as outlined in the Ryan White HIV/AIDS Treatment Extension Act of 2009. |
|
|
|
|
|
|
| REQUIREMENT: At least 75% of your total award (less CQM and Recipient Administration) must be spent on core medical services. |
When reporting Core Medical Services expenditures, the Total in Section C, Row 1, Column F of the Expenditure Report which includes carryover dollars, must meet the 75% minimum requirement. The exception to this requirement is only for those recipients that requested, and were approved by HRSA, for a Part C Core Medical Services Waiver.
To the right in red, is the percentage of your Current Fiscal Year Core Medical Services expenditures divided by your Total Part C Award less the CQM and Recipient Administrative expenditures (F15 / F45). Please check to make sure this percentage is 75% or greater. |
0.0% |
|
|
|
|
|
|
| REQUIREMENT: Clinical Quality Management expenditures should be reasonable. |
| To the right in red, are your total CQM Expenditures (F47) which includes carryover dollars. Please check to make sure your CQM Expenditures are reasonable. |
$0 |
(CQM Expenditures) |
|
|
|
|
|
|
| REQUIREMENT: No more than 10% of your total award can be spent on Recipient Administration. |
When reporting Recipient Administration expenses, the total (carryover included) must be 10% or less than the award amount.
To the right in red, is the maximum (Capped Amount) you can spend on Recipient Administration (B11 * .10) as well as your Total Recipient Administration expenditures (F48) which includes carryover dollars. Please check to make sure your Recipient Administration expenditures do not exceed your Capped Amount. |
$0 |
(Capped Amount) |
| $0 |
(Admin Expenditures) |