5

---

Overview

Allocations Report
CHECKLIST

---

Sheet 1: Allocations Report

FY 2008 Part C Allocations Report
Section A: Identifying Information
~ Enter Name of Grantee Here ~
~ Enter Grant Number Here ~
~ Enter Preparer's Name Here ~
~ Enter Preparer's Phone Number Here ~
~ Enter Preparer's Email Address Here ~
Section B: FY 2008 Award Information
1. Part C Grant Award Amount
Section C: Allocations Categories	Amount	Percent
1. Core Medical Services Subtotal1 (see CHECKLIST)	$0	0%
a. Outpatient /Ambulatory Health Services		- -
b. AIDS Drug Assistance Program (ADAP) Treatments		- -
c. AIDS Pharmaceutical Assistance (local)		- -
d. Oral Health Care		- -
e. Health Insurance Premium & Cost Sharing Assistance		- -
f. Home Health Care		- -
g. Home and Community-based Health Services		- -
h. Hospice Services		- -
i. Mental Health Services		- -
j. Medical Nutrition Therapy		- -
k. Medical Case Management (including Treatment Adherence)		- -
l. Substance Abuse Services - outpatient		- -
2. Support Services Subtotal	$0	0%
a. Case Management (non-Medical)		- -
b. Health Education/Risk Reduction		- -
c. Linguistics Services		- -
d. Medical Transportation Services		- -
e. Outreach Services		- -
f. Psychosocial Support Services		- -
g. Referral for Health Care/Supportive Services		- -
h. Rehabilitation Services		- -
i. Respite Care		- -
j. Treatment Adherence Counseling		- -
3. Total Service Allocations	$0	- -
4. Non-services Subtotal	$0	- -
a. Clinical Quality Management Activities1 (see CHECKLIST)		- -
b. Grantee Administration2 (see CHECKLIST)		- -
5. Total Allocations (Service + Non-service)4 (see CHECKLIST)	$0	- -
FOR OFFICE USE ONLY:
o Grantee received waiver for 5% clinical quality management activities.
o Grantee received waiver for 75% core medical services requirement.
NOTE: Detailed instructions for completing and submitting your report can be downloaded from the HRSA Electronic Handbook: https://grants.hrsa.gov/webexternal/Login.asp

---

Sheet 2: CHECKLIST

FY 2008 Part C Allocations Report Checklist
OMB No. 0915-xxxx Expiration Date:
	Please check the following before submitting your report!
1	75% of your award must be spent on core medical services. After meeting the requirements below, if this percentage is less than 75%, you must adjust your report so that at least 75% of your grant award is allocated to core medical services.	0.0%
2	You may not spend more than 5% on clinical quality management unless you have received a waiver from the Division of Community Based Programs. If this percentage is more than 5% you must have received a waiver from the Division of Community Based Programs.	0.0%
3	You may not spend more than 10% on grantee administration. If this percentage is more than 10%, you must adjust your report accordingly.	0.0%
4	You must allocate your entire award. This amount will equal zero if you allocated the entire amount listed in Section B. The amount in Section B must match the amount on your NGA. If this amount does not equal zero, you must adjust your report accordingly.	$0
	NOTE: Detailed instructions for completing and submitting your report can be downloaded from the HRSA Electronic Handbook: https://grants.hrsa.gov/webexternal/Login.asp