Ryan White Part A Implementation Plan Provider: __________________________________ Fiscal Year______ Page ______ of ____ Pages Service Priority Name: Total Priority Allocation: Service Priority Number: n/a Part A Core Medical Part A Support MAI Core Medical MAI Support ☐ ☐ ☐ ☐ Service Goal: Reference Current Comprehensive Plan: n/a 3. Quantity 4. Time Frame: 5. Funds: Indicate the estimated 1. Objectives: 2. Service Unit 3b) Total Provide the duration of activity List quantifiable time-limited Definition: 3a) Number of Number of approximate amount of relating to the objectives related to the service Define the service unit to people to be service units funds to be used to objective listed priorities listed above be provided served to be provide this service. provided Start Date End Date a: b: c: d: e. 6. Select a minimum of two objectives and list planned client level outcomes to be tracked:
Ryan White Part A Implementation Plan Provider: __________________________________ Fiscal Year______ Page ______ of ____ Pages Service Priority Name: Total Priority Allocation: Service Priority Number: n/a Part A Core Medical ☐ Part A Support ☐ MAI Core Medical ☐ MAI Support ☐ Service Goal: Reference Current Comprehensive Plan: n/a 1. Objectives: List quantifiable time-limited objectives related to the service priorities listed above 2. Service Unit Definition: Define the service unit to be provided 3. Quantity 4. Time Frame: Indicate the estimated duration of activity relating to the objective listed 5. Funds: Provide the approximate amount of funds to be used to provide this service. 3a) Number of people to be served 3b) Total Number of service units to be provided Start Date End Date a: b: c: d: e. 6. Select a minimum of two objectives and list planned client level outcomes to be tracked:
FY%202013%20Part%20A%20Implementation%20Plan%20Form%20and%20Sample.docx