704 Section 704 APR Part II

Section 704 Annual Performance Report (Parts I and II)

1820-0606 Part II Instrument 2014

Section 704 Annual Performance Report for Centers for Independent Living Program Part II

OMB: 0985-0043

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Reporting Instrument


OMB Control Number: 1820-0606

Expiration Date: xx-xx-201x

UniTed States Department of Education

Office of Special Education and RehabilitatiVE Services

Rehabilitation Services Administration



Section 704

annual performance report

For

Centers for Independent Living Program

(Title VII, Chapter 1, Part C of the Rehabilitation Act of 1973, as amended)


Part II

INSTRUMENT


(To be completed by Centers for Independent Living)




Fiscal Year: ____________________________________

Grant #: _______________________________________

Name of Center: ________________________________

Acronym for Center (if applicable): ________________

State: _________________________________________

Counties Served: _______________________________


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. Public reporting burden for this collection of information is estimated to average 35 hours per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is required to obtain or retain benefit (P.L. 105-220 Section 410 Workforce Investment Act). Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Rehabilitation Services Administration, LBJ Basement, Attention: Timothy Beatty, PCP Room 5057, U.S. Department of Education, 400 Maryland Ave, SW, Washington, DC 20202-2800 or email [email protected] and reference the OMB Control Number 1820-0606.Chapter 1, Title VII of the Rehabilitation Act.


SUBPART I – ADMINISTRATIVE DATA


Section A– Sources and Amounts of Funds and Resources

Section 725(c)(8)(D) of the Act; 34 CFR 366.50(i)(4)

Indicate the amount received by the CIL as per each funding source. Enter “0” for none.


Item 1 - All Federal Funds Received


(A) Title VII, Ch. 1, Part B

$

(B) Title VII, Ch. 1, Part C

$

(C) Title VII, Ch. 2

$

(D) Other Federal Funds

$


Item 2 - Other Government Funds



(E) State Government Funds


$


(F) Local Government Funds


$

Item 3 - Private Resources



(G) Foundations, Corporations, or Trust Grants


$


(H) Donations from Individuals


$


(I) Membership Fees


$


(J) Investment Income/Endowment


$


(K) Fees for Service (program income, etc.)


$


(L) Other resources (in-kind, fundraising, etc.)


$

Item 4 - Total Income


Total income = (A)+(B)+(C)+(D)+(E)+(F)+(G)+(H)+(I)+(J)+(K)+(L)


$

Item 5 - Pass Through Funds


Amount of other government funds received as pass through funds to consumers (include funds, received on behalf of consumers, that are subsequently passed on to consumers, e.g., personal assistance

services, representative payee funds, or Medicaid funds)




$


Item 6 - Net Operating Resources


[Total Income (Section 4)<minus> amount paid out to Consumers

(Section 5) = Net Operating Resources


$


SubPart II – Number and Types of Individuals with significant disabilities receiving services

Section 725(c)(8)(B) of the Act; 34 CFR 366.50(i)(2)


Section A – Number of Consumers Served During the Reporting Year


Include Consumer Service Records (CSRs) for all consumers served during the year.



# of CSRs

(1) Enter the number of active CSRs carried over from September 30 of the preceding reporting year


(2) Enter the number of CSRs started since October 1 of the reporting year


(3) Add lines (1) and (2) to get the total number of consumers served



Section B –Number of CSRs Closed by September 30 of the Reporting Year


Include the number of consumer records closed out of the active CSR files during the reporting year because the individual has:



# of CSRs

  1. Moved


  1. Withdrawn


  1. Died


  1. Completed all goals set


  1. Other


  1. Add lines (1)+(2)+(3)+(4)+(5) to get total CSRs closed



Section C –Number of CSRs Active on September 30 of the Reporting Year


Indicate the number of CSRs active on September 30th of the reporting year.



# of CSRs

Section A(3) <minus> Section (B)(6) = Section C



Section D – IL Plans and Waivers


Indicate the number of consumers in each category below.



# of Consumers

  1. Number of consumers who signed a waiver


  1. Number of consumers with whom an ILP was developed


  1. Total number of consumers served during the reporting year



Section E – Age


Indicate the number of consumers in each category below.



# of Consumers

  1. Under 5 years old


  1. Ages 5 – 19


  1. Ages 20 – 24


  1. Ages 25 – 59


  1. Age 60 and Older


  1. Age unavailable



Section F – Sex


Indicate the number of consumers in each category below.



