Form 1 Annual Report Template

Attachment B Annual Report Template OMB control number 0000-0000

Expiration Date: 00/00/0000

Attachment B

Annual Report Template

THE PAPERWORK REDUCTION ACT OF 1995

Public reporting burden for this collection of information is estimated to average 1,412 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information.

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.

Section 1: Goal

Directions for completing Section 1: Grantees will state the program goal as they appear in the application for funding. Section 1 will be completed for each goal. Grantees will also use this section to indicate for each goal area(s) of emphasis, core function, and type of activity the goal addresses.

Goal #: (Write out goal)

Area of Emphasis: (Check below the area(s) of emphasis addressed by the goal)

___ Quality Assurance

___Education and Early Intervention

___Child Care

___Health

___Employment

___Housing

___Transportation

___Recreation

___Other - Explain

Core Function: (Check the core function as it applies to the goal).

___Pre-service Preparation and Continuing Education

___Community Services – Training, Technical Assistance, Direct Services, and Demonstration Projects

___Research

___Information Dissemination

Type of Activity: (Check the type(s) of activity/activities used to address the goal).

___Advocacy

___Capacity Building

___Systemic Change

Section 2: Results and Outcomes

Directions for completing Section 2: Grantees will use Section 2 to provide a narrative update on progress achieved in meeting the goal stated in Section 1. Section 2 will be completed for each goal. The grantees will also use Section 2 to describe the strategies that either attributed to or prohibited goal achievement. This may include reference to any of the objectives listed in the original application for funding or specific activities identified in the application for funding.

Extent to Which Goal was Achieved: (Check below to indicate the extent to which the goal was achieved).

____Achieved

____In Progress

____Not Achieved

Explanation (provide a narrative describing the strategies used to meet the goal and any factors inhibiting the attainment of the goal)

Section 3: Funds Leveraged

Directions for completing Section 3: Grantees will use Section 3 to describe the funds leveraged overall to carry out the goals outlined in the application for core funding. The figures provided will describe the UCEDD’s leveraging of funds overall and not by goal.

Total Amount of Funding Leveraged:______________________

Source(s) of Funding: ______________________

______________________

______________________

Section 4: Results from the Measurement of the Indicators of Progress

Directions for completing Section 4: Grantees will use quantitative data to report on the outcomes and results of the activities in which they engaged (e.g., advocacy, capacity building, systemic change) related to the indicators of progress (e.g., measures of improvement, consumer satisfaction, and collaboration) during the year. Grantees will report measures of improvement and measures of consumer satisfaction by core function.

Measures of Improvement: One indicator of progress to be reported on is through measures of improvement. Grantees must provide evidence of progress achieved as a result of advocacy, capacity building, and systemic change activities in terms of improvement measures. Grantees will report measures of improvement for each core function. Under each core function, the grantees will report measures of improvement by each area of emphasis identified in their application for funding. Grantees will report measures of improvement regardless of funding source.

Measures of Consumer Satisfaction: Another indicator of progress to be reported on is through measures of consumer satisfaction. Grantees must provide evidence of progress achieved as a result of advocacy, capacity building, and systemic change activities in terms of consumer satisfaction measures. Below are guidelines for gathering consumer satisfaction data:

• The grantee will choose one area of emphasis to collect and report consumer satisfaction data on projects and/or activities that directly apply to each UCEDD core function (e.g., interdisciplinary pre-service preparation and continuing education; community services – training, technical assistance, direct services, and demonstration projects; research; and information dissemination). For example, a UCEDD may choose to report consumer satisfaction data on the area of emphasis of housing. When reporting consumer satisfaction for housing-related activities, the UCEDD will provide data on interdisciplinary pre-service preparation and continuing education; community services – training, technical assistance, direct services, and demonstration projects; research; and information dissemination.

• The consumer satisfaction data will be collected and reported on projects and/or activities regardless of their primary funding source

• When reporting consumer satisfaction data for the core function of interdisciplinary pre-service preparation and continuing education, data will be collected from at least 90% of the trainees. If reporting on less than 90% of the trainees, the grantee shall provide a reason for reporting fewer than the required amount.

