Form 10-397a Other Grantee Performance Report

OMB Control Number: 2900-XXXX

Estimated burden: 30 minutes

Expiration Date: XX/XX/20XX

U.S. Department of Veterans Affairs

Telehealth Grant Program (THGP)

Other Grantee Performance Report

VA Burden Statement: 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 project is 2900-XXXX, and it expires XX/XX/20XX. Public reporting burden for this collection of information is estimated to average 30 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate and any other aspect of this collection of information, including suggestions for reducing the burden, to VA Reports Clearance Officer at [email protected]. Please refer to OMB Control No. 2900-XXXX in any correspondence. Do not send your completed VA Form 10-397a to this email address.

Privacy Act Statement: VA is asking you to provide the information requested in this form under the authority of section 701 of Public Law 116-171 for VA to determine your eligibility to receive a grant under the Telehealth Grant Program. VA may disclose the information that you put on the form as permitted by law. VA may make a "routine use" disclosure of the information for: civil or criminal law enforcement; congressional communications; the collection of money owed to the United States; litigation in which the United States is a party or has interest; the administration of VA grant programs, including verification of your eligibility to participate; and personnel administration. You do not have to provide the requested information to VA; but if you do not, VA may be unable to process your request for consideration in this program. If you provide VA with your Employer Identification Number (EIN), VA will use it to obtain information relevant to determining whether to award a grant and to administer your grant, if awarded. This information also may be used for other purposes as authorized or required by law.

Grantee Name: ________________________________________________________________

Grant Award Number: ______________________

Grant Amount: ____________________________

Name and Title of Contact Completing Form:

______________________________________________________________________________

Contact Email: _________________________________________________________________

Date Report due: _________________________________ Date Submitted: _____________________

OVERVIEW:

Describe any significant events (positive and negative) that occurred within your program during this year (For example, leadership change, staff). Explain how these events impacted your performance.

Do you require additional assistance from the CDR Hannon TH Grant Program Team? If so, please specify the nature of the assistance required.

TELEHEALTH ACCESS STATION SETUP / TRAINING

Please provide overview of your progress toward the following implementation steps:

• Telehealth Access Station Points of Contact established

• Telehealth Access Station setup complete

• Attendant training complete

OUTREACH, SITE AND CLINICAL OPENING

Please provide overview of your progress toward the following implementation steps:

• Telehealth Access Station outreach begins

• Site opening event complete

• Telehealth Access Station services begin

PROGRAM GOALS AND OUTCOMES

Please describe your progress towards the CDR Hannon TH Grant Program goals of

• Expansion of existing telehealth capabilities

• Provision of a Telehealth Access Station to beneficiaries who are in rural, highly rural, or medically underserved areas

• Other goals as outlined in application

VA is interested in learning about strong practices in the field. Please describe strong practices, performance improvement opportunities, and lessons learned from the implementation of your Telehealth Access Station. Please include any Veteran feedback obtained, challenges and mitigating solutions.

Confirm that your program’s data for 100% of participants has been reported accurately to the VA

☐Yes ☐No If No, please explain why.

HHS ACCOUNTS AND DRAWDOWNS

Confirm that the payment requests from HHS Payment Management System reflect actual spending.

☐Yes ☐No If No, please explain why.

Confirm that all expenditures are for costs approved on the CDR Hannon TH Grant Program Budget.

☐Yes ☐No If No, please explain why.

Did you request modifications to your approved CDR Hannon TH Grant Program Budget this reporting period?

☐Yes ☐No

If Yes, please confirm that you have received approval from the CDR Hannon TH Grant Program Team for any modifications made to your approved CDR Hannon TH Grant Program budget.

☐Yes ☐No If No, please explain why.

Confirm that all spending is in compliance with eCFR :: 2 CFR Part 200.

☐Yes ☐No If No, please explain why.

FINANCIAL EXPENDITURE REPORT and FINANCIAL STATUS REPORT

CDR Hannon TH grantees are required to submit the Federal Financial Report (FFR Financial Status Report). Grantees must complete this report within the HHS Payment Management System, available through the Disbursement menu option in the HHS PMS system, no later than 45 days after the end of the project period. Instructions can be found within the HHS PMS web site: http://www.dpm.psc.gov/training/ffr_training.aspx?explorer.event=true

CDR Hannon TH grantees are required to comply 2 CFR 200.501 Audit requirements. a non-Federal entity that expends $750,000 or more during the non-Federal entity’s fiscal year in Federal awards must have a single or program-specific audit conducted for that year in accordance with the provisions of this part.(b) Single audit. A non-Federal entity that expends $750,000 or more during the non-Federal entity’s fiscal year in Federal awards must have a single audit conducted in accordance with§ 200.514 Scope of audit

If a grantee expends less than $750,000 per year in federal awards, it is exempt from the audit requirements for that year. However, records must be available for review or audit by VA, the VA Financial Services Center and/or the U.S. Government Accountability Office (GAO).

I certify that our agency has completed the required FFR Financial Status Reports (FSR) for this grant award in the HHS Payment Management System prior to the submission of this annual report.

☐Yes ☐No If No, please explain why.

Please attach your completed final expenditure report.

This is the Financial Expenditure Report (Microsoft Excel) provided to grantees by VA. Instructions for completing this report are located within the Excel file. Financial reports created external to VA will not be accepted nor will modified versions of the VA’s customized Financial Expenditure Report

Have you complied with all the terms of your CDR Hannon TH Grant Program services grant agreement this review period? If no, please explain.

☐Yes ☐No If No, please explain why.

Additional feedback for CDR Hannon TH Grant Program Team:

CERTIFICATION AND SUBMISSION

I certify that I am authorized to submit this response on behalf of this grant program.

Please note: Documentation supporting all certifications must be maintained by the grantee and made available for monitoring visits and audits.

Signature__________________________________ Date ____________________

Telehealth Grant Number

VA Form 10-397a

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