Title VI PPR Part C

OMB No. 0985-0007

Expiration Date: XX/XX/XXXX

ADMINISTRATION FOR COMMUNITY LIVING

ADMINISTRATION ON AGING

TITLE VI PROGRAM PERFORMANCE REPORT

Report Period April 1, [year] – March 31, [year]

Title VI, Parts A/B and C _______ Title VI, Part A/B only ______

Grantee Name _____________________________________________________________

Telephone_______________________________ Email address__________________________

Part A/B Grant No. _________ Part C Grant No.__________

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TITLE VI, PART A/B REPORT

1. STAFFING INFORMATION

Enter the number of staff paid wholly or partly by Title VI, Part A/B funds.

Full-time staff

Full-time staff	Enter number here	Person(s)

Part-time staff

Part-time staff	Enter number here	Person(s)

2. NUTRITION SERVICES

Congregate Meals

Unduplicated number of eligible persons who received one or more Congregate Meal(s).	Enter number here	Person(s)
Total number of Congregate Meals served.	Enter number here	Meal(s)

Home-Delivered Meals

Unduplicated number of eligible persons who received one or more Home-delivered Meal(s).	Enter number here	Person(s)
Total number of Home-delivered Meals provided.	Enter number here	Meal(s)

Other Nutrition Services

Total number of sessions of Nutrition Education.	Enter number here	Session(s)
Total number of persons who received Nutrition Counseling.	Enter number here	Person(s)
Total number of hours of Nutrition Counseling.	Enter number here	Hour(s)

3. SUPPORTIVE SERVICES

Access Services

Total number of contacts of Information/Assistance.	Enter number here	Contact(s)
Total number of Outreach activities.	Enter number here	Activities
Unduplicated number of persons receiving Case Management.	Enter number here	Person(s)
Total number of hours of Case Management.	Enter number here	Hour(s)
Unduplicated number of persons receiving Transportation.	Enter number here	Person(s)
Total one-way trips of Transportation.	Enter number here	One-way trip(s)

In-home Services

Unduplicated number of persons receiving Homemaker Services.	Enter number here	Person(s)
Total number of hours of Homemaker Services.	Enter number here	Hour(s)
Unduplicated number of persons receiving Personal Care/Home Health Aid Services.	Enter number here	Person(s)
Total number of hours of Personal Care/Home Health Aid Service.	Enter number here	Hour(s)
Unduplicated number of persons receiving Chore Services.	Enter number here	Person(s)
Total number of hours spent on Chore Services.	Enter number here	Hour(s)
Total number of contacts of Visiting.	Enter number here	Contact(s)
Total number of contacts of Telephoning.	Enter number here	Contact(s)

Other Supportive Services

Total number of Social Events held.	Enter number here	Event(s)
Total number of persons receiving Health Promotion and Wellness activities.	Enter number here	Person(s)
Total number of visits to persons in nursing facilities/homes or residential care communities.		Visit(s)

Optional space for other supportive services offered that are not listed above (1500 words or less):

4. FINANCE

Part A/B Spending

Optional explanation of elements included in total amount of funds (1500 words or less):

What other sources of funds help you support your Title VI services:

Tribal funds	Yes or No
State funds	Yes or No
Title III funds	Yes or No
Other grants	Yes or No
Donations	Yes or No

This finance section will be an addendum to the 425. This will NOT be used for audits.

Total amount of funds spent on Congregate and Home-delivered Meals.	Enter number here	Dollars
Total amount of funds spent on Supportive Services Programming.	Enter number here	Dollars

5. STORYTELLING

Please share an example of how your Title VI program has helped an individual or your community (1500 words or less):

**OFFICIAL SIGNATURE** - If only completing Title VI, Part A/B of this report go to page [insert page] to sign and date.

TITLE VI, PART C REPORT

1. STAFFING INFORMATION

Enter the number of staff paid wholly or partly by Title VI, Part C funds.

Full-time staff

Full-time staff	Enter number here	Person(s)

Part-time staff

Part-time staff	Enter number here	Person(s)

2. TOTAL CAREGIVERS SERVED

Caregivers served by the Title VI program are informal, unpaid providers of in-home and community care. Caregivers may be family members, neighbors, friends, or others.

Unduplicated number of caregivers to Elders or individuals of any age with Alzheimer’s disease and related disorders.	Enter number here	Person(s)
Unduplicated number of Elder caregivers caring for children under the age of 18.	Enter number here	Person(s)
Unduplicated number of Elder caregivers providing care to adults 18-59 years old with disabilities.		Person(s)

3. CAREGIVER SUPPORT SERVICES

Services for Caregivers

Total number of activities of Information Services provided.		Activities
Total number of contacts of Information and Assistance provided.		Contact(s)
Unduplicated number of caregivers receiving Counseling (e.g. formal and/or informal counselors).	Enter number here	Person(s)
Total number of hours of Counseling.	Enter number here	Hour(s)
Total number of sessions of Support Group.	Enter number here	Session(s)
Unduplicated number of caregivers served in Caregiver Training.	Enter number here	Person(s)
Total number of hours of Caregiver Training.	Enter number here	Hour(s)

Supplemental Services: (report on units provided, unduplicated caregivers served, service category)

Service Category	Description of Service	Unduplicated Caregivers

There will be a dropdown menu of service categories: Home Modification/Repairs, Consumable Items, Lending Closet, Homemaker/Chore/Personal Care Service, Financial Support, Other.

Respite Care for Caregivers

Respite care is a service for informal caregivers, not Elders or children. Respite care refers to allowing caregivers time away to do other activities by having an Elder, person with a disability, or child cared for by someone else.

Unduplicated number of caregivers of Elders provided Respite Care.	Enter number here	Person(s)
Total number of hours of Respite Care for caregivers of Elders.	Enter number here	Hour(s)
Unduplicated number of caregivers of children under the age of 18 provided Respite Care.	Enter number here	Person(s)
Total number of hours of Respite Care for caregivers of children under the age of 18.	Enter number here	Hour(s)
Unduplicated number of caregivers of adults 18-59 years old with disabilities provided Respite Care.	Enter number here	Person(s)
Total number of hours of Respite Care for caregivers of adults 18-59 years old with disabilities.	Enter number here	Hour(s)

4. FINANCE

Part C Spending

This finance section will be an addendum to the 425. This will NOT be used for audits.

Total amount of funds spent on the Caregiver Program.	Enter number here	Dollars
Total amount of funds spent on Respite Care.	Enter number here	Dollars

Report Certified By ________________________________________________

(Tribal Official or other authorized personnel)

Report Prepared by: ____________________________________________________________

Telephone: _______________________________ Email address: _______________________

Date Submitted: _________________________________________________

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 OMB control number (OMB 0985-0059). Public reporting burden for this collection of information is estimated to average 3.5 hours per response, including time for gathering and maintaining the data needed and completing and reviewing the collection of information. The obligation to respond to this collection is required to retain the statutory authority for the Older Americans Act Amendments of 2006, P.L. 114-144. 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 Kristen Hudgins, or email [email protected].

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