Form A-2 Part A Expenditures Report

Part A Expenditures Report OMB Number (0915-0318)

Expiration date (XX/XX/201X)

FYXX RWHAP Part A Expenditures Report

Current FY

Carryover

Total

1. RWHAP Part A Formula Award Amount

2. RWHAP Part A MAI Award Amount

3. RWHAP Part A Supplemental Award Amount

4. Total RWHAP Part A Funds

RWHAP Part A Formula Award Amount

RWHAP Part A MAI Award

RWHAP Part A Supplemental Award Amount

Aggregate Total

Current FY

Carryover

Total

Current FY

Carryover

Total

Current FY

Total

$

%

$

%

$

$

%

$

%

$

$

%

$

$

Non-Services

a. Clinical Quality Management

b. Administration

Non-services Subtotal

c. Core Medical Services

d. Support Services

Total Service Expenditures

Total Expenditures (Service + Non-service)

RWHAP Part A Formula Award Amount

RWHAP Part A MAI Award Amount

RWHAP Part A Supplemental Award Amount

Aggregate Total

Current FY

Carryover

Total

Current FY

Carryover

Total

Current FY

Total

$

%

$

%

$

$

%

$

%

$

$

%

$

$

%

Core Medical Services

a. AIDS Drug Assistance Program (ADAP) Treatments

b. AIDS Pharmaceutical Assistance

c. Early Intervention Services (EIS)

d. Health Insurance Premium & Cost Sharing Assistance for Low Income Individuals

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

1. Core Medical Services Total

Support Services

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

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 Services (residential)

2. Support Services Total

3. Total Service Expenditures

RWHAP Part A Award

Expenditures

Balance

1. RWHAP Part A Formula Award Amount

2. RWHAP Part A Formula Carryover Amount

3. RWHAP Part A MAI Award Amount

4. RWHAP Part A MAI Carryover Amount

5. RWHAP Part A Supplemental Award

3. Total

- validation: total exp should not be > grant award $

 Recipient received waiver for core medical services requirement.

 I, <PO First Name> <PO Last Name>, confirm that the Core Medical Services waiver as reported by the recipient is correct

<-- display for PO only. Checkbox disabled when recipient did not select the 75% checkbox

Public Burden Statement: The purpose of this data collection system is to collect aggregate data on the number of new and existing clients, and clients who have been out of care treated with EHE initiative funding. HAB will use these data to show the impact of the increased funding on reducing new HIV infections, identifying new HIV infections, engaging clients in care and treatment. 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 control number. The OMB control number for this information collection is 0915-0318 and it is valid until XX/XX/202X. This information collection is mandatory (through increased Authority under the Public Health Service Act, Section 311(c) (42 USC 243(c)) and title XXVI (42 U.S.C. §§ 300ff-11 et seq.). Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or [email protected]