| FY17 RWHAP Part B & MAI Expenditures Report | |||||||||||||
| Detailed instructions for completing and submitting this report can be found in the Electronic Handbooks and download from the web: https://grants.hrsa.gov/webexternal/Login.asp |
Section B: Reporting Year Award Information | Award Amount | Prior Year Carryover | Total Avail. Funds | |||||||||
| 1. RWHAP Part B Base Award | $0 | ||||||||||||
| 2. RWHAP Part B ADAP Earmark Award | $0 | ||||||||||||
| 3. RWHAP Part B ADAP Supplemental Award | $0 | ||||||||||||
| Section A: Identifying Information | 4. Total RWHAP Part B Base + ADAP + ADAP Supplemental Funds | $0 | $0 | $0 | |||||||||
| ~ Enter Name of Recipient Here ~ | 5. RWHAP Part B Emerging Communities Award | $0 | |||||||||||
| ~ Enter Preparer's Name Here ~ | 6. RWHAP Part B Supplemental Award | ||||||||||||
| ~ Enter Preparer's Phone Number Here ~ | 7. Total RWHAP Part B Funds | $0 | $0 | $0 | |||||||||
| ~ Enter Preparer's Email Address Here ~ | 8. RWHAP Part B MAI Award | $0 | |||||||||||
| 9. Total RWHAP Part B + MAI Funds | $0 | $0 | $0 | ||||||||||
| Section C: RWHAP Part B Expenditures by Program Component | 1. Base Award | 2. ADAP Earmark + ADAP Supplemental | 3. Emerging Communities Award | 4. Total Prior Year Carryover | 5. Total (including carryover) | ||||||||
| Award | Carryover | Percent* | Award | Carryover | Percent* | Award | Carryover | Percent* | Amount | Percent | Amount | Percent | |
| 1. RWHAP Part B AIDS Drug Assistance Program Subtotal | $0 | $0 | - - | $0 | $0 | - - | $0 | - - | $0 | - - | $0 | - - | |
| a. ADAP Services | - - | - - | - - | $0 | - - | $0 | - - | ||||||
| b. Health Insurance to Provide Medications | - - | - - | - - | $0 | - - | $0 | - - | ||||||
| c. ADAP Access/Adherence/Monitoring Services | - - | - - | - - | $0 | - - | $0 | - - | ||||||
| 2. RWHAP Part B Health Insurance Premium & Cost Sharing Assistance | - - | - - | $0 | - - | $0 | - - | |||||||
| 3. RWHAP Part B Home and Community-based Health Services | - - | - - | $0 | - - | $0 | - - | |||||||
| 4. RWHAP Part B HIV Care Consortia (Provide service detail in Sec. D, Column 1 & 4) 1 | $0 | - - | - - | - - | $0 | - - | |||||||
| 4a. RWHAP Part B HIV Care Consortia Administration, Planning & Evaluation2 | - - | - - | $0 | - - | $0 | - - | |||||||
| 5. RWHAP Part B State Direct Services (Provide detail in Sec. D, Column 2 & 4)1 | $0 | $0 | - - | $0 | - - | $0 | - - | $0 | - - | ||||
| 6. RWHAP Part B Clinical Quality Management 3 | - - | - - | - - | $0 | - - | $0 | - - | ||||||
| 7. RWHAP Part B Recipient Planning & Evaluation Activities4 | - - | - - | - - | $0 | - - | $0 | - - | ||||||
| 8. Recipient Administration 4 | - - | - - | - - | $0 | - - | $0 | - - | ||||||
| 9. Column Totals | $0 | $0 | 0.00% | $0 | $0 | 0.00% | $0 | 0.00% | $0 | 0.00% | $0 | 0.00% | |
| 10.Total RWHAP Part B Expenditures (excluding carryover) | $0 | ||||||||||||
| Section D: Breakdown for Consortia, State Direct Services and Emerging Communities | 1. Consortia5 | 2. Direct Services | 3. Emerging Communities 6 | 4. Prior Year Carryover | 5. Total (including carryover) | ||||||||
| Award | Percent | Award | Percent | Award | Percent | Amount | Percent | Amount | Percent | ||||
| 1. Core Medical Services Sub-total | $0 | - - | $0 | - - | $0 | - - | $0 | - - | $0 | - - | |||
| 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 Sub-total | $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 | $0 | - - | $0 | - - | $0 | - - | $0 | - - | $0 | - - | |||
| MAI AWARD | |||||||||||||
| REPORTING YEAR AWARD | PRIOR FY CARRYOVER | TOTAL | |||||||||||
| Section E: MAI Expenditures by Program Component | Amount | Percent | Amount | Percent | Amount | Percent | |||||||
| 1. Education to increase minority participation in ADAP | - - | - - | $0 | - - | |||||||||
| 2. Outreach to increase minority participation in ADAP | - - | - - | $0 | - - | |||||||||
| 3. Clinical Quality Management 3 | - - | - - | $0 | - - | |||||||||
| 4. Recipient Planning & Evaluation Activities 4 | - - | - - | $0 | - - | |||||||||
| 5. Recipient Administration 4 | - - | - - | $0 | - - | |||||||||
| 6. Total MAI Expenditures | $0 | 0.00% | $0 | 0.00% | $0 | 0.00% | |||||||
| * Percent is calculated on the total of the current Fiscal Year award. The percent does not include carryover award. | |||||||||||||
| (1) In the Base Award column ONLY, this cell will automatically calculate based on the detail you provide in Section D. | |||||||||||||
