| Grantee name |
|
|
|
| Grant ID |
|
|
|
| Reporting period (start date - end date) |
|
|
|
| Report submission date |
|
|
|
| ALL LIGHT GREEN CELLS SHOULD BE COMPLETED |
|
PWD |
Caregiver |
Total |
| TOTAL SERVED |
|
|
0 |
| Age |
|
|
|
| Under 60 |
|
|
0 |
| 60+ |
|
|
0 |
| Age missing |
|
|
0 |
| Gender |
|
|
|
| Female |
|
|
0 |
| Male |
|
|
0 |
| Gender missing |
|
|
0 |
| Geographic location |
|
|
|
| Urban |
|
|
0 |
| Rural |
|
|
0 |
| Geographic location missing |
|
|
0 |
| Ethnicity |
|
|
|
| Hispanic or Latino |
|
|
0 |
| Not Hispanic or Latino |
|
|
0 |
| Ethnicity missing |
|
|
0 |
| Race |
|
|
|
| American Indian or Alaskan Native |
|
|
0 |
| Asian or Asian American |
|
|
0 |
| Black or African American |
|
|
0 |
| Native Hawaiian or other Pacific Islander |
|
|
0 |
| White |
|
|
0 |
| Race missing |
|
|
0 |
| Military Status |
|
|
|
| Served in the military |
|
|
0 |
| Has not served in the military |
|
|
0 |
| Military status missing |
|
|
0 |
| Relationship to caregiver |
|
|
|
| Spouse or partner |
|
|
0 |
| Parent |
|
|
0 |
| Other caregiver |
|
|
0 |
| No caregiver |
|
|
0 |
| Relationship Missing |
|
|
0 |
| Living arrangement |
|
|
|
| Lives alone, has an identified caregiver |
|
|
0 |
| Lives alone, no identified caregiver |
|
|
0 |
| Does not live alone |
|
|
0 |
| Living arrangement missing |
|
|
0 |
| Grantee |
0 |
|
| Grant ID |
0 |
|
| Reporting period (start date - end date) |
0 |
|
| Report submission date |
0 |
|
| ALL LIGHT GREEN CELLS SHOULD BE COMPLETED |
|
Number of persons trained |
| PERSONS TRAINED |
|
| Information and referral providers, options counselors |
|
| Case managers, care coordinators, discharge planners |
|
| Direct care workers (certified nursing assistants, personal care attendants, companions) |
|
| Health care providers (physicians, nurse practitioners, nurses) |
|
| Health educators, interventionists (providing training to PWD or caregivers) |
|
| First responders |
|
| Clergy, other members of faith community |
|
| Legal professionals |
|
| Community businesses (banks, retail stores, pharmacies, cafes, etc) |
|
| Other |
|
| Grantee |
0 |
|
|
| Grant ID |
0 |
|
|
| Reporting period (start date - end date) |
0 |
|
|
| Report submission date |
0 |
|
|
| ALL LIGHT GREEN CELLS SHOULD BE COMPLETED |
| Services & Expenditures |
Total Units of Direct Service Delivered |
Percentage of Funds Spent on Direct Service Expenses |
Percentage of Funds Spent on Administrative Expenses |
|
|
|
|
| ADSSP grants: It is a statutory requirement that at least 50% of grant funds be spent on direct service costs and that no more than 10% of funds be spent on administrative costs. |
| ADI grants: It is required that at least 30% of the first year budget, 40% of the second year budget, and 50% of the third year budget be spent on direct service costs. |
| If your project has not met these requirements by the end of this reporting period (reflected in the numbers above), please describe -- in the box to the right -- why the project has not met these requirements and confirm that the project will meet these requirements by the end of the grant. |
|