1 Part I Instrument 2017

Reporting Instrument

OMB Control Number: 0985-0043

Expiration Date: December 31, 2018

UniTed States Department of Health and Human Services

Administration for community living

independent living administration

Section 704

annual performance report

for

STATE INDEPENDENT LIVING SERVICES PROGRAM

(Title VII, Chapter 1, Subchapter B of the Rehabilitation Act of 1973, as amended)

INSTRUMENT

(To be completed by Designated State Entities

and Statewide Independent Living Councils)

Reporting Fiscal Year:

State:

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 Office of Management and Budget (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 the Administration for Community Living, U.S. Department of Health and Human Services, 330 C Street, SW, Washington, DC 20201-0008, Attention Peter Nye, or email [email protected] and reference the OMB Control Number 0985-0043. Note: Please do not return the completed Program Performance Report to this address.

SubPart I – Administrative Data

Section A – Sources and Amounts of Funds and Resources

Sections 704(c) and 704(m)(3) and (4) of the Act

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

Item 1 - All Federal Funds Received

(A) Title VII, Ch. 1, Subchapter B	$
(B) Title VII, Ch. 1, Subchapter C – For Section 723 states Only	$
(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) Fees for Service (program income, etc.)	$
(H) Other resources	$

Item 4 - Total Income

Total income = (A)+(B)+(C)+(D)+(E)+(F)+(G)+(H)

$

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, Medicaid funds, etc.)

$

Item 6 - Net Operating Resources

[Total Income (Section 4) <minus> amount paid out to Consumers (Section 5) = Net Operating Resources

$

Section B – Distribution of Title VII, Chapter 1, Subchapter B Funds

Section 713 of the Act; 45 CFR 1329.10

What Activities were Conducted with Subchapter B Funds?	Expenditures of Subchapter B Funds for Services by DSE Staff	Expenditures for Services Rendered By Grant or Contract
Provided resources to the SILC to carry out its functions	$	$
Provided IL services to individuals with significant disabilities	$	$
Demonstrated ways to expand and improve IL services	$	$
Supported the general operation of CILs that are in compliance with the standards and assurances set forth in subsections (b) and (c) of section 725 of the Act	$	$
Supported activities to increase capacity to develop approaches or systems for providing IL services	$	$
Conducted studies and analyses, gathered information, developed model policies, and presented findings in order to enhance IL services	$	$
Provided training regarding the IL philosophy	$	$
Provided outreach to unserved or underserved populations, including minority groups and urban and rural populations	$	$

Section C – Grants or Contracts Used to Distribute Title VII, Chapter 1, Subchapter B Funds

Sections 704(f) and 713 of the Act

Enter the requested information for all DSE grants or contracts, funded at least in part by Subchapter B funds, in the chart below. If a column is not applicable to a particular grant or contract, enter “N/A.” If there were no non-Subchapter B funds provided to this grantee or contractor for the purpose listed, enter “$0” in that column. Add more rows as necessary.

Name of Grantee or Contractor	Use of Funds (based on the activities listed in Subpart I, Section B)	Amount of Subchapter B Funds	Amount of Non-Subchapter B Funds	Consumer Eligibility Determined By DSE or Provider	Consumer Service Records (CSRs) Kept With DSE or Provider
Total Amount of Grants and Contracts		$	$

Section D - Grants or Contracts for Purposes Other than Providing IL Services or for the General Operation of Centers

Section 713 of the Act

Describe the objectives, activities and results for each Subchapter B grant or contract awarded for purposes other than IL services or the general operation of centers.

Section E – Monitoring Title VII, Chapter 1, Subchapter B Funds

Provide a summary of the program or fiscal review, evaluation and monitoring conducted by the state of any of the grantees/contractors receiving Subchapter B funds during the reporting year.

Section F – Administrative Support Services and Staffing

Section 704(c)(2) and 704 (m)(2) and (4) of the Act

Item 1 – Administrative Support Services

Describe any administrative support services, including staffing, provided by the DSE to the Part B Program.

Item 2 – Staffing

Enter requested staff information for the DSE and service providers listed in Section C, above (excluding Subchapter C funded CILs):

Type of Staff	Total Number of FTEs	FTEs filled by Individuals with Disabilities
Decision-Making Staff
Other Staff

Section G – For Section 723 States ONLY

Section 723 of the Act, 45 CFR 1329.12

Item 1 – Distribution of Subchapter C Funds to Centers

In the chart below, please provide the following information:

1. name of each center within your state that received Subchapter C funding during the reporting year;

2. amount of Subchapter C funding each center received;

3. whether the Subchapter C funding included a cost-of-living increase;

4. whether the Subchapter C funding included any excess funds remaining after cost-of-living increases were provided;

5. whether any of the centers received its Subchapter C funding pursuant to a competition for a new center in the state; and

6. whether the center was the subject of an onsite compliance review conducted by the DSE during the reporting year.

