Form RSA-509 ANNUAL PROTECTION & ADVOCACY OF INDIVIDUAL RIGHTS PROGRA

FORM RSA-509 OMB NO. 1820- 0627

EXPIRES XXX XXX XXX

ANNUAL PROTECTION & ADVOCACY OF INDIVIDUAL RIGHTS (PAIR)

PROGRAM PERFORMANCE REPORT

Fiscal Year

DESIGNATED AGENCY IDENTIFICATION
Name:
Address:
E-mail Address (if applicable):
Website Address (if applicable):
Phone: ( )	TTY: ( )
Toll-free Phone: ( )	Toll-free TTY: ( )
Fax: ( )
Name of P&A Executive Director:
Name of PAIR Director/Coordinator:
Person to contact regarding report:
Contact Person's phone: ( )
PART I. NON-CASE SERVICES:
A. Individual Information and Referral Services (I&R): (Multiple responses are not permitted.)
1. Individuals receiving I&R within PAIR's priority areas
2. Individuals receiving I&R outside of PAIR's priority areas
3. Total individuals receiving I&R (lines A1+A2)
B. Training Activities:
1. Number of trainings presented by PAIR staff
2. Number of individuals who attended these trainings (approximate)
Describe the trainings presented by PAIR staff. Be sure to include information about the topics covered, the training methods used, and the purpose for the training. Use separate sheets if necessary.
C. Information Disseminated to the Public:
1. Radio and TV appearances by PAIR staff
2. Newspaper/magazine/journal articles
3. PSAs/videos aired
4. Hits on the PAIR/P&A website
5. Publications/booklets/brochures disseminated
6. Other (specify on separate sheet)

