| FY 2017 RWHAP Part B (X07) and MAI Allocations Report | ||||||||
| Instructions are located in EHB: https://grants.hrsa.gov/webexternal/Login.asp | Section B: Reporting Year Award Information | |||||||
| 1. Part B Base Award | ||||||||
| 2. Part B ADAP Earmark Award | ||||||||
| Section A: Identifying Information | 3. Part B ADAP Supplemental Award | |||||||
| ~ Enter Name of Recipient Here ~ | 4. Total ADAP Award (ADAP Base + Supplemental) | $0 | ||||||
| ~ Enter Preparer's Name Here ~ | 5. Part B Emerging Communities Award | |||||||
| ~ Enter Preparer's Phone Number Here ~ | 6. Total Part B X07 Funds | $0 | ||||||
| ~ Enter Preparer's Email Address Here ~ | 7. Part B MAI Award | |||||||
| 8. Total Part B X07 Award | $0 | |||||||
| Section C: Part B Allocations by Program Component | 1. Base Award | 2. ADAP + ADAP Supplemental Award | 3. Emerging Communities Award (EC) | 4. Total | ||||
| Amount | Percentage | Amount | Percentage | Amount | Percentage | Amount | Percentage | |
| 1. Part B AIDS Drug Assistance Program Subtotal | $0 | - - | $0 | - - | $0 | - - | $0 | - - |
| a. ADAP Services | - - | - - | - - | $0 | - - | |||
| b. Health Insurance to Provide Medications | - - | - - | - - | $0 | - - | |||
| c. ADAP Access/Adherence/Monitoring Services | - - | - - | - - | $0 | - - | |||
| 2. Part B Health Insurance Premium & Cost Sharing Assistance | - - | - - | $0 | - - | ||||
| 3. Part B Home and Community-based Health Services | - - | - - | $0 | - - | ||||
| 4a. Part B HIV Care Consortia/EC services (Provide detail in Section D, Column 1 or 3)1 | $0 | - - | $0 | - - | $0 | - - | ||
| 4b. Part B HIV Care Consortia Administration2 | - - | - - | $0 | - - | ||||
| 5. Part B State Direct Services (Provide detail in Section D, Column 2)1 | $0 | - - | $0 | - - | ||||
| 6. Part B Clinical Quality Management3 | - - | - - | - - | $0 | - - | |||
| 7. Part B Recipient Planning & Evaluation Activities4 | - - | - - | - - | $0 | - - | |||
| 8. Recipient Administration 4 | - - | - - | - - | $0 | - - | |||
| 9. Column Totals | $0 | 0.00% | $0 | 0.00% | $0 | 0.00% | $0 | - - |
| 10.Total Part B X07 Allocations5 | $0 | |||||||
| Section D: Breakdown for Consortia, State Direct Services and Emerging Communities | 1. Consortia7 | 2. Direct Services | 3. Emerging Communities | 4. Total | ||||
| Amount | Percentage | Amount | Percentage | Amount | Percentage | Amount | Percentage | |
| 1. Core Medical Services Sub-total | $0 | - - | $0 | - - | $0 | - - | $0 | - - |
| a. AIDS Drug Assistance Program (ADAP) Treatments | ||||||||
| 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 (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 Sub-total | $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 Services Allocations | $0 | - - | $0 | - - | $0 | - - | $0 | - - |
| MAI Award | Footnotes: (1) The total services amounts will automatically be calculated based on the details you provide in Section D, column 1 or 2 or 3. (2) Consortia/Emerging Communities Administration, Planning and Evaluation costs may not exceed 10% of their respective total funds. (3) Clinical Quality Management may not exceed 5% of the Part B X07 award, or 3 million, whichever amount is smaller. (4) Planning & Evaluation or Recipient Administration may not exceed 10% of the Part B X07 award. Additionally, the combined costs for these two categories may not exceed 15% of the Part B X07 award. (5) This amount must equal the recipient's total Part B X07 Award. (7) All services in this column are considered Support Services. |
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| Section E: MAI Allocations by Program Component | Amount | Percentage | ||||||
| 1. Education to increase minority participation in ADAP | - - | |||||||