Name of CIL	Amount of Sub-chapter C Funding Received	Cost of Living Increase? (Yes/No)	Excess Funds After Cost of Living Increase? (Yes/No)	New Center? (Yes/No)	Onsite Compliance Review of Center? (Yes/No)

Add additional rows as necessary.

Item 2 – Administrative Support Services

Section 704(c)(2) of the Act

Describe the administrative support services used by the DSE to administer the Subchapter C program.

Item 3 – Monitoring and Onsite Compliance Reviews

Section 723(g), (h), and (i)

Provide a summary of the monitoring activities involving Subchapter C centers conducted by the state during the current reporting year, including the onsite reviews of at least 15% of centers receiving Subchapter C funds under section 723. The summary should include, at least, the following:

1. centers’ level of compliance with the standards and assurances in Section 725 of the Act;

2. any adverse actions taken against centers;

3. any corrective action plans entered into with centers; and

4. exemplary, replicable or model practices for centers.

Item 4 – Updates or Issues

Provide any updates to the administration of the Subchapter C program by the DSE, if any, including any significant changes in the amount of earmarked funds or any changes in the order of priorities in the distribution of Subchapter C funds. Provide a description of any issues of concern addressed by the DSE in its administration of the Subchapter C program.

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

Section 704(m)(4) of the Act; 45 CFR 1329.12(a)(3–4)

In this section, provide data from all service providers (DSE, grantees, contractors) who received Subchapter B funds and who were listed in Subpart I, Section C of this report, except for the centers that receive Subchapter C funds. Subchapter C centers will provide this data themselves on their annual CIL PPRs.

Section A – Number of Consumers Served During the Reporting Year

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

	# of CSRs
Enter the number of active CSRs carried over from September 30 of the preceding reporting year
Enter the number of CSRs started since October 1 of the reporting year
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
Moved
Withdrawn
Died
Completed all goals set
Other
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 30^th 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
Number of consumers who signed a waiver
Number of consumers with whom an ILP was developed
Total number of consumers served during the reporting year

Section E – Age

Indicate the number of consumers in each category below.

	# of Consumers
Under 5 years old
Ages 5 – 19
Ages 20 – 24
Ages 25 – 59
Age 60 and Older
Age unavailable

Section F – Sex

Indicate the number of consumers in each category below.

	# of Consumers
Number of Females served
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 Program Performance 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
Cognitive
Mental/Emotional
Physical
Hearing
Vision
Multiple Disabilities
Other

SubPart III – Individual Services and Achievements funded through Title VII, Chapter 1, SUBCHAPTER B funds

Sections 13 and 704(m)(4); 45 CFR 1329.12(a)(3–4); Government Performance Results Act (GPRA) Performance Measures

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

Section A – Individual Services and Achievements

For the reporting year, indicate in the chart below how many consumers requested and received each of the following IL services. Include all consumers who were provided services during the reporting year through Subchapter B funds, either directly by DSE staff or via grants or contracts with other providers. Do not include consumers who were served by any centers that received Subchapter C funds during the reporting year.

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
Self-Advocacy/Self-Empowerment
Communication
Mobility/Transportation
Community-Based Living
Educational
Vocational
Self-care
Information Access/Technology
Personal Resource Management
Relocation from a Nursing Home or Institution to Community-Based Living
Community/Social Participation
Other

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

1. 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 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 document that follow-up contacts with these consumers showed access to previously unavailable transportation, health care and assistive technology.

(B) I&R Information

To inform ACL 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 – community Activities AND Coordination

Section 704(i), (l), and (m)(4) of the Act; 45 CFR 1329.17(c)

Section A – Community Activities

Item 1 – Community Activities Table

In the table below, summarize the community activities involving the DSE, SILC and CILs in the Statewide Network of Centers (excluding Subchapter C fund recipients) during the reporting year. For each activity, identify the primary disability issue(s) addressed as well as the type of activity conducted. Indicate the entity(ies) primarily involved and the time spent. Describe the primary objective(s) and outcome(s) for each activity. Add more rows as necessary.

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

Issue Area	Activity Type	Primary Entity	Hours Spent	Objective(s)	Outcomes(s)

Item 2 – Description of Community Activities

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

Section B – Working Relationships among Various Entities

Describe DSE and SILC activities to maximize the cooperation, coordination, and working relationships among the independent living program, the SILC, and CILs; and the DSE, other state agencies represented on the SILC, other councils that address the needs of specific disability populations and issues, and other public and private entities. Describe the expected or actual outcomes of these activities.

SUBPart V – Statewide Independent Living Council (SILC)

Section 705 of the Act; 45 CFR Part 1329.14–16

Section A - Composition and Appointment

Item 1 – Current SILC Composition

In the chart below, provide the requested information for each SILC member. The category in which the member was appointed can be described, for example, as ex-officio state agency representative, other state agency representative, center representative, person with a disability not employed by a center or state agency, section 121 funded project director, parent of person with a disability, community advocate, other service provider, etc. Include current vacancies, along with the corresponding appointment category for each. Add more rows as necessary.

Name of SILC member	Employed by CIL, State Agency or Neither	Appointment Category	Voting or Non-Voting	Term Start Date	Term End Date

Item 2 – SILC Composition Requirements

Please provide the information requested in the chart below. Include any current vacancies in a particular appointment category.

SILC Composition	# of SILC members
(A) How many members are on the SILC?
(B) How many members of the SILC are individuals with disabilities not employed by a state agency or a center for independent living?
(C) How many members of the SILC are voting members?
(D) How many of the voting members of the SILC are individuals with disabilities not employed by a state agency or a center for independent living?

Section B – SILC Membership Qualifications

Section 705(b)(4) of the Act; 45 CFR 1329.14(a)

Item 1 – Statewide Representation

Describe how the SILC is composed of members who provide statewide representation.

Item 2 – Broad Range of Individuals with Disabilities from Diverse Backgrounds

Describe how the SILC members represent a board range of individuals with disabilities from diverse backgrounds.

Item 3 – Knowledgeable about IL

Describe how SILC members are knowledgeable about centers for independent living and independent living services.

Section C – SILC Staffing and Support

Item 1 – SILC Staff

Please provide the name and contact information for the SILC executive director. Indicate the number and titles of any other SILC staff, if applicable. Also indicate whether any SILC staff is also a state agency employee.

Item 2 – SILC Support

Describe the administrative support services provided by the DSE, if any.

Section D – SILC Duties

Section 705(c); 45 CFR 1329.15

Item 1 – SILC Duties

Provide a summary of SILC activities conducted during the reporting year related to the SILC’s duties listed below:

(A) State Plan Development

Describe any activities related to the joint development of the state plan. Include any activities in preparation for developing the state plan, such as needs assessments, evaluations of consumer satisfaction, hearings and forums.

(B) Monitor, Review and Evaluate the Implementation of the State Plan

Describe any activities related to the monitoring, review and evaluation of the implementation of the state plan.

(C) Coordination with Other Disability Councils

Describe the SILC’s coordination of activities with the State Rehabilitation Council (SRC) established under section 105, if the state has such a Council, or the commission described in section 101(a)(21)(A), if the state has such a commission, and councils that address the needs of specific disability populations and issues under other Federal law. Please state whether the SILC has at least one representative serving as a member of the SRC and whether the SILC has any members serving on other councils, boards or commissions in the state.

(D) Public Meeting Requirements

Describe how the SILC has ensured that all regularly scheduled meetings and other public hearings and forums hosted by the SILC are open to the public and sufficient advance notice is provided.

Item 2 – Other Activities

Describe any other SILC activities funded by non-Subchapter B funds.

Section E – Training and Technical Assistance Needs

Section 721(b)(3) of the Act

Please identify the SILC’s training and technical assistance needs. The needs identified in this chart will guide the priorities set by ACL for the training and technical assistance provided to CILs and SILCs.

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 Program Performance 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 VI – State plan for independent living (SPIL) Comparison and updates, Other Accomplishments and Challenges of the Reporting Year

Section 704(n) of the Act

Section A – Comparison of Reporting Year Activities with the SPIL

Item 1 – Progress in Achieving Objectives and Goals

Describe progress made in achieving the objectives and goals outlined in the most recently approved SPIL. Discuss goals achieved and/or in progress as well as barriers encountered.

Item 2 – SPIL Information Updates

If applicable, describe any changes to the information contained in the SPIL that occurred during the reporting year, including the placement, legal status, membership or autonomy of the SILC; the SILC resource plan, the design of the statewide network of centers; and the DSE administration of the ILS program.

Section B– Significant Activities and Accomplishments

If applicable, describe any significant activities and accomplishments achieved by the DSE and SILC not included elsewhere in the report, e.g. brief summaries of innovative practices, improved service delivery to consumers, etc.

Section C – Substantial Challenges

If applicable, describe any substantial problems encountered by the DSE and SILC, not included elsewhere in this report, and discuss resolutions/attempted resolutions, e.g., difficulty in outreach efforts; disagreements between the SILC and the DSE; complications recruiting SILC members; complications working with other state agencies or organizations within the state.

Section D – Additional Information

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

SubPART VII - signatures

Please sign and print the names, titles and telephone numbers of the DSE directors(s) and SILC chairperson.

SIGNATURE OF SILC CHAIRPERSON	DATE
NAME AND TITLE OF SILC CHAIRPERSON	PHONE NUMBER
SIGNATURE OF DSE DIRECTOR	DATE
NAME AND TITLE OF DSE DIRECTOR	PHONE NUMBER

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