# of Consumers

  1. Number of Females served


  1. Number of Males served




Section G – Race And Ethnicity


Indicate the number of consumers served in each category below. Each consumer may be counted under ONLY ONE of the following categories in the 704 Report, even if the consumer reported more than one race and/or Hispanic/Latino ethnicity).


This section reflects a new OMB directive.

Please refer to the Instructions before completing.



# of Consumers

(1) American Indian or Alaska Native


(2) Asian


(3) Black or African American


(4) Native Hawaiian or Other Pacific Islander


(5) White


(6) Hispanic/Latino of any race or Hispanic/ Latino only


(7) Two or more races


(8) Race and ethnicity unknown



Section H – Disability


Indicate the number of consumers in each category below.



# of Consumers

  1. Cognitive


  1. Mental/Emotional


  1. Physical


  1. Hearing


  1. Vision


  1. Multiple Disabilities


  1. Other


Section I – Individuals Served by County During the Reporting Year

Section 704(m)(4)(D) of the Act


List each county within the CIL’s service area, as indicated in the CIL’s application for Part C funds and the approved SPIL. Add additional rows as necessary. For each county, indicate how many individuals residing in that county were served by the CIL during the reporting year.


County Name

Number of County Residents Served































SubPart III – Individual Services and Achievements

Sections 13 and 725(c)(8)(C) of the Act; 34 CFR 366.50(i)(3); Government Performance Results Act (GPRA) Performance Measures


Subpart III contains new data requests. Please refer to the Instructions before completing.


Section A – Individual Services


For the reporting year, indicate in the table below how many consumers requested and received each of the following IL services.


Services

Consumers Requesting

Services

Consumers Receiving Services

(A) Advocacy/Legal Services



(B) Assistive Technology



(C) Children’s Services



(D) Communication Services



(E) Counseling and Related Services



(F) Family Services



(G) Housing, Home Modifications, and Shelter Services



(H) IL Skills Training and Life Skills Training



(I) Information and Referral Services



(J) Mental Restoration Services



(K) Mobility Training



(L) Peer Counseling Services



(M) Personal Assistance Services



(N) Physical Restoration Services



(O) Preventive Services



(P) Prostheses, Orthotics, and Other Appliances



(Q) Recreational Services



(R) Rehabilitation Technology Services



(S) Therapeutic Treatment



(T) Transportation Services



(U) Youth/Transition Services



(V) Vocational Services



(W) Other Services




Section B – Increased Independence and Community Integration


Item 1 – Goals Related to Increased Independence in a Significant Life Area


Indicate the number of consumers who set goals related to the following significant life areas, the number whose goals are still in progress, and the number who achieved their goals as a result of the provision of IL services.


Significant Life Area

Goals Set

Goals Achieved

In Progress

  1. Self-Advocacy/Self-Empowerment




  1. Communication




  1. Mobility/Transportation




  1. Community-Based Living




  1. Educational




  1. Vocational




  1. Self-care




  1. Information Access/Technology




  1. Personal Resource Management




  1. Relocation from a Nursing Home or Institution to Community-Based Living




  1. Community/Social Participation




  1. Other





Item 2 – Improved Access To Transportation, Health Care Services, and Assistive Technology


(A) Table


In column one, indicate the number of consumers who required access to previously unavailable transportation, health care services, or assistive technology during the reporting year. Of the consumers listed in column one, indicate in column two, the number of consumers who, as a result of the provision of IL services (including the four core services), achieved access to previously unavailable transportation, health care services, or assistive technology during the reporting year. In column three, list the number of consumers whose access to transportation, health care services or assistive technology is still in progress at the end of the reporting year.


Areas

# of Consumers Requiring Access

# of Consumers Achieving Access

# of Consumers Whose Access is in Progress

(A) Transportation




(B) Health Care Services




(C) Assistive Technology





Note: For most IL services, a consumer’s access to previously unavailable transportation, health care and assistive technology is documented through his or her CSR. In some instances, consumers may achieve an outcome solely through information and referral (I&R) services. To document these instances as successful outcomes, providers are not required to create CSRs for these consumers but must be able to report that follow-up contacts with these consumers showed access to previously unavailable transportation, health care and assistive technology.


(B) I&R Information


To inform RSA how many service providers engage in I&R follow-up contacts regarding access to transportation, health care services or assistive technology, please indicate the following:


The service provider did ___ / did not ___ engage in follow-up contacts with I & R recipients to document access gained to previously unavailable transportation, health care or assistive technology.


Section C – Additional Information Concerning Individual Services or Achievements

Please provide any additional description or explanation concerning individual services or achievements reported in subpart III, including outstanding success stories and/or major obstacles encountered.

SUBPART IV – Extent of CIL Compliance with the Six Evaluation Standards

Section 725(b) and section 725(c)(8)(A) of the Act; 34 CFR 366.63


Section A – Compliance Indicator 1: Philosophy


Item 1 - Consumer Control

34 CFR 366.63(a)(1); 34 CFR 366.50(i)(5) and (6)


(A) Board Member Composition


Enter requested governing board information in the table below:


Total Number of Board Members

Number of Board Members with Significant Disabilities






(B) Staff Composition


Enter requested staff information in the table below:



Total Number

of

FTEs

FTEs

Filled by Individuals with Disabilities

FTEs Filled by Individuals From Minority Populations

Decision-Making Staff





Other Staff






Item 2 - Self-Help and Self-Advocacy

34 CFR 366.63(a)(2)


Briefly describe how the CIL has promoted self-help and self-advocacy among individuals with significant disabilities during the reporting year.


Item 3 - Peer Relationships and Peer Role Models

34 CFR 366.63(a)(3)


Briefly describe how, during the reporting year, the CIL has promoted the development of peer relationships and peer role models among individuals with significant disabilities.



Item 4 - Equal Access

34 CFR 366.63(a)(4)


(A) Briefly describe how, during the reporting year, the CIL has ensured equal access of individuals with significant disabilities, including communication and physical access, to the center's services, programs, activities, resources, and facilities, whether publicly or privately funded. Equal access, for the purposes of this indicator, means that the same access is provided to any individual with a significant disability regardless of the individual’s type of significant disability.



(B) Briefly describe how, during the reporting year, the CIL has advocated for and conducted activities that promote the equal access to all services, programs, activities, resources, and facilities in society, whether public or private, and regardless of funding source, for individuals with significant disabilities. Equal access, for the purposes of this indicator, means that the same access provided to individuals without disabilities is provided in the center’s service area to individuals with significant disabilities.



Item 5 – Alternative Formats

34 CFR 366.63(a)(4)


Briefly describe how, during the reporting year, the CIL has ensured the availability in alternative formats of all of its written policies and materials and IL services, as appropriate.



Section B – Compliance Indicator 2: Provision of Services on a Cross-Disability Basis

Section 725(b)(2) of the Act; 34 CFR 366.63(b)


Briefly describe how, during the reporting year, the CIL has ensured that IL services are provided to eligible individuals with a diversity of significant disabilities and individuals who are members of populations that are unserved or underserved, without restrictions based on the particular type or types of significant disability and in a manner that is neither targeted nor limited to a particular type of significant disability.



Section C – Compliance Indicator 3: Independent Living Goals

Section 725(b)(3) of the Act; 34 CFR 366.63 (c)


Item 1 – Consumer Information


Briefly describe how, during the reporting year, the CIL has ensured that consumers have the opportunity to develop and achieve their goals (either with or without an ILP) and that the consumer has the opportunity to express satisfaction with the center and such consumer satisfaction results are evaluated by the center.



Item 2 – Consumer Service Record Requirements


Briefly describe how, during the reporting year, the CIL ensured that each consumer’s CSR contains all of the required information.



Section D – Compliance Indicator 4: Community Options and Community Capacity

Section 725(b)(4) and (6) of the Act; 34 CFR 366.63(d)


This section contains new data requests. Please refer to the Instructions before completing.


Item 1 – Community Activities Table


In the table below, summarize the community activities involving the CIL’s staff and board members during the reporting year. For each activity, identify the primary disability issue(s) addressed as well as the type of activity conducted. Describe the primary objective(s) and outcome(s) for each activity. Add more rows as necessary.


Issue Area

Activity Type

Hours Spent

Objective(s)

Outcomes(s)






































Item 2 – Description of Community Activities


For the community activities mentioned above, provide additional details such as the role of the CIL staff board members and/or consumers, names of any partner organizations and further descriptions of the specific activities, services and benefits.


Section E – Compliance Indicator 5: IL Core Services and Other IL Services

Section 725(b)(5) of the Act; 34 CFR 366.63(e)


In addition to the data provided in Subpart III, describe how information and referral services and the other IL core and other IL services are provided to those who request such services in formats accessible to the individual requesting the services. Describe any innovative practices (not mentioned elsewhere in this report) to enhance the availability and effectiveness of IL services.



Section F – Compliance Indicator 6: IL Resource Development Activities

Section 725(b)(7); 34 CFR 366.63(f)


Briefly describe the CIL’s resource development activities conducted during the reporting year to expand funding from sources other than chapter 1of title VII of the Act.


