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[" FY 2008 Part A & MAI Allocations Report"]
[]
["Section A: Identifying Information",null,"Detailed instructions for completing\nand submitting this report can be \nfound in the Electronic Handbooks \nand downloaded from the web at https://grants.hrsa.gov/webexternal/Login.asp"]
["~ Enter Name of Grantee Here ~"]
["~ Enter Preparer's Name Here ~"]
["~ Enter Preparer's Phone Number Here ~"]
["~ Enter Preparer's Email Address Here ~"]
[]
["Section B: FY 2008 Award Information"]
["1. Part A Grant Award Amount"]
["2. MAI Grant Request / Award Amount"]
["3. Total Part A Funds",0]
[]
["Section C: Allocation Categories","1. Part A Award",null,"2. MAI Award",null,"3. Combined Total"]
[]
[null,"Amount","Percentage","Amount","Percentage","Amount","Percentage"]
["1. Core Medical Services Subtotal1 (see CHECKLIST)",0,0,0,0,0,0]
["a. Outpatient /Ambulatory Health Services",null,"- -",null,"- -",0,"- -"]
["b. AIDS Drug Assistance Program (ADAP) Treatments",null,"- -",null,"- -",0,"- -"]
["c. AIDS Pharmaceutical Assistance (local)",null,"- -",null,"- -",0,"- -"]
["d. Oral Health Care",null,"- -",null,"- -",0,"- -"]
["e. Early Intervention Services ",null,"- -",null,"- -",0,"- -"]
["f. Health Insurance Premium & Cost Sharing Assistance ",null,"- -",null,"- -",0,"- -"]
["g. Home Health Care ",null,"- -",null,"- -",0,"- -"]
["h. Home and Community-based Health Services",null,"- -",null,"- -",0,"- -"]
["i. Hospice Services",null,"- -",null,"- -",0,"- -"]
["j. Mental Health Services",null,"- -",null,"- -",0,"- -"]
["k. Medical Nutrition Therapy",null,"- -",null,"- -",0,"- -"]
["l. Medical Case Management (incl. Treatment Adherence)",null,"- -",null,"- -",0,"- -"]
["m. Substance Abuse Services - outpatient",null,"- -",null,"- -",0,"- -"]
["2. Support Services Subtotal",0,0,0,0,0,0]
["a. Case Management (non-Medical) ",null,"- -",null,"- -",0,"- -"]
["b. Child Care Services",null,"- -",null,"- -",0,"- -"]
["c. Emergency Financial Assistance",null,"- -",null,"- -",0,"- -"]
["d. Food Bank/Home-Delivered Meals",null,"- -",null,"- -",0,"- -"]
["e. Health Education/Risk Reduction",null,"- -",null,"- -",0,"- -"]
["f. Housing Services",null,"- -",null,"- -",0,"- -"]
["g. Legal Services",null,"- -",null,"- -",0,"- -"]
["h. Linguistics Services",null,"- -",null,"- -",0,"- -"]
["i. Medical Transportation Services",null,"- -",null,"- -",0,"- -"]
["j. Outreach Services",null,"- -",null,"- -",0,"- -"]
["k. Psychosocial Support Services",null,"- -",null,"- -",0,"- -"]
["l. Referral for Health Care/Supportive Services",null,"- -",null,"- -",0,"- -"]
["m. Rehabilitation Services",null,"- -",null,"- -",0,"- -"]
["n. Respite Care",null,"- -",null,"- -",0,"- -"]
["o. Substance Abuse Services - residential",null,"- -",null,"- -",0,"- -"]
["p. Treatment Adherence Counseling ",null,"- -",null,"- -",0,"- -"]
["3. Total Service Allocations",0,"- -",0,"- -",0,"- -"]
["4. Non-services Subtotal",0,"- -",0,"- -",0,"- -"]
["a. Clinical Quality Management2 (see CHECKLIST)",null,"- -",null,"- -",0,"- -"]
["b. Grantee Administration 3 (see CHECKLIST)",null,"- -",null,"- -",0,"- -"]
["5. Total Allocations (Service + Non-service)4 (see CHECKLIST)",0,"- -",0,"- -",0,"- -"]
[]
["FOR OFFICE USE ONLY:"]
["o Grantee received waiver for 75% core medical services requirement."]

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[" FY 2008 Part A & MAI Allocations Report CHECKLIST"]
["OMB No. 0915-xxxx    Expiration Date:"]
["~ Enter Name of Grantee Here ~"]
[]
[null,"Please check the following before submitting your report!","Part A Award","MAI Grant \nRequest / Award","Total"]
[1,"75% of your combined awards must be spent on core medical services.\nWhen reporting Core Medical Services allocations, the percentages for the Part A Award (Row 1, Column 1) and the MAI Award (Row 1, Column 2) do not necessarily need to be 75% as long as the COMBINED Total (Row 1, Column 3) meets the required minimum 75%.  If the percentage to the right is less than 75%, you must adjust your allocations so that at least 75% of your combined award amounts (Part A Award + MAI Award) are allocated for Core Medical Services.  The exception to this requirment is only for those grantees that requested, and were approved by HRSA, for an FY 2008 Part A Core Medical Services Waiver.",null,null,0]
[2,"You may not spend more than 5% or 3 million dollars (whichever is smaller) on clinical quality management.\nIf either of these percentages is more than 5% or the amounts is more than $3,000,000 you must go back and adjust your report accordingly.",0,0]
[null,null,0,0]
[3,"You may not spend more than 10% on grantee administration.\nIf either of these percentages is more than 10%, you must adjust your report accordingly.",0,0]
[4,"You must allocate your entire award.\nThe total allocations in Section C (Row 5, Column 3) should equal the total amount of funds expected to be available as shown in Section B. "]
[]
[null,"Detailed instructions for completing and submitting this report can be \nfound in the Electronic Handbooks and downloaded from the web at \nhttps://grants.hrsa.gov/webexternal/Login.asp"]