| 2. Outreach to increase minority participation in ADAP | - - | |||||||
| 3. Clinical Quality Management 3 | - - | |||||||
| 4. Recipient Planning & Evaluation Activities 4 | - - | |||||||
| 5. Recipient Administration 4 | - - | |||||||
| 6. Total MAI Allocations | $0 | 0.00% | ||||||
| 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 12 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 help determine whether or not the various Part B legislative spending requirements have been met. For more information on each of these requirements, please refer to the Ryan White HIV/AIDS Treatment Extension Act of 2009. | |||||
| CORE MEDICAL SERVICES | Amount | Percentage (Amount / Total Service Allocations) |
|||
| ADAP (H16) | $0 | - - | |||
| Home-and Community-based Health Services (H21) | $0 | - - | |||
| Health Insurance Premium & Cost Sharing Assistance (H20) | $0 | - - | |||
| State-Direct Services: Core Medical Services (D33) | $0 | - - | |||
| Emerging Communities: Core Medical Services (F33) | $0 | - - | |||
| Total Core Medical Services Allocations | $0 | - - | |||
| Support Services Allocations | Amount | Percent | |||
| Consortia Services (B22) + Consortia Administration (B23) | $0 | - - | |||
| State-Direct Services: Support Services (D47) | $0 | - - | |||
| Emerging Communities: Support Services (F47) | $0 | - - | |||
| MAI Allocations for Education + Outreach Services (B67 + B68) | $0 | - - | |||
| Total Support Services Allocations | $0 | - - | |||
| Total Service Allocations | $0 | ||||
| CLINICAL QUALITY MANAGEMENT | |||||
| Total Clinical Quality Management allocations must be 5% of the total X07 award or $3 million (whichever is smaller.) To the right in red, is the maximum (Capped Amount) that may be allocated to Clinical Quality Management (the lessor of I11 * .05 or $3 million) as well as the amount of Current Fiscal Year dollars allocated (CQM Allocations) on Clinical Quality Management (H25+B69). Please check to make sure the Allocations do not exceed the Capped Amount. |
$0 | (Capped Amount) | |||
| $0 | (CQM Allocations) | ||||
| PLANNING AND EVALUATION / RECIPIENT ADMINISTRATION | |||||
| Total Part B X07 Planning and Evaluation allocations and total Recipient Administration allocations must each be 10% or less than the total X07 award. Planning and Evaluation and Recipient Administration do not necessarily need to be 10% of each funding stream as long as the combined total of each is 10% or less of the total X07 award. In addition, Planning and Evaluation and Recipient Administration allocations combined must not exceed 15% of the total X07 award. To the right in red, is the percentage of Planning and Evaluation allocations divided by the Total X07 award (H26 + B70) / I11 and Recipient Administration allocations divided by the Total X07 award (H27 + B71) / I11. Please check to make sure these percentage are not greater than 10%. Also shown is the percentage of the combined Planning and Evaluation and Recipient Administration allocations divided by the Total X07 Award (H26 + H27 + B70 + B71) / I11. Please check to make sure this percentage is not greater than 15%. |
$0 | 0.0% | (Planning & Evaluation) | ||
| $0 | 0.0% | (Recipient Administration) | |||
| $0 | 0.0% | (Planning & Evaluation + Recipient Administration) | |||
| CONSORTIA ADMINISTRATION | |||||
| Consortia administration allocations must be 10% or less than the total Consortia funds. To the right in red, is the percentage of consortia administration allocations divided by the consortia allocations (B23 / B22). Please check to make sure this percentage does not exceed 10%. |
|||||
| $0 | 0.0% | (Consortia Administration) | |||
| EC ADMINISTRATION | |||||