SUBPART V – ANNUAL PROGRAM AND FINANCIAL PLANNING OBJECTIVES

Section 725(c)(4) of the Act


Section A –Work Plan for the Reporting Year


Item 1 – Achievements


Discuss the work plan’s proposed goals and objectives and the progress made in achieving them during the reporting year.



Item 2 – Challenges


Describe any substantial challenges or problems encountered by the CIL, and the resolutions/attempted resolutions.



Item 3 – Comparison with Prior Reporting Year

34 CFR 366.50(i)(7)


As appropriate, compare the CIL’s activities in the reporting year with its activities in prior years, e.g., recent trends.



Section B – Work Plan for the Year Following the Reporting Year


Item 1 – Annual Work Plan


List the CIL’s annual work plan goals, objectives and action steps planned for the year following the reporting year.



Item 2 – SPIL Consistency


Explain how these work plan goals, objectives and action steps are consistent with the approved SPIL.



SUBPART VI - TRAINING AND TECHNICAL ASSISTANCE NEEDS

Section 721(b)(3) of the Act.




Training And Technical Assistance Needs


Choose up to 10 Priority Needs ---

Rate items 1-10 with 1 being most important

Advocacy/Leadership Development


General Overview


Community/Grassroots Organizing


Individual Empowerment


Systems Advocacy


Legislative Process


Applicable Laws


General overview and promulgation of various disability laws


Americans with Disabilities Act


Air-Carrier’s Access Act


Fair Housing Act


Individuals with Disabilities Education Improvement Act


Medicaid/Medicare/PAS/waivers/long-term care


Rehabilitation Act of 1973, as amended


Social Security Act


Workforce Investment Act of 1998


Ticket to Work and Work Incentives Improvement Act of 1999


Government Performance Results Act of 1993


Assistive Technologies


General Overview


Data Collecting and Reporting


General Overview


704 Reports


Performance Measures contained in 704 Report


Dual Reporting Requirements


Case Service Record Documentation

Disability Awareness and Information


Specific Issues


Evaluation


General Overview


CIL Standards and Indicators


Community Needs Assessment


Consumer Satisfaction Surveys


Focus Groups


Outcome Measures


Financial: Grant Management


General Overview


Federal Regulations


Budgeting


Fund Accounting


Financial: Resource Development


General Overview


Diversification of Funding Base


Fee-for-Service Approaches


For Profit Subsidiaries


Fund-Raising Events of Statewide Campaigns


Grant Writing


Independent Living Philosophy


General Overview


Innovative Programs


Best Practices


Specific Examples


Management Information Systems


Computer Skills


Software

Marketing and Public Relations


General Overview


Presentation/Workshop Skills


Community Awareness


Networking Strategies


General Overview


Electronic


Among CILs & SILCs


Community Partners


Program Planning


General Overview of Program Management and Staff Development


CIL Executive Directorship Skills Building


Conflict Management and Alternative Dispute Resolution


First-Line CIL Supervisor Skills Building


IL Skills Modules


Peer Mentoring


Program Design


Time Management


Team Building


Outreach to Unserved/Underserved Populations


General Overview


Disability


Minority


Institutionalized Potential Consumers


Rural


Urban


SILC Roles/Relationship to CILs


General Overview


Development of State Plan for Independent Living


Implementation (monitor & review) of SPIL


Public Meetings


Role and Responsibilities of Executive Board


Role and Responsibilities of General Members


Collaborations with In-State Stakeholders


CIL Board of Directors


General Overview


Roles and Responsibilities


Policy Development


Recruiting/Increasing Involvement


Volunteer Programs


General Overview


Optional Areas and/or Comments (write-in)









SUBPART VII – ADDITIONAL INFORMATION

Section 704(m)(4)(D) of the Act


Section A – Other Accomplishments, Activities and Challenges


Describe any additional significant accomplishments, activities and/or challenges not included elsewhere in the report, e.g. brief summaries of innovative practices, improved service delivery to consumers, etc.



Section B – Additional Information


Provide additional information, comments, explanations or suggestions not included elsewhere in the report.


SubPART VIII - signatures


Please sign and print the names, titles and telephone numbers of the CIL director and board chair.




SIGNATURE OF CENTER DIRECTOR

DATE



NAME AND TITLE OF CENTER DIRECTOR

PHONE NUMBER





SIGNATURE OF CENTER BOARD CHAIRPERSON

DATE



NAME AND TITLE OF CENTER BOARD CHAIRPERSON

PHONE NUMBER


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File TitleREPORTING INSTRUMENT
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