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["FY 2008 Part C Expenditures Report"]
[]
["Section A: Identifying Information",null,null,"NOTE:  Detailed instructions for completing and submitting your report can be downloaded from the HRSA Electronic Handbook: https://grants.hrsa.gov/webexternal/Login.asp"]
["~ Enter Name of Grantee Here ~"]
["~ Enter Grant Number 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 C Grant Award Amount"]
[]
[null,"CURRENT FY",null,"PRIOR FY CARRYOVER",null,"TOTAL"]
["Section C: Expenditure Categories","Amount","Percent","Amount","Percent","Amount","Percent"]
["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. Health Insurance Premium & Cost Sharing Assistance ",null,"- -",null,"- -",0,"- -"]
["f. Home Health Care ",null,"- -",null,"- -",0,"- -"]
["g. Home and Community-based Health Services",null,"- -",null,"- -",0,"- -"]
["h. Hospice Services",null,"- -",null,"- -",0,"- -"]
["i. Mental Health Services",null,"- -",null,"- -",0,"- -"]
["j. Medical Nutrition Therapy",null,"- -",null,"- -",0,"- -"]
["k. Medical Case Management (including Treatment Adherence)",null,"- -",null,"- -",0,"- -"]
["l. 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. Health Education/Risk Reduction",null,"- -",null,"- -",0,"- -"]
["c. Linguistics Services",null,"- -",null,"- -",0,"- -"]
["d. Medical Transportation Services",null,"- -",null,"- -",0,"- -"]
["e. Outreach Services",null,"- -",null,"- -",0,"- -"]
["f. Psychosocial Support Services",null,"- -",null,"- -",0,"- -"]
["g. Referral for Health Care/Supportive Services",null,"- -",null,"- -",0,"- -"]
["h. Rehabilitation Services",null,"- -",null,"- -",0,"- -"]
["i. Respite Care",null,"- -",null,"- -",0,"- -"]
["j. Treatment Adherence Counseling ",null,"- -",null,"- -",0,"- -"]
["3. Total Service Expenditures",0,"- -",0,"- -",0,"- -"]
["4. Non-services Subtotal",0,"- -",0,"- -",0,"- -"]
["a. Clinical Quality Management Activities1 (see CHECKLIST)",null,"- -",null,"- -",0,"- -"]
["b. Grantee Administration2 (see CHECKLIST)",null,"- -",null,"- -",0,"- -"]
["5. Total Expenditures (Service + Non-service)",0,"- -",0,"- -",0,"- -"]
[]
["FOR OFFICE USE ONLY:"]
["o Grantee received waiver for 5% clinical quality management activities."]
[]
["o Grantee received waiver for 75% core medical services requirement."]

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["FY 2008 Part C Expenditures Report Checklist"]
["OMB No. 0915-xxxx Expiration Date:"]
[null,"Please check the following before submitting your report!"]
[1,"75% of your award must be spent on core medical services.\nAfter meeting the requirements below, this percentage should not be less than 75%.",0]
[2,"You may not spend more than 5% on clinical quality management unless you have received a waiver from the Division of Community Based Programs.\nIf this percentage is more than 5% you must have received a waiver from the Division of Community Based Programs.",0]
[3,"You may not spend more than 10% on grantee administration.\nThis percentage should not be more than 10%.",0]
[]
[null,"NOTE:  Detailed instructions for completing and submitting your report can be downloaded from the \nHRSA Electronic Handbook: https://grants.hrsa.gov/webexternal/Login.asp"]