| FY 2008 Part B & MAI Allocations Report OMB No. 0915-xxxx Expiration Date: |
|
| Detailed instructions for completing and submitting this report can be
found in the Electronic Handbooks and download from the web:
https://grants.hrsa.gov/webexternal/Login.asp |
Section B: FY 2008 Award Information |
| 1. Part B Base Award |
|
| 2. Part B ADAP Earmark Award |
|
| 3. Part B Supplemental Award |
|
| Section A: Identifying Information |
|
4. Total Part B ADAP + Supplemental Award |
$0 |
| ~ Enter Name of Grantee Here ~ |
|
5. Part B Emerging Communities Award |
|
| ~ Enter Preparer's Name Here ~ |
|
6. Total Part B Award |
$0 |
| ~ Enter Preparer's Phone Number Here ~ |
|
7. Part B MAI Award |
|
| ~ Enter Preparer's Email Address Here ~ |
|
8. Total Part B + MAI Award |
$0 |
|
| Section C: Part B Allocations by Program Component |
1. Base Award |
2. ADAP Earmark + Supplemental Award |
3. Emerging Communities Award |
4. Total |
| Amount |
Percentage |
Amount |
Percentage |
Amount |
Percentage |
Amount |
Percentage |
| 1. Part B AIDS Drug Assistance Program Subtotal |
$0 |
- - |
$0 |
- - |
$0 |
- - |
$0 |
- - |
| a. ADAP Services |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| b. Health Insurance to Provide Medications |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| c. ADAP Access/Adherence/Monitoring Services |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| 2. Part B Health Insurance Premium & Cost Sharing Assistance |
|
- - |
|
|
|
- - |
$0 |
- - |
| 3. Part B Home and Community-based Health Services |
|
- - |
|
|
|
- - |
$0 |
- - |
| 4. Part B HIV Care Consortia Services (Provide detail in Section D, Column 1) 1 |
$0 |
- - |
|
|
|
- - |
$0 |
- - |
| 5. Part B State Direct Services (Provide detail in Section D, Column 2)1 |
$0 |
- - |
|
|
|
- - |
$0 |
- - |
| 6. Part B Clinical Quality Management2 |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| 7. Part B Grantee Planning & Evaluation Activities3 |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| 8. Grantee Administration 3 |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| 9. Column Totals |
$0 |
- - |
$0 |
- - |
$0 |
- - |
$0 |
- - |
| 10.Total Part B Allocations4 |
$0 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Section D: Breakdown for Consortia, State Direct Services and Emerging Communities |
1. Consortia5 |
2. Direct Services |
3. Emerging Communities 6 |
4. Total |
| Amount |
Percentage |
Amount |
Percentage |
Amount |
Percentage |
Amount |
Percentage |
| 1. Core Medical Services Sub-total7 |
$0 |
- - |
$0 |
- - |
$0 |
- - |
$0 |
- - |
| a. Outpatient /Ambulatory Health Services |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| b. AIDS Drug Assistance Program (ADAP) Treatments |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| c. AIDS Pharmaceutical Assistance (local) |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| d. Oral Health Care |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| e. Early Intervention Services |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| f. Health Insurance Premium & Cost Sharing Assistance |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| g. Home Health Care |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| h. Home and Community-based Health Services |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| i. Hospice Services |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| j. Mental Health Services |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| k. Medical Nutrition Therapy |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| l. Medical Case Management (including Treatment Adherence) |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| m. Substance Abuse Services–outpatient |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| 2. Support Services Sub-total |
$0 |
- - |
$0 |
- - |
$0 |
- - |
$0 |
- - |
| a. Case Management (non-Medical) |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| b. Child Care Services |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| c. Emergency Financial Assistance |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| d. Food Bank/Home-Delivered Meals |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| e. Health Education/Risk Reduction |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| f. Housing Services |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| g. Legal Services |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| h. Linguistics Services |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| i. Medical Transportation Services |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| j. Outreach Services |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| k. Psychosocial Support Services |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| l. Referral for Health Care/Supportive Services |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| m. Rehabilitation Services |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| n. Respite Care |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| o. Substance Abuse Residential Services |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| p. Treatment Adherence Counseling |
|
- - |
|
- - |
|
- - |
$0 |
- - |
| 3. Total |
$0 |
- - |
$0 |
- - |
$0 |
- - |
$0 |
- - |
|
|
MAI Award |
|
| Section E: MAI Allocations by Program Component |
Amount |
Percentage |
|
| 1. Education to increase minority participation in ADAP |
|
- - |
|
FOR OFFICE USE ONLY: |
| 2. Outreach to increase minority participation in ADAP |
|
- - |
|
o Grantee received waiver for 75% core medical services requirement. |
| 3. Clinical Quality Management 2 |
|
- - |
|
| 4. Grantee Planning & Evaluation Activities 3 |
|
- - |
|
| 5. Grantee Administration 3 |
|
- - |
|
| 6. Total MAI Allocations5 |
$0 |
0% |
|
| (1) In the Base Award column ONLY, this cell will automatically calculate based on the detail you provide in Section D. |
| (2) May not exceed 5% of the Part B award, or 3 million, whichever amount is smaller. |
| (3) May not exceed 10% of the Part B award for either Planning & Evaluation or Grantee Admin. Additionally, the combined costs for these two categories may not exceed 15% of the Part B award. |
| (4) This amount must equal the combined total of the Part B Base, ADAP, ADAP Supplemental, and Emerging Communities awards. |
| (5) All services in this column are considered Supprt Services. |
| (6) In the Emerging Communities Column ONLY, the Total Allocations should equal the combined total of Rows 4 + 5 in Section C, Column 3. |