HIV CARE SECTION Ryan White Programs – Upon receipt of this completed form, HIV Care Section Staff will contact you within 3 business days Agency Name: Date of Request: Contact Person: Phone: Email Address: What RW Programs are you Funded for? RW Part A RW Part B RW Part B Supplemental RW Part C RW Part D RW Minority AIDS Initiative (MAI) Care Coordination Seeking Technical Assistance for : RW Part B RW Part B Supplemental RW Part D RW MAI Care Coordination MIDAP Grants and Contracts Budget/Fiscal Quality Management Data CAREWare Other (explain below) Explanation of Other: Description of Technical Assistance Needs: Format Requested for Technical Assistance: In-Person Conference Call Webinar Tools/Resource Materials Description of Expected Outcome after Technical Assistance: Please complete and return form to MDHHS via: Send to Hope McElhone at MDHHS Date Received: Date Response Sent by G&C: TA Disposition: Accepted Denied If Denied, provide rationale: HIV Care TA Lead: Priority Rating: High Moderate Low TA Format: TA Follow-up Date: Date of Completion: TA Action Plan: TA Outcome:
HIV CARE SECTION – Ryan White Programs Upon receipt of this completed form, HIV Care Section Staff will contact you within 3 business days Agency Name: Date of Request: Contact Person: Phone: Email Address: What RW Programs are you Funded for? RW Part A RW Part B RW Part B Supplemental RW Part C RW Part D RW Minority AIDS Initiative (MAI) Care Coordination Seeking Technical Assistance for : RW Part B RW Part B Supplemental RW Part D RW MAI Care Coordination MIDAP Grants and Contracts Budget/Fiscal Quality Management Data CAREWare Other (explain below) Explanation of Other: Description of Technical Assistance Needs: Format Requested for Technical Assistance: In-Person Conference Call Webinar Tools/Resource Materials Description of Expected Outcome after Technical Assistance: Please complete and return form to MDHHS via: Send to Hope McElhone at MDHHS Date Received: Date Response Sent by G&C: TA Disposition: Accepted Denied If Denied, provide rationale: HIV Care TA Lead: Priority Rating: High Moderate Low TA Follow-up Date: TA Format: Date of Completion: TA Action Plan: TA Outcome: