Form 1 Part A Allocations Report 30MAR2017 Final_modification

Ryan White HIV/AIDS Program Allocation and Expenditure Forms

Part A Allocations Report 30MAR2017 Final_modification sent 7242017.xlsx

Part A Allocation and Expenditures Forms

OMB: 0915-0318

Document [xlsx]
Download: xlsx | pdf

Overview

Allocations Report
Legislative Requirements


Sheet 1: Allocations Report

FY17 RWHAP Part A & MAI Allocations 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: Reporting Year Award Information
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

Section C: Allocation Categories 1. Part A1 Award 2. MAI Award 4. Combined Total
Amount Percentage Amount Percentage Amount Percentage
1. Core Medical Services Subtotal $0 0.00% $0 0.00% $0 0.00%
a. AIDS Drug Assistance Program (ADAP) Treatments
- -
- - $0 - -
b. AIDS Pharmaceutical Assistance (LPAP)
- -
- - $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 (incl. 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 0.00% $0 0.00% $0 0.00%
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 Allocations $0 - - $0 - - $0 - -
4. Non-services Subtotal $0 - - $0 - - $0 - -
a. Clinical Quality Management2 (see CHECKLIST)
- -
- - $0 - -
b. Recipient Administration 3 (see CHECKLIST)
- -
- - $0 - -
5. Total Allocations (Service + Non-service)4 (see CHECKLIST) $0 - - $0 - - $0 - -







o Recipient received waiver for 75% core medical services requirement.
















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.



Sheet 2: Legislative Requirements

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 Allocations Report which shows individual allocations as a percentage of total allocations, this table shows allocations 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 allocated to core medical services.
When reporting Core Medical Services allocations, the Current FY totals in Section C, Row 1 of the Allocation Report for PART A AWARD and MAI AWARD and SUPPLEMENTAL 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 allocations divided by your Total Part A Award less CQM and Recipient Administration allocations (F18 /F48). 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 allocated to Clinical Quality Management.
When reporting Clinical Quality Management allocations, the Current FY totals in Section C, Row 4a of the Allocations Report for PART A AWARD and MAI AWARD and SUPPLEMENTAL 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 allocate on Clinical Quality Management (the lessor of B13 * .05 or $3 million) as well as the amount of Current Fiscal Year dollars allocated (CQM Allocations) on Clinical Quality Management (F50). Please check to make sure your Allocations do not exceed your Capped Amount.
$0 (Capped Amount)
$0 (CQM Allocations)






REQUIREMENT: No more than 10% of your total award can be allocated to Grantee Administration.
When reporting Recipient Administration allocations, the Current FY totals in Section C, Row 4b of the Allocations Report for PART A AWARD and MAI AWARD and SUPPLEMENTAL 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 allocations divided by your Total Part A Award (F51 / B13.) Please check to make sure this percentage is not greater than 10%.
0.0%
File Typeapplication/vnd.openxmlformats-officedocument.spreadsheetml.sheet
File Modified0000-00-00
File Created0000-00-00

© 2024 OMB.report | Privacy Policy