| FY17 RWHAP Part D 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 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 D Grant Award Amount |
|
|
|
|
|
|
|
|
|
|
|
|
REPORTING FY |
PRIOR FY CARRYOVER |
TOTAL |
| Section C: Expenditure Categories |
Amount |
Percent |
Amount |
Percent |
Amount |
Percent |
| 1. Medical Services Subtotal |
$0 |
0% |
$0 |
0% |
$0 |
0% |
| a. AIDS Drug Assistance Program (ADAP) Treatments |
|
- - |
|
- - |
$0 |
- - |
| b. AIDS Pharmaceutical Assistance (CPAP) |
|
- - |
|
- - |
$0 |
- - |
| c. Health Insurance Premium & Cost Sharing Assistance |
|
- - |
|
- - |
$0 |
- - |
| d. Home and Community-based Health Services |
|
- - |
|
- - |
$0 |
- - |
| e. Home Health Care |
|
- - |
|
- - |
$0 |
- - |
| f. Hospice |
|
- - |
|
- - |
$0 |
- - |
| g. Medical Case Management (including Treatment Adherence Services) |
|
- - |
|
- - |
$0 |
- - |
| h. Medical Nutrition Therapy |
|
- - |
|
- - |
$0 |
- - |
| i. Mental Health Services |
|
- - |
|
- - |
$0 |
- - |
| j. Oral Health Care |
|
- - |
|
- - |
$0 |
- - |
| k. Outpatient /Ambulatory Health Services |
|
- - |
|
- - |
$0 |
- - |
| l. Substance Abuse Outpatient Care |
|
- - |
|
- - |
$0 |
- - |
| 2. Support Services Sub-total |
$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 Activities (See Legislative Requirements) |
|
- - |
|
- - |
$0 |
- - |
| b. Grantee Administration (See Legislative Requirements) |
|
- - |
|
- - |
$0 |
- - |
| c. Indirect Costs (See Legislative Requirements) |
|
- - |
|
- - |
$0 |
- - |
| 5. Total Expenditures |
$0 |
- - |
$0 |
- - |
$0 |
- - |
|
|
|
|
|
|
|
| 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 4.5 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 a percentage of award for specific categories as outlined in the Ryan White HIV/AIDS Treatment Extension Act of 2009. |
|
|
|
|
|
|
| REQUIREMENT: Clinical Quality Management expenditures should be reasonable. |
| To the right in red, are your total CQM Expenditures (F46) 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 (F47 +F48) which includes carryover dollars. Please check to make sure your Recipient Administration expenditures do not exceed your Capped Amount. Note that Indirect Costs are included as part of the Recipient Administration cap. |
$0 |
(Capped Amount) |
| $0 |
(Admin Expenditures) |