PART II. INDIVIDUALS SERVED:
A. Individuals Served: (An individual is counted only once per fiscal year. Multiple counts are not permitted for lines A1 through A3.)
1. Individuals who were still being served as of October 1 (carryover from prior fiscal year)
2. Additional individuals who were served during the year
3. Total individuals served (lines A1+A2)
4. Individuals who had more than one case file opened/closed during the fiscal year. (This number is not added to the total on line A3 above.)
B. Individuals still served as of September 30 (carryover to next year) (May not exceed total on line II.A.3 above.)
C. Problem Areas/Complaints of Individuals Served:
1. Architectural accessibility
2. Employment
3. Program access
4. Housing
5. Government benefits/services
6. Transportation
7. Education
8. Assistive technology
9. Voting
10. Health care
11. Insurance
12. Non-government services
13. Privacy rights
14. Access to records
15. Abuse
16. Neglect
17. Other
D. Reasons for Closing Individual's Case Files:
1. Issues resolved partially or completely in the individual's favor
2. Other representation found
3. Individual withdrew complaint
4. Appeals were unsuccessful
5. PAIR services not needed due to individual's death, relocation, etc.
6. PAIR withdrew from case
7. PAIR unable to take case because of lack of resources
8. Individual's case lacks legal merit
9. Other (Please explain on separate sheet.)
E. Intervention Strategies Used in Serving Individuals: (List the highest level of intervention used by PAIR prior to closing each case file.)
1. Technical assistance in self-advocacy
2. Short-term assistance
3. Investigation/monitoring
4. Negotiation
5. Mediation/alternative dispute resolution
6. Administrative hearings
7. Litigation (including class actions)
8. Systemic/policy activities
PART III. STATISTICAL INFORMATION ON INDIVIDUALS SERVED:
Age of Individuals Served: (as of October 1) (Multiple responses not permitted.)
1. 0 - 4
2. 5 - 22
3. 23 - 59
4. 60 - 64
5. 65 and over
B. Gender of Individuals Served: (Multiple responses not permitted)
1. Females
2. Males
C. Race/Ethnicity of Individuals Served:
Hispanic /Latino of any race
For individuals who are non-Hispanic/Latino only:
2. American Indian or Alaska Native
3. Asian
4. Black or African American
5. Native Hawaiian or other Pacific Islander
6. White
7. Two or more races
8. Race/ethnicity unknown
D. Living Arrangements of Individuals Served: (Multiple responses not permitted)
1. Independent
2. Parental or other family home
3. Community residential home
4. Foster care
5. Nursing home
6. Public institutional living arrangement
7. Private institutional living arrangement
8. Jail/prison/detention center
9. Homeless
10. Other living arrangements
11. Living arrangements not known
E. Primary Disability of Individuals Served: (Identify the individual's primary disability, namely the one directly related to the issues/complaints raised by the individual.)
1. Blind/visual impairment
2. Deaf/hard of hearing
3. Deaf-blind
4. Orthopedic impairment
5. Mental illness
6. Substance abuse
7. Mental retardation
8. Learning disability
9. Neurological impairment
10. Respiratory impairment
11. Heart/other circulatory impairment
12. Muscular/skeletal impairment
13. Speech impairment
14. AIDS/HIV
15. Traumatic brain injury
16. Other disability
PART IV. SYSTEMIC ACTIVITIES AND LITIGATION:
A. Systemic Activities:
1. Number of policies/practices changed as a result of non-litigation systemic activities
2. Number of individuals potentially impacted by policy changes
Describe your systemic activities. Be sure to include information about the policies that were changed and how these changes benefit individuals with disabilities. Include case examples of how your systemic activities impacted individuals served. (Attach separate sheets if necessary.)
B. Litigation/Class Actions:
1. Number of individuals potentially impacted by changes as a result of PAIR's litigation/class action efforts
2. Number of individuals named in class actions
Describe your litigation/class action activities. Explain how individuals with disabilities benefited from your litigation activities. Be sure to include case examples that demonstrate the impact of your litigation. (Attach separate sheets if necessary.)
PART V. PAIR'S PRIORITIES AND OBJECTIVES: Priorities and Objectives for the Fiscal Year Covered by this Report: For each of your PAIR program priorities for the fiscal year covered by this report, please: 1. Identify and describe the priority. 2. Identify the need, issue or barrier addressed by this priority. 3. Identify and describe indicators PAIR used to determine successful outcome of activities pursued under this priority. 4. Explain whether pursuing this priority involved collaborative efforts by other entities. If so, describe this collaboration. 5. Provide the number of cases handled under the priority. Indicate how many of these, if any, were class actions. 6. Provide at least one case summary that demonstrates the impact of the priority. Priorities and Objectives for the Current Fiscal Year: Please include a statement of priorities and objectives for the current fiscal year (the fiscal year succeeding that covered by this report), which should contain the following information: a statement of each priority; the need addressed by each priority; and; a description of the activities to be carried out under each priority.
PART VI. NARRATIVE: At a minimum, you must include all of the information requested. You may include any other information, not otherwise collected on this reporting form that would be helpful in describing the extent of PAIR activities during the prior fiscal year. Please limit the narrative portion of this report, including attachments, to 20 pages or less. The narrative should contain the following information. The instructions for this form outline the information that should be contained in each section. A. Sources of funds received and expended B. Budget for the fiscal year covered by this report C. Description of PAIR staff (duties and person-years) D. Involvement with advisory boards (if any) E. Grievances filed under the grievance procedure F. Coordination with the Client Assistance Program (CAP) and the State long-term care program, if these programs are not part of the P&A agency

Reports are to be submitted to RSA within 90 days after the end of the fiscal year covered by this report. Please be reminded that you can enter data directly into RSA’s Management Information System (MIS) via the Internet. Information on transmittal of the form, including electronic transmission, is found on pages 18 and 19 of the reporting instructions.

Signature of agency official Date

Paperwork Burden Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is 1820-0627. The time required to complete this information collection is estimated to average 16 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. The obligation to respond to this collection is required to obtain or retain benefit pursuant to Section 509 of the Rehabilitation Act of 1973, as amended, and its implementing federal regulations at 34 CFR Part 381. If you have any comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: U.S. Department of Education, Washington, DC 20202-2703. If you have comments or concerns regarding the status of your individual submission of this form, write directly to: OSERS/RSA, U.S. Department of Education, 400 Maryland Avenue S.W, Washington, DC 20202-2800.