| EC administration allocations must be 10% or less than the total EC funds. To the right in red, is the percentage of EC administration allocations divided by the EC award (F27 / I8). Please check to make sure this percentage does not exceed 10%. |
|||||
| $0 | 0.0% | (EC Administration) | |||
| INSTRUCTIONS FOR FY 2017 RWHAP PART B SUPPLEMENTAL PROGRAM AWARD ALLOCATIONS REPORT |
| Please print this sheet to review the instructions. |
| Supplemental Allocations Report |
| Recipients shall provide an Supplemental Allocations Report (blue tab) for the FY 2017 Ryan White HIV/AIDS Program (RWHAP) Part B Supplemental Program Award using the following template format provided. |
| Do not enter information into the gray cells, as they contain formulas and will automatically populate. |
| Recipient Name: Enter the name of the recipient using the name from the Notice of Award (NoA). |
| Preparer Name: Enter the name of the preparer. |
| Preparer Phone Number: Enter the phone number (including area code) of the preparer. |
| FY 2017 RWHAP Part B Supplemental Program Award: Enter the FY 2017 RWHAP Part B Supplemental Program Award amount from the NoA. |
| Section A: Planned Funding by Program Component |
| Enter the amounts allocated from the RWHAP Part B Supplemental Award using the components listed in rows numbered 1 - 8. RWHAP Part B HIV Care Consortia (# 4a) & RWHAP Part B State Direct Services (# 5) are automatically populated from Section B: Breakdown of Funding. |
| Section B: Breakdown of Funding |
| Enter the amount breakdown for funding for Core Medical Services and Support Services. |
| Notes |
| 1. All services delivered for or through Consortia (including Core Medical Services) are deemed to be Support Services. |
| 2. AIDS Drug Assistance Program (ADAP) Treatments funding is accounted for in Section A. |
| 3. Health Insurance and Home/Community Based Health are not allowed as a Direct Service. If these services are not funded by Consortia, they are accounted for in Planned Funding by Program Component (Section A). |
| Core Medical Calculation |
| This calculation sheet (yellow tab) provides an overview of the funding for FY 2017 RWHAP Part B Supplemental Program Award Allocations Core Medical & Support Services. Amounts for this tab will auto-populated from the Supplemental Allocations Report. |
| Recipient Name: Enter the name of the recipient using the name from the NoA. |
| Reminder: The 75/25 Core Medical Services Requirement applies to the RWHAP Part B Supplemental Program Award. |
| FY 2017 RWHAP Part B Supplemental Program Award Allocations Report | ||||
| Recipient Name | ||||
| Preparer Name | ||||
| Preparer Phone Number | ||||
| FY 2017 RWHAP Part B Supplemental Program Award | ||||
| Section A: Planned Funding by Program Component | Total FY 2017 RWHAP Part B Supplemental Program Award | |||
| Amount | Percent | |||
| 1. RWHAP Part B Supplemental AIDS Drug Assistance Program Subtotal | $0 | - - | ||
| a. ADAP Services | - - | |||
| b. Health Insurance to Provide Medications | - - | |||
| c. ADAP Access/Adherence/Monitoring Services | - - | |||
| 2. RWHAP Part B Supplemental Health Insurance Premium & Cost Sharing Assistance | - - | |||
| 3. RWHAP Part B Supplemental Home and Community-based Health Services | - - | |||
| 4a. RWHAP Part B Supplemental HIV Care Consortia (Provide detail in Section B) | $0 | - - | ||
| 4b. RWHAP Part B Supplemental HIV Care Consortia/EC Administration | - - | |||
| 5. RWHAP Part B Supplemental State Direct Services (Provide detail in Section B) | $0 | - - | ||
| 6. RWHAP Part B Supplemental Clinical Quality Management 1 | - - | |||
| 7. RWHAP Part B Supplemental Recipient Planning & Evaluation Activities2 | - - | |||
| 8. Recipient Administration2 | - - | |||
| 9. Total RWHAP Part B Supplemental Program Funding Amounts | $0 | 0.00% | ||
| Section B: Breakdown for Consortia, State Direct Services, and Emerging Communities Final Funding | Consortia3 | Direct Services | ||
| Amount | Percent | Amount | Percent | |
| 10. Core Medical Services Sub-total | $0 | - - | $0 | - - |
| a. AIDS Drug Assistance Program (ADAP) Treatments | ||||
| b. AIDS Pharmaceutical Assistance (LPAP) | - - | - - | ||
| c. Early Intervention Services | - - | - - | ||
| d. Health Insurance Premium & Cost Sharing Assistance | - - | |||
| e. Home and Community-based Health Services | - - | |||
| f. Home Health Care | - - | - - | ||
| g. Hospice | - - | - - | ||
| h. Medical Case Management (including Treatment Adherence Services) | - - | - - | ||
| i. Medical Nutrition Therapy | - - | - - | ||
| j. Mental Health Services | - - | - - | ||
| k. Oral Health Care | - - | - - | ||
| l. Outpatient /Ambulatory Health Services | - - | - - | ||
| m. Substance Abuse Outpatient Care | - - | - - | ||
| 11. Support Services Sub-total | $0 | - - | $0 | - - |
| a. Child Care Services | - - | - - | ||
| b. Emergency Financial Assistance | - - | - - | ||
| c. Food Bank/Home-Delivered Meals | - - | - - | ||
| d. Health Education/Risk Reduction | - - | - - | ||
| e. Housing | - - | - - | ||
| f. Linguistics Services | - - | - - | ||
| g. Medical Transportation Services | - - | - - | ||
| h. Non-Medical Case Management Services | - - | - - | ||
| i. Other Professional Services | - - | - - | ||
| j. Outreach Services | - - | - - | ||
| k. Psychosocial Support Services | - - | - - | ||
| l. Referral for Health Care and Support Services | - - | - - | ||
| m. Rehabilitation Services | - - | - - | ||
| n. Respite Care | - - | - - | ||
| o. Substance Abuse Residential Services | - - | - - | ||
| 12. Total Funding Amounts | $0 | - - | $0 | - - |
| (1) May not exceed 5% of the FY 2017 RWHAP Part B Supplemental Program award, or $3 million, whichever amount is smaller. | ||||
| (2) May not use more than 10% of the FY 2017 RWHAP Part B Supplemental Program award for either Planning and Evaluation or Recipient Administration; additionally, the combined costs for these two categories may not exceed 15% of the FY 2016 RWHAP Part B Supplemental award. | ||||
| (3) All services in this column are considered Support Services. | ||||
| Automatic Calculation of FY 2017 RWHAP Part B Supplemental Program Award Allocations Core Medical & Support Services |
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| Recipient Name: | |||||
| This table is provided for grantees to automatically calculate their total Core Medical Service allocations/percentages across all FY 2017 RWHAP Part B Supplemental Program Award service dollars. | |||||
| The figures below reflect the amounts entered in the Suppl Allocations Report (yellow tab). | |||||
| Core Medical Services Allocations | Amount | Percentage (Amount / Total Service Allocations) |
|||
| ADAP (B12) | $0 | - - | |||
| Health Insurance Premium & Cost Sharing Assistance (B16) | $0 | - - | |||
| Home-and Community-based Health Services (B17) | $0 | - - | |||
| State-Direct Services: Core Medical Services (D29) | $0 | - - | |||
| Total Core Medical Services Allocations | $0 | - - | |||
| Support Services Allocations | Amount | Percent | |||
| Consortia Services (B18) + Consortia Administration (B19) | $0 | - - | |||
| State-Direct Services: Support Services (D43) | $0 | - - | |||
| Total Support Services Allocations | $0 | - - | |||
| Total FY 2017 RWHAP Part B Supplemental Program Award Core Medical & Support Services Allocations Amount |
$0 | - - | |||
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |