TBI State Partnership Program Performance Measures

NOTE TO REVIEWERS: This set of questions will be programmed into an online reporting tool. Guidance and instructions presented in this document in blue font may be edited for clarity and to align with online navigation.

PURPOSE AND GENERAL INSTRUCTIONS: ACL designed this report to provide opportunities for Traumatic Brain Injury State Partnership Program grantees to submit information about the activities they are carrying out using program funds. ACL will use these data to measure the aggregate performance of all grantees. ACL’s primary purpose in requesting this information is to understand how grantees are using TBI State Partnership Program funds and what impact they are having across all participating states.

The questions included in this report are the ones ACL would like all grantees to be able to answer in the future, to the extent they are applicable to grantees’ work. However, ACL understands that grantees have different reporting capacity and may not be able to respond fully to every question. We encourage grantees to report as comprehensively as they can, accessing only the data they can feasibly access, and using the notes fields to describe the data they are reporting as needed so ACL can interpret it correctly.

Grantees should focus on reporting about the activities funded with program funds only. Program funds are defined as those funds awarded to the grantee by ACL plus any funds or other resources (e.g., facilities, staff time) used as the required match for the grant award. Grantees should not report about activities that program funds do not support – even if they are related to other program-funded activities. If a mixture of program funds and funds from other sources are used to carry out an activity, grantees should report on that activity in the most appropriate way they can. For example, if program funds and other funds are blended together and the people being reached with these funds include a mix of TBI survivors and others, grantees may report about these activities in different ways. One grantee may be able to access data from all funded partners and report the total number of TBI survivors reached or served with program funds. Another grantee may only have data about the total number of people served including TBI survivors and others, by one funded partner only, and cannot distinguish between those reached with program funds and those reached with other funds. Both grantees should report the data they have about the people reached and use the notes field to describe the parameters and limitations of their data as appropriate.

This electronic form has numerous fields that are pre-populated and auto-calculated to generate sums and percentages. This will save grantees time and will reduce the chance of arithmetical errors. Grantees will enter relevant information for year one of the grant; in subsequent grant years, grantees will have to enter only necessary edits rather than the previously entered data from earlier years. The system will automatically save and display the data from past years.

Grant Activities (all grantees respond)

In this first section of the report, grantees will identify which activities they are carrying out using program funds as outlined in their grant work plan. The form will ask grantees to report further about the areas of activity they select below. It will not ask them to report further about activities below that they do not select.

GUIDANCE: You should select only those activities below that the lead grantee agency or a partnering agency carries out with program funds. Program funds are defined as those funds awarded to the grantee by ACL plus any funds or other resources (e.g., facilities, staff time) used as the required match for the grant award. Do not select an activity below if it is funded entirely by other sources.

Please review the following examples to help determine which activities you should select in Question 1.

Example 1: The lead grantee agency uses TBI State Partnership Program funds from ACL to support provision of I&R/A to their grant’s target population. Grantee should select I&R/A from answer options below.

Example 2: The lead grantee agency uses program funds from ACL to pay another entity to support provision of I&R/A to their grant’s target population. Grantee should select I&R/A from answer options below.

Example 3: The lead grantee agency does not use program funds received from ACL to support provision of I&R/A, but they designated other funds that are being used for I&R/A as state matching funds for this grant. Grantee should select I&R/A below.

Example 4: The lead grantee agency coordinates closely with another entity in the state that provides I&R/A for TBI survivors. This entity is a partner and a collaborator but they do not use program funds to provide I&R/A. They may receive program funds to work on other activities, but they do not use any program funds (direct or matching) to provide I&R/A. Grantee should NOT select I&R/A below.

Which activities did you carry out as part of your ACL project using program funding during this reporting period?

Partnership Development - identifying and reaching out to new partners, coordinating and aligning activities, information exchange, collaboration on grant activities, collaboration on activities related to the grant
Planning and Infrastructure Development - state planning, policy and procedures development, state councils, needs assessment, surveillance, registry, IT systems
Information and Referral/Assistance (I&R/A) - bringing people and services together, answering questions from individuals and families about human service resources, helping people get connected to public benefits, sharing information about available services like home care and adaptive equipment. Note: I&R is about bringing people and services together. Individuals may reach out once or many times, but I&R typically does not involve ongoing engagement of individuals like Resource Facilitation. If the description provided here does not align with how your program defines this activity, please provide your definition here:
Screening and/or Assessment - using a standardized procedure, structured interview, or tool to elicit the lifetime history of TBI for an individual. Screening and/or assessments can be used for clinical, research, programmatic, eligibility determination, service delivery or treatment purposes. If the description provided here does not align with how your program defines this activity, please provide your definition here:
Resource Facilitation – this category of activity could include development of resources such as databases, resource directories, and communications tools to improve service delivery. It could also mean providing assistance through an accessible, holistic, and person-centered process that engages individuals in decision making about their options, preferences, values, and financial resources and helps connect them with programming, services and supports they choose. In some states this may be called service coordination, service navigation, case management, options counseling, or person centered counseling. Resource facilitation could be of short term or long term duration. If the description provided here does not align with how your program defines this activity, please provide your definition here:
Training, Outreach and Awareness - continuing education for professionals who may work with or provide services for people who have experienced a TBI, training for individuals who have experienced a TBI, public education and awareness, training for caregivers, on-the-job training for agency staff, cross-training with partnering agencies. If the description provided here does not align with how your program defines this activity, please provide your definition here:
Other (Describe) Grantees will be able to add as many topics as needed

Did you target or limit some or all of your grant activities to support people in a particular setting or particular population during this reporting period? If yes, please select all that apply.