| (2) Administration expenditures for first-line entities is capped at 10% of the aggregate amount allocated for services. Therefore, Consortia Administration, Planning and Evaluation may not exceed 10% of Consortia funds. | |||||||||||||
| (3) May not exceed 5% of the RWHAP Part B award, or 3 million, whichever amount is smaller. | |||||||||||||
| (4) May not exceed 10% of the RWHAP Part B award for either Planning & Evaluation or Recipient Admin. Additionally, the combined costs for these two categories may not exceed 15% of the RWHAP Part B award. | |||||||||||||
| (5) All services in this column are considered Support Services. | |||||||||||||
| (6) In the Emerging Communities Column ONLY, the Total Allocations should equal the combined total of Rows 4 + 5 in Section C, Column 3. | |||||||||||||
| FOR OFFICE USE ONLY: | |||||||||||||
| o Recipient received waiver for 75% core medical services requirement. | |||||||||||||
| LEGISLATIVE REQUIREMENTS CHECKLIST | |||||
| INSTRUCTIONS: Recipients and Project Officers should use the following table to help determine whether or not the various RWHAP 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 Expenditures) |
|||
| ADAP (M16-K16) | $0 | - - | |||
| Home-and Community-based Health Services (M21-K21) | $0 | - - | |||
| Health Insurance Premium & Cost Sharing Assistance (M20 - K20) | $0 | - - | |||
| State-Direct Services: Core Medical Services (D33) | $0 | - - | |||
| Emerging Communities: Core Medical Services (F33) | $0 | - - | |||
| Total Core Medical Services Expenditures | $0 | - - | |||
| Support Services Expenditures | 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 (B69 + B70) | $0 | - - | |||
| Total Support Services Expenditures | $0 | - - | |||
| Total Service Expenditures (excludes carryover dollars) | $0 | ||||
| CLINICAL QUALITY MANAGEMENT | |||||
| Total Clinical Quality Management expenditures 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 you can spend on Clinical Quality Management (the lessor of G12 * .05 or $3 million) as well as the amount of Current Fiscal Year dollars spent (CQM Expenditures) on Clinical Quality Management (M25 - K25) + (F70 - D70). Carryover dollars are excluded from this calculation. Please check to make sure the Expenditures do not exceed the Capped Amount. |
$0 | (Capped Amount) | |||
| $0 | (CQM Expenditures) | ||||
| PLANNING AND EVALUATION / GRANTEE ADMINISTRATION | |||||
| Total RWHAP Part B X07 Planning and Evaluation expenditures and total Recipient Administration expenditures 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 expenditures combined must not exceed 15% of the total X07 award. To the right in red, is the percentage of Planning and Evaluation expenditures divided by the Total X07 award (M26-K26) / G12 and Recipient Administration expenditures divided by the Total X07 award (M27-K27) / G12. 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 expenditures divided by the Total X07 Award (M26+M27-K26-K27) / G12. Carryover dollars are excluded from this calculation. 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 expenditures must be 10% or less than the total Consortia funds. To the right in red, is the percentage of consortia administration expenditures divided by the consortia expenditures (B23/B22). Carryover dollars are excluded from this calculation. Please check to make sure this percentage does not exceed 10%. |
|||||
| $0 | 0.0% | (Consortia Administration) | |||
| EC ADMINISTRATION | |||||
| EC administration expenditures must be 10% or less than the total EC funds. To the right in red, is the percentage of EC administration expenditures divided by the EC award (H27/G8). Carryover dollars are excluded from this calculation. Please check to make sure this percentage does not exceed 10%. |
|||||
| $0 | 0.0% | (EC Administration) | |||
| FY 2017 RWHAP PART B SUPPLEMENTAL EXPENDITURE REPORT INSTRUCTIONS | ||||||||
| Please print this sheet to review instructions. | ||||||||
| Recipients should complete the Suppl Expenditures Report (blue tab) to prepare the required "FY 2017 Ryan White HIV/AIDS Program (RWHAP) Part B Supplemental Expenditures Report". Complete steps 1-4 below and fill the areas or cells highlighted in light yellow with appropriate data. NOTE: Please do not enter any information into cells highlighted in gray, as these cells contain formulas. |
||||||||
| Identifying information (yellow section): Enter the name of the recipient, name of the preparer, and preparer's phone number. | ||||||||
