Form 1 SCDD Performance Report

OMB 0980-0172

Expiration Date: XX/XX/XXXX

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13)

Public reporting burden for this collection of information is estimated to average 138 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.

ANNUAL PROGRAM PERFORMANCE REPORT TEMPLATE

STATE COUNCILS ON D EVELOPMENTAL DISABILITIES o

SECTION I: IDENTIFICATION

1. State/Territory:

2. Federal Fiscal Year Reporting: October 1, 20___ through September 30, 20___

3. Contact person regarding PPR information:

4. Contact person’s phone number:

5. Contact person’s e-mail address:

6. Council is its own DSA: ____Yes ____No

SECTION II: PROGRESS REPORT

Section II.a. Detailed Progress Report on Goals

Goal #: Goal statement would be taken directly from State Plan

Area(s) of Emphasis:

Area of Emphasis	Planned for this goal Taken directly from State Plan; areas checked off	Areas addressed To be completed annually; Council checks off Areas
Quality Assurance
Education and Early Intervention
Child Care
Health
Employment
Housing
Transportation
Recreation
Formal and Informal Community Supports

Strategies:

Strategies	Planned for this goal Taken directly from State Plan; strategies checked off	Strategies Used To be completed annually; Council checks off Strategies Used
Outreach
Training
Technical Assistance
Supporting and Educating Communities
Interagency Collaboration and Coordination
Coordination with Related Councils, Committees and Programs
Barrier Elimination
Systems Design and Redesign
Coalition Development and Citizen Participation
Informing Policymakers
Demonstration of New Approaches to Services and Supports
Other Activities

Intermediaries/Collaborators:

Intermediaries/Collaborators	Planned for this goal Taken directly from State Plan; Intermediaries/Collaborators checked off	Actual To be completed annually; Council checks off Intermediaries/Collaborators
State Protection and Advocacy System
University Center(s)
State DD agency
Other:
Other:
Other:

Objectives/Implementation Activities/Timeline:

Objectives	Implementation Activities	Timeline
Objective Taken directly from State Plan	Taken directly from State Plan	Taken directly from State Plan
Narrative Result1: For each objective, the Council would complete this section annually, providing a narrative report of how the objective was implemented, if there were activities planned for during the reporting timeframe. The Council would not provide a narrative report for objectives not planned for during the reporting timeframe.
Objective
Narrative Result:

Section II.b. Summary

This section would be used to provide a summary report of overall progress, to discuss challenges and to describe significant achievements not reported elsewhere.

SECTION III: PROJECTED COUNCIL BUDGET [Section 124(c)(5)(B) and 125(c)(8)]

Budget Planned

The chart below would be taken directly from the State Plan

Goal	Subtitle B $	Other(s) $	TOTAL
Goal
Goal
Goal
Goal
Goal
General management (Personnel, Budget, Finance, Reporting)
Functions of the DSA
TOTAL	$	$	$

Actual Expenditures

The Council would complete this chart annually, identifying the actual expenditures for the year

Goal	Subtitle B $	Other(s) $	TOTAL
Goal
Goal
Goal
Goal
Goal
General management (Personnel, Budget, Finance, Reporting)
Functions of the DSA
TOTAL	$	$	$

SECTION IV: PERFORMANCE MEASURES

1. Self-advocacy measure:

   1. (Annual) The number of people with developmental disabilities and families of those with developmental disabilities who were provided assistance in becoming active participants in making decisions that affect their lives

   2. (Annual) The percent of those people (in number one) who became active participants in making decisions that affect their lives.

2. Systems Change measure:

   1. (Annual) The number of systems² with whom you worked to transform their fragmented approaches into a coordinated and effective system that represents outcomes specified in the Act.

2. (5 year measure) The unduplicated number of systems modified³ to transform fragmented approaches into a coordinated and effective system that represents outcomes specified in the Act.

Note: this measure would not be reported on annually. Instead, data would be reported for this measure every 5 years.

SECTION V: SATISFACTION WITH COUNCIL SUPPORTED OR CONDUCTED ACTIVITIES 

Section V.a. Individual Reponses

1. Number of responses:

2. Respect: I (or my family member) was treated with respect during project activity.

____% Yes

____% No

3. Choice: I (or my family member have more choice and control as a result of project activity.

____% Yes

____% No

4. Community: I (or my family member) can do more things in my community as a result of project activity.

____% Yes

____% No

5. Satisfied: I am satisfied with project activity.

____% Strongly Agree

____% Agree

____% Disagree

____% Strongly Disagree

6. Better Life: My life is better because of project activity.

____% Strongly Agree

____% Agree

____% Disagree

____% Strongly Disagree

7. Rights: Because of this project activity, I (or my family member) know my rights.

____% Yes

____% No

8. Safe: I (or my family member) are more able to be safe and protect myself from harm as a result of activity.

____% Yes

____% No

9. Comments:

Section V.b. Stakeholders Responses

1. Number of responses:

2. Impact: Council activities have improved the ability of the individuals with developmental disabilities and family members to:

1. Make choices and exert control over the services and support they use

___% Strongly Agree

___% Agree

___% Somewhat Agree

___% Somewhat Disagree

___% Disagree

___% Strongly Disagree

2. participate in community life:

___% Strongly Agree

___% Agree

___% Somewhat Agree

___% Somewhat Disagree

___% Disagree

___% Strongly Disagree

3. Satisfaction: Council activities promote self-determination and community participation for individuals with developmental disabilities.

___% Strongly Agree

___% Agree

___% Somewhat Agree

___% Somewhat Disagree

___% Disagree

___% Strongly Disagree

4. Comments:

SECTION VI: 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

___Quality of Life

___Other – Assistive Technology

___Other – Cultural Diversity

___Other - Leadership

___Other – please specify:

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:

1 Narrative results are only reported for active objectives and not those objectives planned for subsequent years

2 Number of systems is derived from the number of organizations/agencies/coalitions/networks involved (any organized group of individuals with an identifiable mission statement)

3 "Modified" means any of the following: created/improved/refined/deleted policies and/or procedures; created/improved refined/deleted programs; leveraged/allocated/reallocated/dedicated use of funds; leveraged/allocated/reallocated/dedicated use of resources, other than dollars; Individuals/family members participating in policy/advisory/planning/governing bodies; trained people in content areas/systems advocacy/self-advocacy; involved people in self-advocacy; engaged people in systems change efforts; reached policymakers; engaged organizations in systems change efforts, including best practices developed, implemented and replicated; involved organizations in coalitions/networks

Page | 1 DRAFT – APRIL 2012