B-2 Part B Expenditures Report

FY17 RWHAP Part B & MAI Expenditures Report
Prior Year Carryover

Award Amount

OMB Number 0915-0318

Total Avail. Funds

OMB Number 0915-0318
Expiration date XX/XX/202X

1. RWHAP Part B Base Award
2. RWHAP Part B ADAP Earmark Award
3. RWHAP Part B ADAP Supplemental Award
4. Total RWHAP Part B Base + ADAP + ADAP Supplemental Funds
5. RWHAP Part B Emerging Communities Award
6. RWHAP Part B Supplemental Award
7. Total RWHAP Part B Funds
8. RWHAP Part B MAI Award
9. Total RWHAP Part B + MAI Funds

1. Base Award
Carryover

Award

2. ADAP Earmark + ADAP Supplemental
Percent

Carryover

Award

3. Emerging Communities Award
Percent

Carryover

Award

4. Total Prior Year Carryover
Percent

Amount

Percent

5. Total (including carryover)
Amount

Percent

1. RWHAP Part B AIDS Drug Assistance Program Subtotal
a. ADAP Services
b. Health Insurance to Provide Medications
c. ADAP Access/Adherence/Monitoring Services
2. RWHAP Part B Health Insurance Premium & Cost Sharing
Assistance
3. RWHAP Part B Home and Community-based Health Services
4. RWHAP Part B HIV Care Consortia
4a. RWHAP Part B HIV Care Consortia Administration, Planning &
Evaluation
5. RWHAP Part B State Direct Services
6. RWHAP Part B Clinical Quality Management

--

7. RWHAP Part B Recipient Planning & Evaluation Activities

--

8. Recipient Administration

--

9. Column Totals
10.Total RWHAP Part B Expenditures (excluding carryover)

validation: Total Prior year Carryover Expenditure should be <= Prior Year Carryover award amount??? Yes

11. Total Unobligated Carryover Funds

- validation: total exp should not be > grant award amount

- Need to confirm logic. Correct
1. Consortia
Award

2. Direct Services
Percent

Award

3. Emerging Communities
Percent

Award

Percent

4. Prior Year Carryover
Amount

Percent

5. Total (including carryover)
Amount

Percent

Core Medical Services
a. AIDS Drug Assistance Program (ADAP) Treatments

--

b. AIDS Pharmaceutical Assistance (LPAP)

--

c. Early Intervention Services

--

d. Health Insurance Premium & Cost Sharing Assistance

--

e. Home and Community-based Health Services

--

f. Home Health Care

--

g. Hospice

--

h. Medical Case Management (incl. 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

--

1. Core Medical Services Total

--

Support Services
a. Child Care Services
b. Emergency Financial Assistance
c. Food Bank/Home-Delivered Meals
d. Health Education/Risk Reduction
e. Housing
f. Linguistics 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
2. Support Services Total
3. Total
MAI AWARD
PRIOR FY CARRYOVER
Amount

Percent

REPORTING YEAR AWARD
Amount

Percent

TOTAL
Amount

Percent

1. Education to increase minority participation in ADAP
2. Outreach to increase minority participation in ADAP
3. Clinical Quality Management
4. Recipient Planning & Evaluation Activities
5. Recipient Administration
6. Total MAI Expenditures
7. Total Unobligated Carryover Funds

Part B Expenditures Report page mockup - Roberts copy for making a WORD copy

Part B Supplemental Grant Award Amount

OMB Number 0915-0318
Expiration date XX/XX/202X
Total
Award

Percent

1. RWHAP Part B Supplemental AIDS Drug Assistance
Program Subtotal
a. ADAP Services
b. Health Insurance to Provide Medications
c. ADAP Access/Adherence/Monitoring Services
2. RWHAP Part B Supplemental Health Insurance
Premium & Cost Sharing Assistance
3. RWHAP Part B Supplemental Home and Communitybased Health Services
4a. RWHAP Part B Supplemental HIV Care Consortia
4b. RWHAP Part B Supplemental HIV Care Consortia/EC
Administration
5. RWHAP Part B Supplemental State Direct Services
6. RWHAP Part B Supplemental Clinical Quality
Management
7. RWHAP Part B Supplemental Recipient Planning &
Evaluation Activities
8. Recipient Administration
9. Column Totals
No carry over total

Consortia
Amount

Direct Services
Percent

Amount

Percent

Core Medical Services

a. AIDS Drug Assistance Program (ADAP)
Treatments
b. AIDS Pharmaceutical Assistance (LPAP)

--

--

c. Early Intervention Services

--

--

d. Health Insurance Premium & Cost Sharing
Assistance

--

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

--

--

1. Core Medical Services Total
Support Services

a. Child Care Services
b. Emergency Financial Assistance

c. Food Bank/Home-Delivered Meals
d. Health Education/Risk Reduction
e. Housing
f. Linguistics Services
g. Medical Transportation Services
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 Residential Services
2. Support Services Total
3. Total Service Expenditures

Core Medical Services Expenditures

Amount

Percentage
(Amount / Total
Service Expenditures)

Amount

Percent

ADAP
Health Insurance Premium & Cost Sharing Assistance
Home-and Community-based Health Services
State-Direct Services: Core Medical Services
Total Core Medical Services Expenditures
Support Services Expenditures

Consortia Services
State-Direct Services: Support Services
Total Support Services Expenditures
Total RWHAP Part B Supplemental Core Medical & Support Services
Expenditures

Public Burden Statement: The purpose of this data collection system is to collect aggregate data on the number of new and existing clients, and clients who have
been out of care treated with EHE initiative funding. HAB will use these data to show the impact of the increased funding on reducing new HIV infections,
identifying new HIV infections, engaging clients in care and treatment. 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 XX/XX/202X. 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 1 hour 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