B-4 TC Part B X08 Expenditures Report 4_9_2021_tracked changes.

RWHAP Part B Supplemental Grant Award Amount	Need to add carryover box
RWHAP Part B Supplemental Approved Carryover Amount
Total RWHAP Part B Supplemental Funds

OMB Number 0915-0318

Expiration date 09/30/2023

	Total
	Add Carryover Column	Award	Total	Percent
1. RWHAP Part B Supplemental AIDS Drug Assistance Program Subtotal
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
4b. RWHAP Part B Supplemental HIV Care Consortia/ Administration	Should be blacked out as carryover cannot be used for administration
5. RWHAP Part B Supplemental State Direct Services
6. RWHAP Part B Supplemental Clinical Quality Management	Should be blacked out as carryover cannot be used for CQM
7. RWHAP Part B Supplemental Recipient Planning & Evaluation Activities	Should be blacked out as carryover cannot be used for administration
8. Recipient Administration	Should be blacked out as carryover cannot be used for administration
9. Column Totals

	Consortia				Direct Services
	Add Carryover Column	Amount	Total	Percent	Add Carryover Column	Amount	Total	Percent
Core Medical Services
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				- -				- -
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 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
2. Support Services Total
3. Total Service Expenditures

Core Medical Services Expenditures	Amount	Percentage (Amount / Total Service Expenditures)
ADAP
Health Insurance Premium & Cost Sharing Assistance
Home-and Community-based Health Services
State-Direct Services: Core Medical Services
Total Core Medical Services Expenditures
Support Services Expenditures	Amount	Percent
Consortia Services
State-Direct Services: Support Services
Total Support Services Expenditures
Total RWHAP Part B Supplemental Core Medical & Support Services 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 RWHAP Part B supplemental 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 09/30/2023. 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 2 hours 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]