Alzheimer's Disease Supportive Services Program (ADSSP) Data Collection

Alzheimer's Disease Supportive Services Program (ADSSP) Data Collection

ADSSP Data Collection Reporting Form (2).xls

Alzheimer's Disease Supportive Services Program (ADSSP) Data Collection

OMB: 0985-0022

Document [xlsx]
Download: xlsx | pdf

Overview

PWD Charac
CG Characteristics
Svcs, Exp, Participation


Sheet 1: PWD Charac

Person with Dementia Age of Person with Dementia

Under 60 60+ Totals
Gender



Female

0
Male

0
Gender Missing

0
Geographic Location



Urban

0
Rural

0
Geographic Location Missing

0
Relationship to Caregiver



Spouse

0
Unmarried Partner

0
Parent

0
Child

0
Other relative

0
Non-relative

0
Relationship Missing

0
Person with Dementia by Ethnicity



Hispanic or Latino

0
Not Hispanic or Latino

0
Ethnicity Missing

0
Person with Dementia by Race



White - Non-Hispanic

0
White - Hispanic



American Indian or Alaska Native

0
Asian

0
Black or African-American

0
Native Hawaiian or Other Pacific Islander

0
Persons Reporting Some Other Race

0
Persons Reporting 2 or More Races

0
Race Missing

0
Veteran Status



Veteran Status

0
Non-Veteran

0
Veteran Status Missing

0
Gray boxes are not to be filled out.




Sheet 2: CG Characteristics

Caregiver Age of Primary Caregiver

Under 60 60+ Totals
Gender

Female

0
Male

0
Gender Missing

0
Geographic Location

Urban

0
Rural

0
Geographic Location Missing

0
Relationship to Person with Dementia

Spouse

0
Unmarried Partner

0
Child

0
Parent

0
Other relative

0
Non-relative

0
Relationship Missing

0
Primary Caregiver by Ethnicity



Hispanic or Latino

0
Not Hispanic or Latino

0
Ethnicity Missing

0
Primary Caregiver by Race

White - Non-Hispanic

0
White - Hispanic

0
American Indian or Alaska Native

0
Asian

0
Black or African-American

0
Native Hawaiian or Other Pacific Islander

0
Persons Reporting Some Other Race

0
Persons Reporting 2 or More Races

0
Race Missing

0
Veteran Status



Veteran

0
Non-Veteran

0
Veteran Status Missing

0





Gray boxes are not to be filled out.




Sheet 3: Svcs, Exp, Participation

Services & Expenditures Total Units of Direct Service Delivered Total ADSSP Expenditures Total Federal Funds Spent on Direct Services Total Federal Funds Spent on Administrative Services Percentage of Federal Funds Spent on Direct Service Expenses Percentage of Federal Funds Spent on Administrative Expenses














Narrative





It is a statutory requirement for the Alzheimer’s Disease Supportive Services Program that at least 50% of federal grant funds spent be spent on direct service costs and that no more than 10% of federal funds be spent on administrative costs. If your project has not met these requirements by the end of this reporting period (reflected in the numbers above), please describe -- in the box to the right -- why the project has not met these requirements and confirm that the project will meet these requirements by the end of the grant.














Participation* Program Entrants Program Completers

















*Only complete for Evidence-Based Projects





File Typeapplication/vnd.ms-excel
AuthorLStalbaum
Last Modified ByWidge_A
File Modified2010-08-03
File Created2006-05-31

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