• When reporting consumer satisfaction data for the core function of community services (training, technical assistance, direct services, and demonstration projects), UCEDDs will implement data collection methods feasible and appropriate to the activity that ensures a representative sample of participants. UCEDDs should make every effort to employ random, non-purposive sampling techniques. In cases where the UCEDD must use purposive techniques, an explanation should be provided.

• When using mail-in survey techniques in the collection of consumer satisfaction data, UCEDDs are expected to obtain a response rate of at least 50%. If reporting less than 50%, the grantee shall provide a reason for reporting fewer than the required amount.

• The UCEDDs will use a standard question for assessing consumer satisfaction (see definitions and measures document for the standard questions to be used for the collection of consumer satisfaction data). To ensure accessibility, including cognitive accessibility, of the standard consumer satisfaction question, UCEDDs should make accommodations or modifications, as appropriate, to the item. An accommodation allows an individual to complete the question as others, but with some type of change in the administration of the item, such as timing, formatting, setting, scheduling, response and/or presentation. This accommodation does not alter in any significant way what the question measures. A modification is an adjustment to the question that changes the standard or what the question intends to measure. Examples of possible modifications include an individual completing an alternate question that is more easily achievable than the standard question.

• When ever collecting consumer satisfaction data, UCEDDs must ensure the protection of the informant’s confidentiality to the extent permitted by law. Information gathering techniques for the collection of consumer satisfaction data are to be conducted without inclusion of names or other identifying information of the respondents. Respondents are to be assured that the information they provide is confidential and will be used for the stated purpose for which they were collected. In addition, respondents are to be assured that their participation evaluating satisfaction is voluntary. In keeping with ADD practices with respect to cultural competence and the ADA, alternative formats must be made available. In conducting the evaluative activities, the UCEDDs will ensure the respondents’ confidentiality in a variety of formats, including oral and written statements. If UCEDDs use written survey techniques, a standard written statement about confidentiality must be included. All statements about confidentiality will explain that responses are voluntary, confidential information will not be shared with others, and that answers will be used for the purpose for which they were collected. In keeping with agency practices with respect to cultural competence issues, literacy, and visual or auditory ability, alternative formats will be made available.

• When recording information collected through the various evaluative activities, the UCEDDs must maintain a coding system that protects the identity, if known, of the respondent. Measures should be taken to ensure the confidentiality of files, including the use of locked file cabinets and passwords on computers where data is kept.

• None of the data that is entered into NIRS will be confidential. No personally identifiable information should appear in NIRS.

Measures of Collaboration: The last indicator of progress to be reported on is through measures of collaboration. Grantees will report on the collaborative efforts across the three DD Network programs authorized by the DD Act of 2000. In addition, they will report on collaborations with other non-DD Act funded programs.

The sections that follow provide additional information about the measures of the indicators of progress. First is a series of charts that outlines the specific measures of improvement and measures of consumer satisfaction that grantees will use for reporting purposes. This is followed by a list of questions that will be used to report on measures of collaboration.

Measures of Improvement and Consumer Satisfaction:

Area of Emphasis: Quality Assurance

	CORE FUNCTION
	Interdisciplinary Pre-Service Preparation and Continuing Education	Community Services: Training and TA	Community Services: Direct Services & Demonstration Projects	Research	Information Dissemination
Type of Activity	___Advocacy ___Capacity Building ___Systemic Change	___Advocacy ___Capacity Building ___Systemic Change	___Advocacy ___Capacity Building ___Systemic Change	___Advocacy ___Capacity Building ___Systemic Change	___Advocacy ___Capacity Building ___Systemic Change
Improvement Measure	Number of trainees who gained the knowledge and skills to promote quality assurance activities for IWDD1.	Number of individuals in the community who gained knowledge and skills related to promoting quality assurance activities for IWDD.	Number of individuals in the community who received services and/or supports related to promoting quality assurance activities for IWDD.	Number of research and evaluation activities conducted that investigated strategies to promote quality assurance activities for IWDD.	Number of products developed and disseminated on quality assurance activities for IWDD.
Consumer Satisfaction Measure	Percentage of trainees who reported satisfaction with the knowledge and skills gained to promote quality assurance activities for IWDD.	Percentage of individuals in the community who reported satisfaction with the knowledge and skills gained related to promoting quality assurance activities for IWDD.	Percentage of individuals in the community who reported satisfaction with the services and/or supports received related to promoting quality assurance activities for IWDD.		Percentage of recipients of products disseminated on quality assurance activities for IWDD who reported satisfaction with the quality of the item.

Area of Emphasis: Education and Early Intervention

	CORE FUNCTION
	Interdisciplinary Pre-Service Preparation and Continuing Education	Community Services: Training and TA	Community Services: Direct Services & Demonstration Projects	Research	Information Dissemination
Type of Activity	___Advocacy ___Capacity Building ___Systemic Change	___Advocacy ___Capacity Building ___Systemic Change	___Advocacy ___Capacity Building ___Systemic Change	___Advocacy ___Capacity Building ___Systemic Change	___Advocacy ___Capacity Building ___Systemic Change
Improvement Measure	Number of trainees who gained the knowledge and skills to serve as a resource for achieving the developmental and educational goals of IWDD from birth to 22 years of age.	Number of individuals in the community who gained knowledge and skills related to achieving the developmental and educational goals of IWDD from birth to 22 years of age.	Number of individuals in the community who received services and/or supports related to achieving the developmental and educational goals of IWDD from birth to 22 years of age.	Number of research and evaluation activities conducted that investigated strategies to foster the achievement of the developmental and educational goals of IWDD from birth to 22 years of age.	Number of products developed and disseminated related to achieving developmental and educational goals of IWDD from birth to 22 years of age.
Consumer Satisfaction Measure	Percentage of trainees who reported satisfaction with the knowledge and skills gained to serve as a resource for achieving the developmental and educational goals of IWDD from birth to 22 years of age.	Percentage of individuals in the community who reported satisfaction with the knowledge and skills gained to support the achievement of the developmental and educational goals of IWDD from birth to 22 years of age.	Percentage of individuals in the community who reported satisfaction with the services and/or supports received related to achieving the developmental and educational goals of IWDD from birth to 22 years of age.		Percentage of recipients of products disseminated related to achieving developmental and educational goals of IWDD from birth to 22 years of age who reported satisfaction with the quality of the item.

Area of Emphasis: Child Care

	CORE FUNCTION
	Interdisciplinary Pre-Service Preparation and Continuing Education	Community Services: Training and TA	Community Services: Direct Services & Demonstration Projects	Research	Information Dissemination
Type of Activity	___Advocacy ___Capacity Building ___Systemic Change	___Advocacy ___Capacity Building ___Systemic Change	___Advocacy ___Capacity Building ___Systemic Change	___Advocacy ___Capacity Building ___Systemic Change	___Advocacy ___Capacity Building ___Systemic Change
Improvement Measure	Number of trainees who gained the knowledge and skills to provide accessible and appropriate child care and to serve as a resource for family members/caregivers of CWDD2 to gain access to and use appropriate child care.	Number of individuals in the community who gained knowledge and skills related to appropriate child care for CWDD and serving as a resource for family members/caregivers of CWDD to access and use appropriate child care.	Number of individuals in the community who received services and/or supports related to appropriate child care for CWDD and serving as a resource for family members/caregivers of CWDD to access and use appropriate child care.	Number of research and evaluation activities conducted that investigated strategies to foster the provision of, accessibility to, and use of appropriate child care for CCWD.	Number of products developed and disseminated on accessing, using, and providing appropriate child care.
Consumer Satisfaction Measure	Percentage of trainees who reported satisfaction with the knowledge and skills gained to provide accessible and appropriate child care and to serve as a resource for family members/caregivers of CWDD to gain access to and use appropriate child care.	Percentage of individuals in the community who reported satisfaction with the knowledge and skills gained related to appropriate child care for CWDD and serving as a resource for family members/caregivers of CWDD to access and use appropriate child care.	Percentage of individuals in the community who reported satisfaction with the services and/or supports received related to appropriate child care for CWDD and serving as a resource for family members/caregivers of CWDD to access and use appropriate child care.		Percentage of recipients of products disseminated on accessing, using, and providing appropriate child care who reported satisfaction with the quality of the item.

Area of Emphasis: Health

	CORE FUNCTION
	Interdisciplinary Pre-Service Preparation and Continuing Education	Community Services: Training and TA	Community Services: Direct Services & Demonstration Projects	Research	Information Dissemination
Type of Activity	___Advocacy ___Capacity Building ___Systemic Change	___Advocacy ___Capacity Building ___Systemic Change	___Advocacy ___Capacity Building ___Systemic Change	___Advocacy ___Capacity Building ___Systemic Change	___Advocacy ___Capacity Building ___Systemic Change
Improvement Measure	Number of trainees who gained knowledge and skills related to the health care needs of IWDD.	Number of individuals in the community who gained knowledge and skills related to the health care needs of IWDD.	Number of individuals in the community who received services and/or supports related to healthy outcomes for IWDD.	Number of research and evaluation activities conducted that investigated strategies to foster healthy outcomes for IWDD.	Number of products developed and disseminated on achieving healthy outcomes for IWDD.
Consumer Satisfaction Measure	Percentage of trainees who reported satisfaction with the knowledge and skills gained related to the health care needs of IWDD.	Percentage of individuals in the community who reported satisfaction with the knowledge and skills gained related to the health care needs of IWDD.	Percentage of individuals in the community who reported satisfaction with the services and/or supports received related to healthy outcomes for IWDD.		Percentage of recipients of products disseminated on achieving healthy outcomes for IWDD who reported satisfaction with the quality of the item.

Area of Emphasis: Employment

	CORE FUNCTION
	Interdisciplinary Pre-Service Preparation and Continuing Education	Community Services: Training and TA	Community Services: Direct Services & Demonstration Projects	Research	Information Dissemination
Type of Activity	___Advocacy ___Capacity Building ___Systemic Change	___Advocacy ___Capacity Building ___Systemic Change	___Advocacy ___Capacity Building ___Systemic Change	___Advocacy ___Capacity Building ___Systemic Change	___Advocacy ___Capacity Building ___Systemic Change
Improvement Measure	Number of trainees who gained the knowledge and skills to serve as a resource for IWDD in increasing their employment, job choice, and career opportunities.	Number of individuals in the community who gained knowledge and skills related to employment, job choice, and career opportunities for IWDD.	Number of individuals in the community who received services and/or supports related to employment, job choice, and career opportunities for IWDD.	Number of research and evaluation activities conducted that investigated strategies to foster employment opportunities and choices for IWDD.	Number of products developed and disseminated on IWDD obtaining and maintaining employment consistent with their interests, abilities, and needs.
Consumer Satisfaction Measure	Percentage of trainees who reported satisfaction with the knowledge and skills gained to serve as a resource for IWDD in increasing their employment, job choice, and career opportunities.	Percentage of individuals in the community who reported satisfaction with knowledge and skills gained related to employment, job choice, and career opportunities for IWDD.	Percentage of individuals in the community who reported satisfaction with the services and/or supports received related to employment, job choice, and career opportunities for IWDD.		Percentage of recipients of products disseminated on IWDD obtaining and maintaining employment consistent with their interests, abilities, and needs who reported satisfaction with the quality of the item.

Area of Emphasis: Housing

	CORE FUNCTION
	Interdisciplinary Pre-Service Preparation and Continuing Education	Community Services: Training and TA	Community Services: Direct Services & Demonstration Projects	Research	Information Dissemination
Type of Activity	___Advocacy ___Capacity Building ___Systemic Change	___Advocacy ___Capacity Building ___Systemic Change	___Advocacy ___Capacity Building ___Systemic Change	___Advocacy ___Capacity Building ___Systemic Change	___Advocacy ___Capacity Building ___Systemic Change
Improvement Measure	Number of trainees who gained the knowledge and skills to serve as a resource for IWDD to choose where and with whom they will live and to facilitate the level of services needed to support those choices.	Number of individuals in the community who gained knowledge and skills related to IWDD choosing where and with whom they might live and facilitate the type and level of services needed to support those choices.	Number of individuals in the community who received services and/or supports related to IWDD choosing where and with whom to live and the services needed to support those choices.	Number of research and evaluation activities conducted that investigated strategies to foster the choices of IWDD on where and with whom to live and the services needed to support those choices.	Number of products developed and disseminated on IWDD choosing where and with whom to live and facilitating the services needed to support those choices.
Consumer Satisfaction Measure	Percentage of trainees who reported satisfaction with the knowledge and skills gained to serve as a resource for to choose where and with whom they will live and to facilitate the level of services needed to support those choices.	Percentage of individuals in the community who reported satisfaction with knowledge and skills gained related to IWDD to choosing where and with whom they will live and to facilitate the level of services needed to support those choices.	Percentage of individuals in the community who reported satisfaction with the services and/or supports received related to IWDD choosing where and with whom they will live and to facilitate the level of services needed to support those choices.		Percentage of recipients of products disseminated on IWDD choosing where and with whom to live and facilitating the services needed to support those choices who reported satisfaction with the quality of the item.

Area of Emphasis: Transportation

	CORE FUNCTION
	Interdisciplinary Pre-Service Preparation and Continuing Education	Community Services: Training and TA	Community Services: Direct Services & Demonstration Projects	Research	Information Dissemination
Type of Activity	___Advocacy ___Capacity Building ___Systemic Change	___Advocacy ___Capacity Building ___Systemic Change	___Advocacy ___Capacity Building ___Systemic Change	___Advocacy ___Capacity Building ___Systemic Change	___Advocacy ___Capacity Building ___Systemic Change
Improvement Measure	Number of trainees who gained the knowledge and skills to serve as a resource for IWDD to access and use transportation.	Number of individuals in the community who gained knowledge and skills related to IWDD accessing and using transportation.	Number of individuals in the community who received services and/or supports related to IWDD accessing and using transportation.	Number of research and evaluation activities conducted that investigated strategies to foster the accessibility and utility of transportation for IWDD.	Number of products developed and disseminated on IWDD accessing and using transportation.
Consumer Satisfaction Measure	Percentage of trainees who reported satisfaction with the knowledge and skills gained to serve as a resource for IWDD to access and use transportation.	Percentage of individuals in the community who reported satisfaction with the knowledge and skills gained related to IWDD accessing and using transportation.	Percentage of individuals in the community who reported satisfaction with the services and/or supports received related to IWDD accessing and using transportation.		Percentage of recipients of products disseminated on IWDD accessing and using transportation who reported satisfaction with the quality of the item.

Area of Emphasis: Recreation

	CORE FUNCTION
	Interdisciplinary Pre-Service Preparation and Continuing Education	Community Services: Training and TA	Community Services: Direct Services & Demonstration Projects	Research	Information Dissemination
Type of Activity	___Advocacy ___Capacity Building ___Systemic Change	___Advocacy ___Capacity Building ___Systemic Change	___Advocacy ___Capacity Building ___Systemic Change	___Advocacy ___Capacity Building ___Systemic Change	___Advocacy ___Capacity Building ___Systemic Change
Improvement Measure	Number of trainees who gained the knowledge and skills to serve as a resource for IWDD to access and participate in recreational, leisure, and social activities in their communities.	Number of individuals in the community who gained knowledge and skills related to IWDD accessing and participating in recreational, leisure, and social activities in their communities.	Number of individuals in the community who received services and/or supports related to IWDD accessing and participating in recreational, leisure, and social activities in their communities.	Number of research and evaluation activities conducted that investigated strategies to foster accessibility to and participation in recreational, leisure, and social activities for IWDD in their communities.	Number of products developed and disseminated on IWDD accessing and participating in recreational, leisure, and social activities in their communities.
Consumer Satisfaction Measure	Percentage of trainees reported satisfaction with the knowledge and skills gained to serve as a resource for IWDD to access and participate in recreational, leisure, and social activities in their communities.	Percentage of individuals in the community who reported satisfaction with the knowledge and skills gained related to IWDD accessing and participating in recreational, leisure, and social activities in their communities.	Percentage of individuals in the community who reported satisfaction with the services and/or supports received related to IWDD accessing and participating in recreational, leisure, and social activities in their communities.		Percentage of recipients of products disseminated on IWDD accessing and participating in recreational, leisure, and social activities in their communities who reported satisfaction with the quality of the item.

Area of Emphasis: Other

OTHER	CORE FUNCTION
	Interdisciplinary Pre-Service Preparation and Continuing Education	Community Services: Training and TA	Community Services: Direct Services & Demonstration Projects	Research	Information Dissemination
Type of Activity	___Advocacy ___Capacity Building ___Systemic Change	___Advocacy ___Capacity Building ___Systemic Change	___Advocacy ___Capacity Building ___Systemic Change	___Advocacy ___Capacity Building ___Systemic Change	___Advocacy ___Capacity Building ___Systemic Change
Improvement Measure	Number of trainees who gained the knowledge and skills to serve as a resource for IWDD in other areas not listed above.	Number of individuals in the community who gained knowledge and skills related to IWDD in other areas not listed above.	Number of individuals in the community who received services and/or supports related to IWDD in other areas not listed above.	Number of research and evaluation activities conducted on issues related to IWDD in other areas not listed above.	Number of products developed and disseminated on IWDD in other areas not listed above.
Consumer Satisfaction Measure	Percentage of trainees who reported satisfaction with the knowledge and skills gained to serve as a resource for IWDD in other areas not listed above.	Percentage of individuals in the community who reported satisfaction with the knowledge and skills gained related to IWDD in other areas not listed above.	Percentage of individuals in the community who reported satisfaction with the services and/or supports received related to IWDD in other areas not listed above.		Percentage recipients of products disseminated on IWDD in other areas not listed above who reported satisfaction with the quality of the item.

Measures of Collaboration:

1. Identify the critical issues/barriers affecting individuals with developmental disabilities and their families in your State that the DD Network (The State DD Council, Protection and Advocacy Agency, and UCEDD) has jointly identified:

2. Describe the strategies collaboratively implemented by the DD Network for at least one of the issues/barriers identified above:

   1. Issue/Barrier:

   2. Provide a brief description of the collaborative strategies to address issue/barrier and expected outcome(s):

   3. Check applicable areas of emphasis:

___ Quality Assurance

___Education and Early Intervention

___Child Care

___Health

___Employment

___Housing

___Transportation

___Recreation

___Other – explain:

4. Describe the UCEDD’s specific role and responsibilities in this collaborative effort. Include any technical assistance expertise you can provide to other States in this area:

5. Briefly identify problems encountered as a result of this collaboration, and technical assistance, if any, desired:

6. Describe any unexpected benefits of this collaborative effort:

3. Describe your collaborations with non-DD Act funded programs:

   1. List which disability populations benefited from your collaborations.

   2. Estimate the number of individuals with disabilities, other than developmental disabilities, who were affected by your collaborations with non-DD Act funded programs.

   3. Estimate the number of individuals with developmental disabilities who were affected by your collaborations with non-DD Act funded programs.

Section 5: Government Performance and Results Act Measures

Directions for completing Section 5: Grantees will report to ADD quantitative data for two Government Performance and Results Act (GPRA) measures. Grantees will supply to ADD raw data. ADD will use the data to calculate the percentages and report as an aggregate figure across the Network.

GPRA MEASURE 1: Percent of individuals with developmental disabilities who are receiving services through activities in which UCEDD-trained professionals are involved at 1, 5, and 10 years after completion of UCEDD training.

GPRA MEASURE 2: Percent of UCEDD trainees who demonstrate leadership in the developmental disabilities field at 1, 5, and 10 years after completion of UCEDD training.

DATA SOURCES: Data for the GPRA measures will be collected through surveys of interdisciplinary pre-service and continuing education trainees who will be asked questions at 1, 5, and 10 years post training. UCEDDs will submit raw data to ADD the responses from the survey.

GPRA MEASURE 1:

Survey Question: What is the number of individuals with developmental disabilities who are receiving direct services through activities in which you are involved?

Data to ADD: 1) # of individuals reported receiving services and

2) # of responses

GPRA MEASURE 2:

Survey Question: Are you in a leadership position in the field of developmental disabilities?

Data to ADD: 1) # “yes” responses and

2) # of responses

METHOD ADD will tabulate the data sources (for GPRA measure 1: # of individuals reported receiving services and # of responses and for GPRA measure 2: # “yes” responses and # of responses) to calculate an aggregate percentage for the Network.

1 IWDD = Individuals with developmental disabilities

2 CWDD = Children with developmental disabilities

5