| Award Amounts (gold and yellow sections): Enter the FY 2017 RWHAP Part B Supplemental award amount. | ||||||||
| Section A - Expenditures by Program Component (sky blue section): Enter the amounts spent from the RWHAP Part B Supplemental award. For (Section A) rows 4a & 5 are automatically populated from (Section B) . | ||||||||
| Section B - Breakdown of Final Funding (light green section): This section provides details about funding amounts not captured in Section A. Use the columns provided to enter amounts spent by service category in relation to Consortia and State Direct Services final funding. The grantee should use the calculated amount of Total RWHAP Part B Program Supplemental final funding from Section A row 4a (RWHAP Part B Supplemental HIV Care Consortia) and row 5 (RWHAP Part B Supplemental State Direct Services) when you provide a detailed breakdown of final funding in Section B for Consortia and Direct Services respectively. Rows 10a-m are allowable Core Medical Services; rows 11a-o are allowable Support Services. Formulas will generate sub-totals for Core Medical (row 10) and Support Services (row 11); calculate column percentages; and sum column totals (row 12). | ||||||||
| Reminder: The legislation mandates that ALL Consortia Funding be considered 'Support Services.' Notes: (1) Row 10a is blocked for Consortia and Direct Services because those funding amounts are already accounted for in Section A. (2) Rows 10d (Health Insurance Premium & Cost Sharing Assistance) and 10e (Home and Community-based Health Services) are blocked for Direct Services because these funding amounts are already accounted for in Section A. | ||||||||
| Core Medical Services Calculation (yellow tab worksheet): As amounts are entered in the Funding Table (blue-tab), formulas will automatically calculate the amount and percentage of total RWHAP Part B Supplemental service dollars that were spent for Core Medical Services and for Support Services in FY 2017. | ||||||||
| Reminder: Recipients are reminded that the 75% Core Medical Services Requirement is applicable to the RWHAP Part B Supplemental Award. |
| FY 2017 RWHAP Part B Supplemental Expenditures Report | ||||||||||
| Enter Recipient's Name | ||||||||||
| Enter Preparer's Name | ||||||||||
| Enter Preparer's Phone Number | ||||||||||
| Enter FY 2017 RWHAP Part B Supplemental Award | ||||||||||
| Section A: Expenditures by Program Component | Total FY 2017 RWHAP Part B Supplemental 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 ManagementFootnote 1 | - - | |||||||||
| 7. RWHAP Part B Supplemental Recipient Planning & Evaluation ActivitiesFootnote 2 | - - | |||||||||
| 8. Recipient AdministrationFootnote 2 | - - | |||||||||
| 9. Total RWHAP Part B Supplemental Funding Amounts | $0 | 0.00% | ||||||||
| Section B: Breakdown for Consortia, State Direct Services, and Emerging Communities Final Funding | Consortia Footnote 3 | 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 award, or $3 million, whichever amount is smaller. | ||||||||||
| (2) May not use more than 10% of the FY 2017 RWHAP Program Part B Supplemental award for either Planning and Evaluation or Grantee Administration; | ||||||||||
| additionally, the combined costs for these two categories may not exceed 15% of the FY 2017 RWHAP Part B Supplemental award. | ||||||||||
| (3) All services in this column are considered Support Services. | ||||||||||
| Automatic Calculation of FY 2017 RWHAP Part B Supplemental Core Medical & Support Services Expenditures | |||||||
| Recipient Name: | |||||||
| This table is provided for grantees to automatically calculate their final Core Medical Service funding/percentages across all FY 2017 RWHAP Part B Supplemental Award service dollars. | |||||||
| The cell numbers referenced are shown in blue and come from Suppl Expenditures Report (blue tab). | |||||||
| Core Medical Services Expenditures | Amount | Percent Amount / Total Service Funding | |||||
| 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 Expenditure Amount | $0 | - - | |||||
| Support Services Expenditures | Amount | Percent | |||||
| Consortia Services (B18) | $0 | - - | |||||
| State-Direct Services: Support Services (D43) | $0 | - - | |||||
| Total Support Services Expenditure Amount | $0 | - - | |||||
| Total FY 2017 RWHAP Part B Supplemental Core Medical & Support Services Expenditure Amount | $0 | - - | |||||
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |