Alzheimer's Disease Demonstration Grants to States (ADDGS) Program

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Overview

CG Characteristics
PWD Charac
Svcs & Expend
Dev'al Accomp

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Sheet 1: CG Characteristics

Caregivers	Total	Age of Primary Caregiver				Estimated Years of Caregiving				Of total caregivers, estimated number receiving any services through Title III of the Older Americans Act.
		Under 60	60-74	75-84	85+	0-2	3-5	6+	Years Missing	# of Individuals
Total Caregivers
Gender
Female
Male
Gender Missing
Geographic Location*
Urban
Rural
Frontier
Geographic Location Missing
Relationship to Person with Dementia
Husband
Wife
Significant Other
Son/Son-in-Law
Daughter/Daughter-in-Law
Sibling
Parent
Other Relative
Non-Relative
Relationship Missing
Primary Caregiver by Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Ethnicity Missing
Primary Caregiver by Race
White (Alone) -- Non-Hispanic
Total Minorities**
White (Alone) -- Hispanic
American Indian or Alaska Native (Alone)
Asian (Alone)
Black or African-American (Alone)
Native Hawaiian or Other Pacific Islander (Alone)
Persons Reporting Some Other Race
Persons Reporting 2 or More Races
Race Missing
Gray boxes are not to be filled out.
* Geographic Location
Urban: A central place and its adjacent densely settled territories with a combined mimimum population of 50,000
Rural: not Urban or Frontier
Frontier: Determined by population density and distance in miles and travel time from a market service area (http://www.frontierus.org/index.htm?p=2&pid=6003&spid=6019)
** Total Minorities - this will be calculated by AoA sponsored software - will exclude White(Alone) -- Non-Hispanic and Not Reported.

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Sheet 2: PWD Charac

Persons with Dementia	Total	Age of Person with Dementia				Of total persons with dementia, estimated number receiving any services through Title III of the Older Americans Act.
		Under 60	60-74	75-84	85+	# of Individuals
Total Persons with Dementia
Gender
Female
Male
Gender Missing
Geographic Location*
Urban
Rural
Frontier
Geographic Location Missing
Person with Dementia by Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Ethnicity Missing
Person with Dementia by Race
White (Alone) -- Non-Hispanic
Total Minorities**
White (Alone) -- Hispanic
American Indian or Alaska Native (Alone)
Asian (Alone)
Black or African-American (Alone)
Native Hawaiian or Other Pacific Islander (Alone)
Persons Reporting Some Other Race
Persons Reporting 2 or More Races
Race Missing
Gray boxes are not to be filled out.
* Geographic Location
Frontier: Determined by population density and distance in miles and travel time from a market service area (http://www.frontierus.org/index.htm?p=2&pid=6003&spid=6019)
Rural: not Urban or Frontier
Urban: A central place and its adjacent densely settled territories with a combined mimimum population of 50,000
** Total Minorities - this will be calculated by AoA sponsored software - will exclude White(Alone) -- Non-Hispanic and Not Reported.

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Sheet 3: Svcs & Expend

	REQUIRED
Direct Services	Units of Service	Unduplicated Persons Served	ADDGS Expenditures	Total Service Expenditures	Program Income Received	Number of Providers (unduplicated)	Service Modes - Choose all that apply			Service Mode Types	CODE
Adult Day Care										Aging & Disability Resource Center	1
Companion Services										Alzheimer's Association	2
Home Health Care										Area Agency on Aging	3
Personal Care										Consumer-Directed Care/Vouchers	4
Respite "Other" (as approved)										Faith Based Organization	5
Short-term Care in Health Facility										Government (Federal)	6
										Government (State or Local)	7
										Long-Term Care Facility	8
										National Family Caregiver Support Program	9
										Service Provider	10
										University or School	11
										Volunteers	12
										Other (please specify)	13
	REQUIRED	This is OPTIONAL data that you may have collected.
Other ADDGS Services	Check Box(es) of Service(s) Provided	Units of Service	Unduplicated Persons Served	ADDGS Expenditures	Total Service Expenditures	Program Income Received	Number of Providers (unduplicated)	Service Modes - Choose all that apply
Case Management
Information & Referral Services/Helpline
Mental Health Services
Outreach - Participant/Client
Outreach - Professional/Provider
Training - Participant/Client
Training - Professional/Provider
Support Groups
Transportation
Other Service – Not Above (Please Define)

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Sheet 4: Dev'al Accomp

Accomplishments & Collaborations
(Enter Accomplishment Here)			Accomplishment & Collaboration Types	CODE
			Collaboration (Federal)	1
			Collaboration (Non-federal)	2
			Materials Development	3
			Policy Development	4
			Public Education/Awareness	5
			Service (Direct Service defined by ADDGS statute)	6
			Service (Other ADDGS)	7
			Sustainability	8
			Training/Education	9
			Other - Please Specify	10
Accomplishment (Required). Please type narrative in the space above.	Enter Code:
(Enter Collaboration Here)
Collaboration (Required). Please type narrative in the space above.	Enter Code (1 or 2):
(Enter an Optional Accomplishment or Collaboration Here)
Other Accomplishment or Collaboration (Optional). Please type narrative in the space above.	Enter Code: