Form 5 EHE Expenditures Reports

Ryan White HIV/AIDS Program Expenditure Forms

EHE Expendtiure Report

EHE Expenditures Reports

OMB: 0915-0390

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Expenditures Report
UT8HA33 - XXX
Budget Year: 3/1/2021 - 2/28/2022

Report ID: XXX

Report Status: Review

Last Modified Date: 09/07/2022 01:29 PM

Recipient Information

Budget Year Award Information

Official Mailing Address: XXXXX
EIN: XXXX

EHE Grant Award Amount

EHE Approved Carryover Amount

Total EHE Initiative Funds

UEI: XXXX
Preparer's Name: John Smith
Preparer's Title: Grants Analyst
Preparer's Phone: XXX-XXX-XXXX
Preparer's Fax:
Preparer's Email: [email protected]
EHE Program Total
Prior FY Carryover
Amount

Reporting FY

Percent

Amount

Total
Percent

Amount

Percent

Non-Services
a. Clinical Quality Management

b. Recipient Administration

c. Initiative Infrastructure¹

d. Planning and Evaluation²

Non-services Subtotal

e. EHE Initiative Services

f. Core Medical Services

g. Support Services

Total Service Expenditures

Total Expenditures (Service + Non-service)

Printed: 9/7/2022 2:00:30 PM

0
0

Page 1 of 5

Expenditures Report
UT8HA33XXX - XXXXXX
Budget Year: 3/1/2021 - 2/28/2022

Report ID: XXXXX

Report Status: Review

Last Modified Date: 09/07/2022 01:29 PM
EHE Expenditure Categories
Prior FY Carryover
Amount

Reporting FY

Percent

Amount

Total
Percent

Amount

Percent

EHE Initiative Services
$0

0.00%

a. AIDS Drug Assistance Program Treatments

0.00%

b. AIDS Pharmaceutical Assistance

0.00%

c. Early Intervention Services (EIS)

0.00%

d. Health Insurance Premium and Cost Sharing $0
Assistance for Low-Income Individuals

0.00%

e. Home and Community-Based Health
Services

0.00%

f. Home Health Care

0.00%

g. Hospice

0.00%

h. Medical Case Management, including
Treatment Adherence Services

0.00%

i. Medical Nutrition Therapy

0.00%

j. Mental Health Services

0.00%

2.84%

0.00%

k. Oral Health Care

0.00%

l. Outpatient/Ambulatory Health Services

0.00%

m. Substance Abuse Outpatient Care

0.00%

2. Core Medical Services Total

0.00%

a. Child Care Services

0.00%

b. Emergency Financial Assistance

0.00%

c. Food Bank/Home Delivered Meals

0.00%

d. Health Education/Risk Reduction

0.00%

e. Housing

0.00%

1. Ending the HIV Epidemic Initiative
Services³
Core Medical Services

Support Services

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Page 2 of 5

Expenditures Report
UT8HA33XXX - XXXXXX
Budget Year: 3/1/2021 - 2/28/2022

Report ID: XXXXX

Report Status: Review

Last Modified Date: 09/07/2022 01:29 PM
EHE Expenditure Categories
Prior FY Carryover
Amount

Reporting FY

Percent

Amount

Total
Percent

Amount

Percent

f. Linguistic Services

0.00%

g. Medical Transportation

0.00%

h. Non-Medical Case Management Services

0.00%

i. Other Professional Services

0.00%

j. Outreach Services

0.00%

k. Psychosocial Support Services

0.00%

l. Referral for Health Care and Support
Services

0.00%

m. Rehabilitation Services

0.00%

n. Respite Care

0.00%

o. Substance Abuse Services (residential)

0.00%

3. Support Services Total

0.00%

4. Total Service Expenditures

0.00%

EHE Award and Expenditure Summary
Award

Expenditure

Balance

1.EHE Award Amount

2. EHE Approved Carryover Amount

3. Total

¹ Infrastructure are costs associated with the development and expansion of data systems. It may include technical assistance on the type, design, and
building of new data systems, bridging existing systems to achieve data integration, improving data entry to decrease burden and increase accuracy,
training of staff and providers on collecting and using data, and employing experts to provide accurate and in-depth data analysis.
² Planning and evaluation are costs associated with stakeholder engagement and process and outcome evaluation activities.
³ EHE Initiative Services are costs associated with a broader approach to addressing HIV in the community than exists in services authorized by the
RWHAP legislation. For example, the only requirement for determining eligibility is that the individual has an HIV diagnosis. There is no requirement that
individuals served are low-income or that initial eligibility is documented prior to services being provided. Initiative services are services and activities
that do not fit neatly within the RWHAP service categories (e.g., linkage to care). These services may be innovative and creative with a focus on ending
the HIV epidemic
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Page 3 of 5

Expenditures Report
UT8HA33X - XXXXX
Budget Year: 3/1/2021 - 2/28/2022

Report ID: XXXX

Report Status: Review

Last Modified Date: 09/07/2022 01:29 PM
Legislative Requirements Checklist

No more than 5% of your total award or $3 million (whichever is smaller) can be spent on Clinical Quality Management.
When reporting Clinical Quality Management expenses, the Current FY totals for Part A AWARD and MAI AWARD columns do not necessarily need to meet this requirement as long as the
combined total meets the 5% or $3 million (whichever is smaller) requirement.
Below is the maximum (Capped Amount) you can spend on Clinical Quality Management (the lesser of Total Part A Funds for Current FY * 0
. 5 or $3 million) as well as the amount of Current
Fiscal Year dollars spent (CQM Expenditures) on Clinical Quality Management (Current FY Clinical Quality Management for Part A + Current FY Clinical Quality Management for MAI).
Please check to make sure your Expenditures do not exceed your Capped Amount.
Expenditures

Amount

Capped Amount

Clinical Quality Management

No more than 10% of your total award can be spent on Recipient Administration.
When reporting Recipient Administration expenses, the Current FY totals for Part A and MAI Recipient Administration expenses do not necessarily need to meet this requirement as long as
the combined total meets the 10% or less requirement.
Below is the percentage of your Current Fiscal Year Recipient Administration expenditures divided by your Total Part A Award. Please check to make sure this percentage is not greater than
10%.
Expenditures

Amount

Capped Amount

Admin Expenditures

Public Burden Statement:
The purpose of this data collection system is to collect allocations/expenditures information regarding Ending the HIV Epidemic initiative grant 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 4 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]

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File Upload
UT8HA33 - XXXXXX
Budget Year: 3/1/2021 - 2/28/2022

Report ID: XXXXX

Report Status: Review

Last Modified Date: 09/07/2022 01:29 PM

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Printed: 9/7/2022 2:00:30 PM

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File Type	application/pdf
File Title	MainExpenditureReport
File Modified	2023-05-22
File Created	2022-09-07