Form 1 Proposed Alzheimer Disease Prevention Reporting Tool

Alzheimer's Disease Supportive Services Program (ADSSP) Data Collection

0985-0022 Proposed ADP-DRT Data Collection Tool Updated 7.6.17.xlsx

Alzheimer's Disease Supportive Services Program (ADSSP) Data Collection

OMB: 0985-0022

Document [xlsx]
Download: xlsx | pdf

Overview

PWD & caregivers
Professional training
Services & Expenditures


Sheet 1: PWD & caregivers

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

Sheet 2: Professional training

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

Sheet 3: Services & Expenditures

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.
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