B-2 CARES Act Part B Expenditures Report_updated 01.27.2021_

OMB Number (0915-0318)

Expiration date (09/30/2023)

FYXX Ryan White HIV/AIDS Program (RWHAP) Part B Coronavirus Aid, Relief and Economic Security (CARES) Act Expenditures Report

FYXX RWHAP Part B CARES Act (X7C) Expenditures Report

	Current FY	Carryover3	Total
Total RWHAP Part B CARES Act Funds

	Enter Recipient's Name
	Enter Preparer's Name
	Enter Preparer's Phone Number
	Enter FYXX RWHAP Part B CARES Act Award
				FYXX RWHAP Part B CARES Act Award
	Section A: Part B CARES Act Expenditures by Program Component			Current FY				Carryover3			Total
				$		%		$	%		$
	1. RWHAP Part B CARES Act AIDS Drug Assistance Program Subtotal			$0		- -		$0	- -		$0
	a. ADAP Services					- -			- -
	b. Health Insurance to Provide Medications					- -			- -
	c. ADAP Access/Adherence/Monitoring Services					- -			- -
	2. RWHAP Part B CARES Act Health Insurance Premium & Cost Sharing Assistance for Low Income Individuals					- -			- -
	3. RWHAP Part B CARES Act Home and Community-based Health Services					- -			- -
	4a. RWHAP Part B CARES Act HIV Care Consortia (Provide detail in Section B)			$0		- -			- -
	4b. Part B CARES Act HIV Care Consortia Administration2
	5. RWHAP Part B CARES Act State Direct Services (Provide detail in Section B)			$0		- -			- -
	6. RWHAP Part B CARES Act Clinical Quality ManagementFootnote 1					- -			- -
	7. RWHAP Part B CARES Act Recipient Planning & Evaluation ActivitiesFootnote 2					- -			- -
	8. Part B CARES Act Recipient AdministrationFootnote 2					- -			- -
	9. Total RWHAP Part B CARES Act Funding Amounts			$0		0.00%			- -	$0
	Section B: Breakdown of Part B CARES Act Consortia and State Direct Services Final Funding			Current FY				3. Carryover3			4. Total
				1. Consortia		2. Direct Services		$	%		$
				$	%	$	%
	10. Core Medical Services Sub-total			$0	- -	$0-	- -	$0	- -		$0
	a. AIDS Drug Assistance Program (ADAP) Treatments
	b. AIDS Pharmaceutical Assistance				- -	- -	- -		- -
	c. Early Intervention Services				- -	- -	- -		- -
	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				- -		- -		- -
	11. Support Services Sub-total			$0	- -	$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 Services (residential)				- -		- -		- -
	12. Total Funding Amounts			$0	- -	$0	- -	$0	- -		$0
			(1) May not exceed 5% of the FY XXXX RWHAP Part B CARES Act X7C award, or $3 million, whichever amount is smaller.
			(2) May not use more than 10% of the FYXX RWHAP Program Part B CARES Act X7C award for either Planning and Evaluation or Grantee Administration;
			additionally, the combined costs for these two categories may not exceed 15% of the FY XXXX RWHAP Part B CARES Act X7C award.
			(3) Carryover columns do not apply for reporting first year (2020) CARES Act expenditures because there is no previous year funding. Leave the carryover column blank when reporting 2020 CARES Act expenditures.

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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