Form E-1 EHE Allocations Report

Allocations Report

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Budget Year: Report ID:

Report Status: Last Modified Date:

Recipient Information

Budget Year Award Information

Total EHE Award

Official Mailing Address:

EIN:

UEI:

Preparer's Name:

Preparer's Title:

Preparer's Phone:

Preparer's Fax:

Preparer's Email:

EHE Program Total

EHE Award Amount

EHE Award Percent

Non-Services

a.Clinical Quality Management Activities

b.Recipient Administration

c.Initiative Infrastructure¹

d.Planning and Evaluation²

Non-services Subtotal

e.EHE Initiative Services

f.Core Medical Services

g.Support Services

Service Allocations

Total Allocations(Service + Non-service)

EHE Allocations Categories

Service

EHE Award Amount

EHE Award Percent

EHE Initiative Services

EHE Initiative Services³

Core Medical Services

a.AIDS Drug Assistance Program Treatments

b.AIDS Pharmaceutical Assistance

c.Early Intervention Services (EIS)

d.Health Insurance Premium and Cost Sharing Assistance for Low-Income Individuals

e.Home and Community-Based Health Services

f.Home Health Care

g.Hospice

h.Medical Case Management, including Treatment Adherence Services

i.Medical Nutrition Therapy

j.Mental Health Services

k.Oral Health Care

l.Outpatient/Ambulatory Health Services

m.Substance Abuse Outpatient Care

Core Medical Services

Support Services

a.Child Care Services

b.Emergency Financial Assistance

c.Food Bank/Home Delivered Meals

EHE Allocations Categories

Service

EHE Award Amount

EHE Award Percent

Support Services

d.Health Education/Risk Reduction

e.Housing

f.Linguistic Services

g.Medical Transportation

h.Non-Medical Case Management Services

i.Other Professional Services

j.Outreach Services

k.Psychosocial Support Services

l.Referral for Health Care and Support Services

m.Rehabilitation Services

n.Respite Care

o.Substance Abuse Services (residential)

Support Services

Total Service Allocations

¹ Infrastructure are costs associated with the development and expansion of data systems. It may include technical assistance on the type, design, and building of new data systems, bridging existing systems to achieve data integration, improving data entry to decrease burden and increase accuracy, training of staff and providers on collecting and using data, and employing experts to provide accurate and in-depth data analysis. ² Planning and evaluation are costs associated with stakeholder engagement and process and outcome evaluation activities. ³ EHE Initiative Services are costs associated with a broader approach to addressing HIV in the community than exists in services authorized by the RWHAP legislation. For example, the only requirement for determining eligibility is that the individual has an HIV diagnosis. There is no requirement that individuals served are low-income or that initial eligibility is documented prior to services being provided. Initiative services are services and activities that do not fit neatly within the RWHAP service categories (e.g., linkage to care). These services may be innovative and creative with a focus on ending the HIV epidemic. Public Burden Statement: 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 number. The OMB control number for this project is 0915-0318 and it is valid until 09/30/2023. Public reporting burden for this collection of information is estimated to be 4 hours per response. These estimates include the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments to HRSA Reports Clearance Officer, Health Resources and Services Administration, Room 10-33, 5600 Fishers Lane, Rockville, MD. 20857.