| FY17 RWHAP Part A & MAI Expenditures Report | ||||||||||||||
| Section A: Identifying Information | 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 Preparer's Name Here ~ | ||||||||||||||
| ~ Enter Preparer's Phone Number Here ~ | ||||||||||||||
| ~ Enter Preparer's Email Address Here ~ | ||||||||||||||
| Section B: Award Information | Current FY | Carryover | Total | 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 1.5 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. | ||||||||||
| 1. Part A Grant Formula Award Amount | ||||||||||||||
| 2. MAI Grant Award Amount | ||||||||||||||
| 3. Part A Supplemental Award Amount | ||||||||||||||
| 4. Total Part A Grant Funds | $0 | $0 | $0 | |||||||||||
| PART A1 AWARD | MAI AWARD | PART A1 + MAI TOTAL AWARD (includes carryover) |
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| Section C: Expenditure Categories | CURRENT FY | PRIOR FY CARRYOVER | PART A TOTAL | CURRENT FY | PRIOR FY CARRYOVER | MAI TOTAL | ||||||||
| Amount | Percent | Amount | Percent | Amount | Percent | Amount | Percent | Amount | Percent | Amount | Percent | Amount | Percent | |
| 1. Core Medical Services Subtotal (See Legislative Requirements) | $0 | 0.00% | $0 | 0.00% | $0 | 0.00% | $0 | 0.00% | $0 | 0.00% | $0 | 0.00% | $0 | 0.00% |
| a. AIDS Drug Assistance Program (ADAP) Treatments | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| b. AIDS Pharmaceutical Assistance (LPAP) | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| c. Early Intervention Services | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| d. Health Insurance Premium & Cost Sharing Assistance | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| e. Home and Community-based Health Services | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| f. Home Health Care | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| g. Hospice | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| h. Medical Case Management (incl. Treatment Adherence Services) | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| i. Medical Nutrition Therapy | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| j. Mental Health Services | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| k. Oral Health Care | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| l. Outpatient /Ambulatory Health Services | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| m. Substance Abuse Outpatient Care | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| 2. Support Services Subtotal | $0 | 0.00% | $0 | 0.00% | $0 | 0.00% | $0 | 0.00% | $0 | 0.00% | $0 | 0.00% | $0 | 0.00% |
| a. Child Care Services | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| b. Emergency Financial Assistance | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| c. Food Bank/Home-Delivered Meals | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| d. Health Education/Risk Reduction | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| e. Housing | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| f. Linguistics Services | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| g. Medical Transportation | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| h. Non-Medical Case Management Services | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| i. Other Professional Services | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| j. Outreach Services | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| k. Psychosocial Support Services | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| l. Referral for Health Care/Supportive Services | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| m. Rehabilitation Services | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| n. Respite Care | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| o. Substance Abuse Services - residential | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| 3. Total Service Expenditures | $0 | - - | $0 | - - | $0 | - - | $0 | - - | $0 | - - | $0 | - - | $0 | - - |
| 4. Non-services Subtotal | $0 | - - | $0 | - - | $0 | - - | $0 | - - | $0 | - - | $0 | - - | $0 | - - |
| a. Clinical Quality Management2 (See Legislative Requirements) | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| b. Recipient Administration3 (See Legislative Requirements) | - - | - - | $0 | - - | - - | - - | $0 | - - | $0 | - - | ||||
| 5. Total Expenditures4 | $0 | - - | $0 | - - | $0 | - - | $0 | - - | $0 | - - | $0 | - - | $0 | - - |
| Section D: Award & Expenditure Summary | Award | Expenditure | Balance | |||||||||||
| 1. Part A | $0 | $0 | $0 | o Recipient received waiver for 75% core medical services requirement. | ||||||||||
| 2. Part A MAI | $0 | $0 | $0 | |||||||||||
| 3. Total | $0 | $0 | $0 | |||||||||||
| Footnotes: (1) This amount must equal the recipient's total Part A formula and supplemental award. (2) Clinical Quality Management may not exceed 5% of the Part A award, or 3 million, whichever amount is smaller. (3) Recipient Administration may not exceed 10% of the Part A award. (4) This amount must equal the recipient's total Part A Award. |
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| 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 a percentage of award for specific categories 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 expenses, the Current FY totals in Section C, Row 1 of the Expenditure Report for PART A AWARD and MAI AWARD columns do not necessarily need to be 75% of each individual award as long as the combined total meets the 75% minimum requirement. The exception to this requirement is only for those recipients that requested, and were approved by HRSA, for a Part A 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 A Award (B19 + H19) / B13. Please check to make sure this percentage is 75% or greater. |
0.0% | ||||
| REQUIREMENT: No more than 5% of your total award or $3 million (whichever is smaller) can be spent on Clinical Quality Management. | |||||
| When reporting Clinical Quality Management expenses, the Current FY totals in Section C, Row 4a of the Expenditure Report for PART A AWARD and MAI AWARD columns do not necessarily need to meet this requirement as long as the combined total meets the 5% or $3 million (whichever is smaller) requirement. To the right in red, is the maximum (Capped Amount) you can spend on Clinical Quality Management (the lessor of B13 * .05 or $3 million) as well as the amount of Current Fiscal Year dollars spent (CQM Expenditures) on Clinical Quality Management (B51 + H51). Please check to make sure your Expenditures do not exceed your Capped Amount. |
$0 | (Capped Amount) | |||
| $0 | (CQM Expenditures) | ||||
| REQUIREMENT: No more than 10% of your total award can be spent on Recipient Administration. | |||||
| When reporting Recipient Administration expenses, the Current FY totals in Section C, Row 4b of the Expenditure Report for PART A AWARD and MAI AWARD columns do not necessarily need to meet this requirement as long as the combined total meets the 10% or less requirement. To the right in red, is the percentage of your Current Fiscal Year Recipient Administration expenditures divided by your Total Part A Award (B52 + H52) / B13. Please check to make sure this percentage is not greater than 10%. |
$0 | 0.0% | |||
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |