| Allocations Report | ||||||||
| Grant Number and Name: | Budget Period: | |||||||
| Report Status: Accepted | Last Modified Date: | |||||||
| Contact Information of the Person Responsible for This Submission | Award Information | |||||||
| Preparer's Name: | RWHAP Part A Formula Award Amount | $0.00 | ||||||
| Preparer's Phone: | RWHAP Part A Supplemental Award Amount | $0.00 | ||||||
| Preparer's Email: | RWHAP Part A MAI Award Amount | $0.00 | ||||||
| Total RWHAP Part A Funds | $0.00 | |||||||
| RWHAP Part A Program Allocation Totals | ||||||||
| RWHAP Part A Formula and Supplemental Allocation Amounts | RWHAP Part A MAI Allocation Amounts | Total RWHAP Part A Allocation Amounts | ||||||
| Amount | Percent | Amount | Percent | Amount | Percent | |||
| Non-Services | ||||||||
| a. Clinical Quality Management | $0.00 | -- | ||||||
| b. Administrative | $0.00 | -- | ||||||
| Non-services Allocation Subtotal | $0.00 | 0.00% | ||||||
| c. Core Medical Services | $0.00 | |||||||
| d. Support Services | $0.00 | |||||||
| Service Allocation Subtotal | $0.00 | $0.00 | $0.00 | -- | ||||
| Total Allocations (Service + Non-service) |
$0.00 | $0.00 | $0.00 | |||||
| RWHAP Part A and MAI Service Category Allocations | ||||||||
| RWHAP Part A Formula and Supplemental Allocation Amounts | RWHAP Part A MAI Allocation Amounts | Total RWHAP Part A Allocation Amounts | ||||||
| Service | Amount | Percent | Amount | Percent | Amount | Percent | ||
| Core Medical Services | ||||||||
| 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 Assistance for Low-Income Individuals | $0.00 | -- | ||||||
| e. Home and Community-Based Health Services | $0.00 | -- | ||||||
| f. Home Health Care | $0.00 | -- | ||||||
| g. Hospice Services | $0.00 | -- | ||||||
| h. Medical Case Management, including Treatment Adherence Services | $0.00 | -- | ||||||
| i. Medical Nutrition Therapy | $0.00 | -- | ||||||
| j. Mental Health Services | $0.00 | -- | ||||||
| k. Oral Health Care | $0.00 | -- | ||||||
| l. Outpatient/Ambulatory Health Services | $0.00 | -- | ||||||
| m. Substance Abuse Outpatient Care | $0.00 | -- | ||||||
| 1. Core Medical Services Allocation Subtotal | $0.00 | 0.00% | $0.00 | 0.00% | $0.00 | 0.00% | ||
| Support Services | ||||||||
| 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 | -- | ||||
| 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 | -- | ||||
| 2. Support Services Allocation Subtotal | $0.00 | 0.00% | $0.00 | 0.00% | $0.00 | 0.00% | ||
| 3. Service Allocations Total | $0.00 | - - | $0.00 | - - | $0.00 | - - | ||
| Recipient received waiver for 75% core medical services requirement: | No | |||||||
| Legislative Requirements Checklist | ||||||||
| Core Medical Services (CMS) Allocation Requirement: At least 75% of your total service allocations must be allocated on core medical services (unless a Core Medical Services waiver has been approved). | ||||||||
| When reporting CMS allocations, the Total RWHAP Part A Allocation Amounts for CMS must be at least 75% of Total Service Allocations unless a CMS waiver was approved. To the right is the percentage of your Current Fiscal Year (FY) CMS Allocations divided by your Total Part A Formula, Supplemental, and MAI allocations. |
#DIV/0! | |||||||
| Clinical Quality Management (CQM) Allocation Requirement: No more than 5% of your total award or $3 million (whichever is smaller) can be allocated to CQM. | ||||||||
| When reporting CQM allocations, the Total RWHAP Part A Allocation Amounts for CQM must not exceed 5% of the total award amount or $3 million (whichever is smaller). |
||||||||
| Below is the maximum amount (Capped Amount) you can allocate to CQM. The capped amount will be 5% of the total award or $3 million, whichever is smaller. Please check to make sure your CQM allocation does not exceed your Capped Amount. | ||||||||
| Recipient Clinical Quality Management Capped Amount | $0 | |||||||
| Recipient Clinical Quality Management Allocation Amount | $0 | |||||||
| Administration Allocation Requirement: No more than 10% of your total award can be allocated to recipient administration. | ||||||||
| When reporting recipient administration allocations, the Total RWHAP Part A Allocation Amounts for Administration must not exceed 10% of the total award amount. Below is the percentage of your Current Fiscal Year recipient administration allocations divided by your Total Part A Award. Please check to make sure this percentage is not greater than 10%. |
||||||||
| Recipient Administration Allocation Amount | $0 | #DIV/0! | ||||||
| Public Burden Statement: The purpose of this data collection system is to collect allocations/expenditures information regarding Ryan White HIV/AIDS Program (RWHAP) Parts A, B, C, D grant funding. HAB will use these data to show the impact of RWHAP funding on the care and treatment of people with HIV in the United States. 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 paperwork@hrsa.gov |
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| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |