Form D-2 Part D Expenditures Report

Part D Expenditures Report

FYXX RWHAP Part D Expenditures Report
Section A: Identifying Information			OMB Number (0915-0318) Expiration date (XX/XX/201X)
~ Enter Name of Recipient Here ~
~ Enter Grant Number Here ~
~ Enter Preparer's Name Here ~
~ Enter Preparer's Phone Number Here ~
~ Enter Preparer's Email Address Here ~
Section B: Reporting FY Award Information
RWHAP Part D Recipient Award Amount
	REPORTING FY		PRIOR FY CARRYOVER		TOTAL
Section C: Expenditure Categories	Amount	Percent	Amount	Percent	Amount	Percent
1. Medical Services Subtotal	$0	0%	$0	0%	$0	0%
a. AIDS Drug Assistance Program (ADAP) Treatments		- -		- -	$0	- -
b. AIDS Pharmaceutical Assistance		- -		- -	$0	- -
c. Health Insurance Premium & Cost Sharing Assistance for Low Income Individuals		- -		- -	$0	- -
d. Home and Community-based Health Services		- -		- -	$0	- -
e. Home Health Care		- -		- -	$0	- -
f. Hospice		- -		- -	$0	- -
g. Medical Case Management (including Treatment Adherence Services)		- -		- -	$0	- -
h. Medical Nutrition Therapy		- -		- -	$0	- -
i. Mental Health Services		- -		- -	$0	- -
j. Oral Health Care		- -		- -	$0	- -
k. Outpatient /Ambulatory Health Services		- -		- -	$0	- -
l. Substance Abuse Outpatient Care		- -		- -	$0	- -
2. Support Services Sub-total	$0	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 Service Expenditures	$0	- -	$0	- -	$0	- -
4. Non-services Subtotal	$0	- -	$0	- -	$0	- -
a. Clinical Quality Management Activities (See Legislative Requirements)		- -		- -	$0	- -
b. Administrative (See Legislative Requirements)		- -		- -	$0	- -
c. Indirect Costs (See Legislative Requirements)		- -		- -	$0	- -
5. Total Expenditures	$0	- -	$0	- -	$0	- -

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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