B-2 TC Part B Allocations Report_X08 Suppl Revised Version_v03_

OMB Number (0915-0318)

Expiration date (09/30/2023)

Part B X08 Allocations Report

FYXXXX RWHAP Part B Supplemental Program Award Allocations Report
Recipient Name
Preparer Name
Preparer Phone Number
FY XXXX RWHAP Part B Supplemental Program Award
Section A: Planned Funding by Program Component	Total FY XXXX RWHAP Part B Supplemental Program Award
	Amount	Percent
1. RWHAP Part B Supplemental AIDS Drug Assistance Program Subtotal	$0	- -
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 for Low Income Individuals		- -
3. RWHAP Part B Supplemental Home and Community-Based Health Services		- -
4a RWHAP Part B Supplemental HIV Care Consortia (Provide detail in Section B)	$0	- -
4b. RWHAP Part B Supplemental HIV Care Consortia Administration	$0	- -
5. RWHAP Part B Supplemental State Direct Services (Provide detail in Section B)	$0	- -
6. RWHAP Part B Supplemental Clinical Quality Management 1		- -
7. RWHAP Part B Supplemental Recipient Planning & Evaluation Activities2		- -
8. Recipient Administration2		- -
9. Total RWHAP Part B Supplemental Program Funding Amounts	$0	0.00%
Section B: Breakdown for Consortia and State Direct Services Final Funding	Consortia3		Direct Services		Combined Total
	Amount	Percent	Amount	Percent	Amount	Percent
1. Core Medical Services Sub-total	$0	- -	$0	- -
a. AIDS Drug Assistance Program (ADAP) Treatments
b. AIDS Pharmaceutical Assistance (LPAP)		- -		- -
c. Early Intervention Services		- -		- -
d. Health Insurance Premium & 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		- -		- -
2. Support Services Sub-total	$0	- -	$0	- -
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 Services (Residential)		- -		- -
3. Total Funding Amounts	$0	- -	$0	- -
(1) May not exceed 5% of the FY XXXX RWHAP Part B Supplemental Program award, or $3 million, whichever amount is smaller.
(2) May not use more than 10% of the FY XXXX RWHAP Part B Supplemental Program award for either Planning and Evaluation or Recipient Administration; additionally, the combined costs for these two categories may not exceed 15% of the FY XXXX RWHAP Part B Supplemental award.
(3) All services in this column are considered Support Services.

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 RWHAP Part B supplemental 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 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 2 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