OMB No. 0985-0007
Expiration Date: 07/31/2015
Title VI, Parts A/B and C _______ Title VI, Part A/B only ______
Tribal Organization _____________________________________________________________
Address ______________________________________________________________________
Part A/B Grant No. ___________ Part C Grant No.____________ Report Period ____________
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Full-time staff ___________
Part-time staff ___________
B. NUTRITION SERVICES
1, Congregate Meals:
a. UNDUPLICATED NUMBER of eligible persons who received
one or more congregate meal. __________
b. TOTAL NUMBER of congregate meals served. __________
2. Home-Delivered Meals:
a. UNDUPLICATED NUMBER of eligible persons who received
one or more home-delivered meal. ___________
b. TOTAL NUMBER of home-delivered meals provided. ___________
3. Other Nutrition Services:
Nutrition Education ____________
b. Nutrition Counseling ____________
UNDUPLICATED NUMBER of eligible Indians who received
one or more of the supportive services below. ____________
TOTAL NUMBER OF UNITS OF SERVICE in the following categories:
Total Units of Service
ACCESS SERVICES
a. Information/Referral __________
b. Outreach __________
c. Case Management __________
d. Transportation __________
LEGAL ASSISTANCE __________
IN-HOME SERVICES
a. Homemaker Service __________
b. Personal Care/Home Health Aid Service __________
c. Chore Service __________
d. Visiting __________
e. Telephoning __________
f. Family Support __________
OMBUDSMAN SERVICES __________
HEALTH PROMOTION AND WELLNESS __________
ALL OTHERS __________
**OFFICIAL SIGNATURE** - If only completing Title VI, Part A/B of this report go to page 4 to sign and date.
TITLE VI, PART C REPORT
1. Full-time staff ___________
2. Part-time staff ___________
B. CAREGIVER SUPPPORT SERVICES. Enter the UNDUPLICATED NUMBER of
eligible Indians who received each category of support services in the “Unduplicated
Number” column. Enter the TOTAL NUMBER of units of service provided from all
sources of funds (excluding Title III) in the “Total Number” column.
Category Unduplicated Number Total Number
Information about available services. _________ _________
Assistance in gaining access to
available services. _________ __________
Caregiver Services:
Individual Counseling __________ __________
Support Groups __________ __________
Caregiver Training __________ __________
Lending Closet __________ __________
Other __________ __________
d. Respite __________ __________
C. Briefly describe your coordination activities in providing supportive services for
caregivers.
D. Briefly describe the standards and quality assurance mechanisms you are using.
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Report Certified By ________________________________________________
(Tribal Official)
Date Submitted _________________________________________________
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TIME IT TAKES TO COMPLETE THIS FORM
We estimate that it will take you about 2.5 hours to complete this form. This includes the time it will take to read the instructions, gather the necessary facts and fill out the form.
This data collection is authorized by Section 614(a)(3) of the Older Americans Act and Title 45 of the Code of Federal Regulations, Part 92.40(b)(1).
If you have comments or suggestions on this estimate, or on any other aspect of this form, write to the Department of Health and Human Services, Administration on Aging, Attention: Reports Clearance Officer, Room 5704, 1 Massachusetts Avenue, N.W., Washington, D.C., 20001.
INSTRUCTIONS FOR COMPLETING THE AOA
PROGRAM PERFORMANCE REPORT
Always submit any reports or correspondence concerning the Title VI program with the Grant Number. This number can be located on the Grant Award Document.
This report covers the grant period starting April 1 through March 31. A report is due within 30 days of the end of each budget period within the project period and within 90 days of the end of the project period.
SEND ONE COPY OF ALL REPORTS TO:
Mail to: Administration on Aging
Office of Grants Management
Washington, DC 20201
Or
Deliver to: Administration on Aging
Office of Grants Management
1 Massachusetts Ave., NW
Washington, DC 20001
Title VI, Parts A/B and C
Report Data Units and Definitions
A. STAFFING
1) Paid Staff: enter the total number of full and part-time employed by the
grantee who are paid from the Title VI grant.
TITLE VI, PART A/B ONLY
B. NUTRITION SERVICES – This section provides the unduplicated count of people served and the total number of services provided. An eligible participant can be
counted only once each year for congregate meals and once each year for home-delivered
meals. The count starts on April 1 and ends on March 31.
1.a. Unduplicated Number Served Congregate Meals: Enter the unduplicated total
number of eligible persons served one or more congregate meal during the reporting
period. An eligible person is: an Indian elder; a spouse of an Indian elder;
individuals providing volunteer services during meal hours; and non-elderly
handicapped or disabled person who reside at home with and accompany an
elder or who reside in housing facilities occupied primarily by the elderly.
1.b. Total Number of Congregate Meals Served: Enter the total number of meals served
in a congregate setting to eligible persons for the grant year, April 1-March 31.
2.a. Person Served Home Delivered Meals: Enter the unduplicated total number
of eligible persons served one or more home-delivered meal. An eligible
person is: an Indian elder; a spouse of an Indian elder; individuals providing
volunteer services during meal hours; and non-elderly handicapped or disabled
persons who reside at home with and accompany an elder or who reside in housing
facilities occupied primarily by the elderly.
