OMB Control Number: 0985-NEW
Expiration Date: December 31, 2018
UniTed States Department of Health and Human Services
independent living administration
Section 704
annual performance report
for
Centers for Independent Living Program
(Title VII, Chapter 1, Subchapter C of the Rehabilitation Act of 1973, as amended)
Program Performance Report
INSTRUMENT
(To be completed by Centers for Independent Living)
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 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 benefits (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]. Note: Please do not return the completed Program Performance Report to this address.
Section 725(c)(8)(D) of the Act; 34 CFR 366.50(i)(4)
Indicate the amount received by the Center for Independent Living (CIL) as per each funding source. Enter “0” for none.
(A) Title VII, Ch. 1, Subchapter B |
$ |
(B) Title VII, Ch. 1, Subchapter C |
$ |
(C) Title VII, Ch. 2 |
$ |
(D) Other Federal Funds |
$ |
(E) State Government Funds |
$ |
(F) Local Government Funds |
$ |
(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.) |
$ |
Total income = (A)+(B)+(C)+(D)+(E)+(F)+(G)+(H)+(I)+(J)+(K)+(L) |
$ |
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) |
$ |
[Total Income (Section 4)<minus> amount paid out to Consumers (Section 5) = Net Operating Resources |
$ |
Section 725(c)(8)(B) of the Act; 34 CFR 366.50(i)(2)
Include Consumer Service Records (CSRs) for all consumers served during the year.
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# of CSRs |
(1) Enter the number of active CSRs carried over from September 30 of the preceding reporting year |
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(2) Enter the number of CSRs started since October 1 of the reporting year |
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(3) Add lines (1) and (2) to get the total number of consumers served |
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Include the number of consumer records closed out of the active CSR files during the reporting year because the individual has:
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# of CSRs |
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Indicate the number of CSRs active on September 30th of the reporting year.
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# of CSRs |
Section A(3) <minus> Section (B)(6) = Section C |
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Indicate the number of consumers in each category below.
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# of Consumers |
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Indicate the number of consumers in each category below.
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# of Consumers |
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Indicate the number of consumers in each category below.
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# of Consumers |
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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).
Please refer to the Instructions before completing.
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# of Consumers |
(1) American Indian or Alaska Native |
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(2) Asian |
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(3) Black or African American |
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(4) Native Hawaiian or Other Pacific Islander |
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(5) White |
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(6) Hispanic/Latino of any race or Hispanic/Latino only |
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(7) Two or more races |
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(8) Race and ethnicity unknown |
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Indicate the number of consumers in each category below.
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# of Consumers |
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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 Subchapter C funds and the approved State Plan for Independent Living (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 |
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Sections 13 and 725(c)(8)(C) of the Act; 34 CFR 366.50(i)(3); Government Performance Results Act (GPRA) Performance Measures
Please refer to the Instructions before completing.
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 |
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(B) Assistive Technology |
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(C) Children’s Services |
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(D) Communication Services |
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(E) Counseling and Related Services |
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(F) Family Services |
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(G) Housing, Home Modifications, and Shelter Services |
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(H) IL Skills Training and Life Skills Training |
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(I) Information and Referral Services |
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(J) Mental Restoration Services |
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(K) Mobility Training |
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(L) Peer Counseling Services |
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(M) Personal Assistance Services |
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(N) Physical Restoration Services |
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(O) Preventive Services |
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(P) Prostheses, Orthotics, and Other Appliances |
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(Q) Recreational Services |
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(R) Rehabilitation Technology Services |
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(S) Therapeutic Treatment |
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(T) Transportation Services |
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(U) Youth/Transition Services |
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(V) Vocational Services |
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(W) Other Services |
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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 |
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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 |
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(B) Health Care Services |
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(C) Assistive Technology |
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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 ILA 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.
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 |
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(B) Staff Composition
Enter requested staff information in the table below:
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Total Number of FTEs |
FTEs Filled by Individuals with Disabilities |
FTEs Filled by Individuals From Minority Populations |
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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)
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) |
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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 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.
Describe any substantial challenges or problems encountered by the CIL, and the resolutions/attempted resolutions.
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.
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.
SUBPART VII – ADDITIONAL INFORMATION
Section 704(m)(4)(D) of the Act
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.
Provide additional information, comments, explanations or suggestions not included elsewhere in the report.
Please sign and print the names, titles and telephone numbers of the CIL director and board chair.
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SIGNATURE OF CENTER DIRECTOR |
DATE |
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NAME AND TITLE OF CENTER DIRECTOR |
PHONE NUMBER |
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SIGNATURE OF CENTER BOARD CHAIRPERSON |
DATE |
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NAME AND TITLE OF CENTER BOARD CHAIRPERSON |
PHONE NUMBER |
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | REPORTING INSTRUMENT |
| Author | Brenda.Bercegeay |
| File Modified | 0000-00-00 |
| File Created | 2021-01-15 |