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Allocations Report |
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XXXXX |
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| Budget Year: |
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Report ID: |
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| Report Status: |
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Last Modified Date: |
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Recipient Information |
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Official Mailing Address: |
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EIN: |
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UEI: |
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Preparer's Name: |
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Preparer's Title: |
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Preparer's Phone: |
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Preparer's Fax: |
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Preparer's Email: |
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Budget Year Award Information |
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1. RWHAP Part D Recipient Award Amount |
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Part D Program Total |
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Base Award Amount |
Base Award Percent |
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Non-Services |
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a. Clinical Quality Management |
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b. Administrative |
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c. Indirect Costs |
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Non-services Subtotal |
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Core Medical Services |
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Support Services |
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Total Service Allocations |
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Total Allocations(Service + Non-service) |
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Part D Allocations Categories |
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Service |
Base Award Amount |
Base Award Percent |
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Core Medical Services |
a.AIDS Drug Assistance Program Treatments |
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b.AIDS Pharmaceutical Assistance |
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c.Early Intervention Services (EIS) |
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d.Health Insurance Premium and Cost Sharing Assistance for Low-Income Individuals |
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e.Home and Community-Based Health Services |
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f.Home Health Care |
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g.Hospice |
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h.Medical Case Management, including Treatment Adherence Services |
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i.Medical Nutrition Therapy |
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j.Mental Health Services |
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k.Oral Health Care |
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l.Outpatient/Ambulatory Health Services |
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m.Substance Abuse Outpatient Care |
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Core Medical Services Subtotal |
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Support Services |
a.Child Care Services |
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b.Emergency Financial Assistance |
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c.Food Bank/Home Delivered Meals |
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d.Health Education/Risk Reduction |
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e.Housing |
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f.Linguistic Services |
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g.Medical Transportation |
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h.Non-Medical Case Management Services |
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i.Other Professional Services |
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j.Outreach Services |
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k.Psychosocial Support Services |
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l.Referral for Health Care and Support Services |
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m.Rehabilitation Services |
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n.Respite Care |
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o.Substance Abuse Services (residential) |
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Support Services Subtotal |
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Total Service Allocations |
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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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