B-1 Part B Allocations Report

Part B X07 Allocations Report OMB Number (0915-0318)

Expiration date (XX/XX/201X)

FYXX Ryan White HIV/AIDS Program (RWHAP) Part B (X07) Allocations and Minority AIDS Initiative (MAI) Report
				Section B: Reporting Year Award Information
				1. Part B Base Award
				2. Part B ADAP Base 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 for Low Income Individuals		- -				- -	$0	- -
3. Part B Home and Community-based Health Services		- -				- -	$0	- -
4a. Part B HIV Care Consortia (Provide detail in Section D, Column 1 or 3)1	$0	- -			$0	- -	$0	- -
4b. Part B HIV Care Consortia Administration2		- -				- -	$0	- -
#. Part B Emerging Community Services
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		- -				- -	$0	- -
c. Early Intervention Services		- -		- -		- -	$0	- -
d. Health Insurance Premium & Cost Sharing Assistance for Low Income Individuals		- -		- -			$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.
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: 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]

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