2.b. Number of Home Delivered Meals Served: Enter the total number of meals
delivered to eligible persons at home for the grant year, April 1- March 31.
3. Other Nutrition Services: Enter the total number of units of service provided from all
sources of funding (excluding Title III) for each nutrition service.
C. SUPPORTIVE SERVICES
1. Unduplicated Number of persons served: Enter the number of different eligible
persons who received one or more of the supportive services listed below.
2. Enter the total number of services provided from all sources of funds (except for
Title III) for each of the supportive services.
DEFINITIONS FOR UNITS OF SERVICE:
Congregate Meal (1 Meal): Provision, to an eligible participant at a nutrition site, senior center or some other congregate setting, a meal which:
1) complies with the USDA/DHHS Dietary Guidelines for Americans; and
2) provides, if one meal is served, a minimum of 33 ½% of the RDA, 66 2/3% if two
meals are served for one day, and 100% if three meals are served for one day.
Home-Delivered Meal (1 Meal): Provision, to an eligible participant in their place of residence, a meal which:
1) complies with the USDA/DHHS Dietary Guidelines for Americans; and
2) provides, if one meal is served, a minimum of 33 ½% of the RDA; 66 2/3% if two
meals are served for one day, and 100% if three meals are served for one day.
Nutrition Education (1 hour = 1 unit of service): An educational program provided by a knowledgeable person to promote better health by providing accurate and culturally sensitive nutrition or health (as it relates to nutrition) information and instruction in a group or individual setting.
Nutrition Counseling (1hour = 1 unit of service): Provision of individualized advice and guidance to individuals, who are at nutritional risk, because of their health or nutritional history, dietary intake, medication use, or chronic illnesses, about options and methods for improving their nutritional status, performed by a health professional.
Information/Referral (1 contact = 1 unit of service): Provision of concrete information to a client about available public and voluntary services and resources (including name, address, and telephone number of service or resource and linkage with appropriate community resource(s) to ensure necessary service will be delivered to the client. Must include contact and follow-up with the provider and/or client.
Outreach (1 contact = 1 unit of service): Conducting activities to identify elders eligible for services, providing information to eligible elders about available service, and encouraging an elder to use existing services. This is a one-on-one contact, not a group service such as public education.
Case Management (1 hour = 1 unit of service): Assisting either in the form of access or care coordination when the elder or their caregiver is experiencing diminished functioning capacities or other characteristics which require the provision of services by formal service providers. Activities of case management include assessing needs, developing care plans, authorizing services, arranging services, coordinating the provision of services among providers, follow-up and reassessment, as required.
Transportation (1 One Way Trip = 1 unit of service): Includes both transportation (provision of a means of going from one location to another) and assisted transportation (provision of assistance, including escort to a person who has difficulties using regular vehicular transportation). A round trip is counted as two units of services.
Legal Services (1 contact = 1 unit of service): Performing legal and financial transactions on behalf of an elder based upon a legal transfer of responsibility (i.e., as part of protective services) or assisting an elder in legal matters.
Homemaker Services (1 hour = 1 unit of service): Providing assistance for housecleaning, laundry, shopping, and meal preparation.
Personal Care/Home Health Aid Service (1 hour = 1 unit of service): Providing personal assistance with eating, dressing, bathing, toileting, transferring in and out of bed/chair or walking and providing in-home health services such as checking blood pressure and blood glucose and assistance with personal care. Does require trained personnel.
Chore Service (1 hour = 1 unit of service): Providing assistance to persons having difficulty with heavy cleaning, yard work, walk maintenance, minor home repair, wood chopping, hauling water and other heavy duty activities which the older person(s) is unable to handle on his/her own and which do not require the services of a trained homemaker or other specialist.
Visiting (1 contact = 1 unit of service): Visiting services include going to see an elder in order to comfort or help in reading or writing a letter.
Telephoning (1 contact = 1 unit of service): Telephone services include phoning in order to provide comfort or help or check up on the elder.
Family Support (1 contact = 1unit of service): Family support services include providing services to family members who care for an elder such as counseling or discussing the elder’s situation.
Ombudsman (1 contact = 1 unit of service): Investigating and resolving complaints made by or for older Indians residing in long-term care facilities; provide information about problems of resident older Indians.
Health Promotion and Wellness (1 hour = 1 unit of service per person if it is a group activity; for example, a one hour exercise class for 10 people and would count as 10 units of service): Activities conducted to improve the mental and physical health of elders, including walking groups, exercise classes, other types of recreation, and health education classes on health care.
All Others: Other services may include:
Assessment (1 contact = 1 unit of service): Collecting necessary information about a client to determine need and/or eligibility for a service. Information collected may include demographics, health status, financial status, etc. and may also include routine tests such as blood pressure, hearing, vision, etc.
Escort Service (1 contact = 1 unit of service): Accompanying and personally assisting a client to obtain a service.
Public Information (1 hour of preparation = 1 unit of service): Writing, reproducing and mailing a program newsletter; writing a newspaper column; or providing a radio/television interview.
Interpreting/Translating: Explaining the meaning of oral and/or written communication
to non-English speaking and/or handicapped persons unable to perform the function.
| File Type | application/msword |
| Author | Meg Graves |
| Last Modified By | DHHS |
| File Modified | 2015-07-16 |
| File Created | 2015-07-16 |