| FY08 Part D Allocations Report OMB No. 0915-xxxx Expiration Date: |
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| Section A: Identifying Information |
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| ~ Enter Name of Grantee Here ~ |
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| ~ Enter Grant Number Here ~ |
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| ~ Enter Preparer's Name Here ~ |
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| ~ Enter Preparer's Phone Number Here ~ |
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| ~ Enter Preparer's Email Address Here ~ |
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| Section B: FY 2008 Award Information |
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| 1. Part D Grant Award Amount |
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| Section C: Allocations Categories |
Amount |
Percent |
| 1. Medical Services Subtotal |
$0 |
0% |
| a. Outpatient /Ambulatory Health Services |
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- - |
| b. AIDS Pharmaceutical Assistance (local) |
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- - |
| c. Oral Health Care |
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- - |
| d. Home Health Care |
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- - |
| e. Home and Community-based Health Services |
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- - |
| f. Hospice Services |
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- - |
| g. Mental Health Services |
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- - |
| h. Medical Nutrition Therapy |
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- - |
| i. Medical Case Management (including Treatment Adherence) |
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- - |
| j. Substance Abuse Services - outpatient |
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- - |
| 2. Support Services Sub-total |
$0 |
0% |
| a. Case Management (non-Medical) |
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- - |
| b. Child Care Services |
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- - |
| c. Pediatric Developmental Assessment / Early Intervention Services |
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- - |
| d. Emergency Financial Assistance |
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- - |
| e. Food Bank/Home-Delivered Meals |
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- - |
| f. Health Education/Risk Reduction |
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- - |
| g. Legal Services |
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- - |
| h. Linguistics Services |
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- - |
| i. Medical Transportation Services |
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- - |
| j. Outreach Services |
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- - |
| k. Permanency Planning |
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- - |
| l. Psychosocial Support Services |
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- - |
| m. Referral for Health Care/Supportive Services |
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- - |
| n. Rehabilitation Services |
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- - |
| o. Respite Care |
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- - |
| p. Treatment Adherence Counseling |
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- - |
| 3. Total Service Allocations |
$0 |
- - |
| 4. Non-services Subtotal |
$0 |
- - |
| a. Clinical Quality Management Activities |
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- - |
| b. Grantee Administration1 |
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- - |
| c. Indirect Costs |
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- - |
| 5. Total Allocations (Services + Non-services)2 |
$0 |
- - |
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| (1) May not exceed 10% of Part D award. |
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| (2) Must equal the total Part D award. |
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| NOTE: Detailed instructions for completing and submitting your report can be downloaded from the HRSA Electronic Handbook: https://grants.hrsa.gov/webexternal/Login.asp |