| OMB No. 0915-0312 |
| Expiration Date: October 31, 2010 |
|
1 |
Name
of HTC |
empty
|
|
2 |
Reporting
period |
empty
|
| empty
|
empty
|
empty
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|
3 |
Patient
Data |
empty
|
|
4 |
Non-Medicaid
Patients receiving 340B FRP from HTC |
empty
|
|
5 |
Medicaid
patients receiving 340B FRP from HTC |
empty
|
|
6 |
Medicaid
patients receiving non-340B FRP from HTC |
empty
|
|
7 |
Total
number of patients receiving FRP from HTC |
empty
|
| empty
|
empty
|
empty
|
|
8 |
Financial
Data |
empty
|
|
9 |
Balance
at start of reporting period |
|
|
10 |
Add Total FRP Program revenue |
|
|
11 |
From 340B FRP sales |
|
|
12 |
From non-340B sales to HTC patients |
|
|
13 |
Subtract Total FRP Program operating costs |
|
|
14 |
Total cost of FRP |
|
|
15 |
At 340B price |
|
|
16 |
At non-340B price |
|
|
17 |
Cost of pharmacy staff |
|
|
18 |
Cost of contractual services |
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|
19 |
Other direct costs |
|
| empty
|
empty
empty |
empty
|
|
20 |
FRP Program Net Income |
empty
|
|
21 |
Subtract Use of FRP Program Net Income |
empty
|
|
22 |
HTC staff costs |
empty
|
|
23 |
Indirect Costs |
empty
|
|
24
|
Other HTC Costs |
empty
|
| empty |
empty
|
empty
|
|
25 |
Balance
at End of Reporting Period |
empty
|
Public
reporting burden for this collection of information
is estimated to average 30 hours per response, including
the time for reviewing instructions, searching existing
data sources, gathering and maintaining the data needed,
and completing and reviewing the collection of information.
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.
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 Office, 5600 Fishers Lane, Room 14-22, Rockville,
MD 20857. Do not return the completed form to this
address.
|