YES ___, all of our activities were primarily targeted to the groups noted below,

YES____, some of our activities were targeted primarily to the groups noted below

NO ___, all of our activities are designed to more generally support all TBI survivors in our state

Athletes
Children and youth (younger than 22)
Adults (22-59)
Older adults (60 or over)
People who are homeless
People who are hospitalized
People who are incarcerated or formerly incarcerated
Medicaid home and community-based services participants
Native Americans
Other ethnic, racial or linguistic minorities
Residents of nursing facilities, rehab facilities or ICFs/MR
Rural populations
People who experience unhealthy substance use or a substance use disorder
Students
Veterans or current service members
People who are victims of crime, domestic violence, or intimate partner violence
Other (describe)

3. Percent of your state’s counties (parishes or boroughs) targeted and reached through your grant’s activities during this reporting period:

Total number of counties in state #______
Counties targeted for this project #______ _____% *
Counties reached this reporting period #______ _____% *

* [Total number of counties in state will be auto-populated. % is auto calculated based on # of counties reached divided by total number of counties]

For each of your grant activities, please provide how much of your total program funding you spent in the last completed grant year in support of each of the different activities listed below, rounded to closest $1,000.

[Note: This question will be asked once a year in the Dec/Jan timeframe about the last completed grant year].

GUIDANCE: To start, you should determine the total amount of program funding you spent this reporting period – your Total Program Funding. Total program funding should match what you reported in your original application on the SF-424. Of this total, break out the funding you paid to contractors or partners to carry out different activities. If they do not track their actual spending by category of activity in the way below, you should use your program’s budget, your work plan, and the scope of work described in their contracts to estimate how much was spent in each category. Then consider your work plan and the estimated relative time and effort you spent on different activities to allocate the remaining program expenditures into the most appropriate categories accordingly. If there were program funds spent that do not fit easily into one of these categories, report them in one of the “Other” categories and provide an appropriate description.

Do not report funds that support these activities in your state that came from sources other than this grant. For example, your state may spend millions of dollars on provision of I&R/A from many funding streams spread out across many agencies but your state only allocated $100,000 of your TBI State Partnership Program funds to support provision of I&R/A. You should report $100,000 as your total program funds spent in that category. Furthermore, if your ACL grant spent $100,000 in support of I&R/A and these program funds helped make this service available to both TBI survivors and other populations, you should still report the full $100,000.

If you did not spend program funds (either direct or matching) in one or more of the categories below, you should report $0 spent in those categories. ACL will not interpret this to mean that these activities did not occur in your state or that your grant program does not support these activities in non-monetary ways. Reporting $0 spent in a category below means only that none of these particular program funds were used on that activity in the last grant year.

Partnership Development $______ ____% *
Planning and Infrastructure Development $______ ____% *
Information and Referral/Assistance $______ ____% *
Screening and/or Assessment $______ ____% *
Resource Facilitation $______ ____% *
Training, Outreach and Awareness $______ ____% *
Other (describe) _______ $______ ____% *
Other (describe) ________
Funds not yet spent including any carryover funds from last fiscal year $____ ____% *
Total Program Funding $______ **

* [% is auto calculated based on category total divided by sum of categories] ** [auto populated or auto-calculated by summing categories above]

Did your project use any evidence-based practices, interventions, or programs as part of your grant activities during this reporting period? If yes, please describe.

GUIDANCE: Evidence-based practice (EBP) is a process in which the practitioner combines well-researched interventions with clinical experience and ethics, and client preferences and culture to guide and inform the delivery of treatments and services. An evidence-based practice (EBP) is any practice that relies on scientific evidence for guidance and decision-making. According to the Council on Social Work Education, there are five important steps involved in any evidence-based practice model.

1. Formulating a client, community, or policy-related question;

2. Systematically searching the literature;

3. Appraising findings for quality and applicability;

4. Applying these findings and considerations in practice;

5. Evaluating the results.

This last step is particularly significant because evidence-based practice models need to continuously improve if they are to be effective. As a result, each new case should be considered additional evidence and should be analyzed along with the pre-existing data. This kind of perspective helps our social service practices continue to keep pace with a changing world.

YES ___ NO ___

______________________________________________________________________________

Partnership Activities (all grantees respond)

Which organizations in your state received funding through the ACL State Partnership Program to carry out and/or support grant activities (primary awardee and sub-awarded partners) in this reporting period?

GUIDANCE: Program funds are defined as those funds awarded to the grantee by ACL plus any funds or other resources (e.g., facilities, staff time) used as the required match for the grant award.

a. Lead Grantee Agency

[To relieve burden, ACL will fill in a.i and a.ii based on existing information from Notice of Award. Grantee will be able to edit if it is incorrect.]

i. Name of organization ___________________

ii. Type of organization (select all the designations below that apply to this organization):

State Medicaid Agency
State Vocational Rehabilitation Agency,
State Department of Education
State Department of Criminal Justice/Corrections
State Unit on Aging
State Department for Developmental Disabilities
State Behavioral and/or Mental Health Agency
State Department of Public Health
Tribal Council
Other State Agency
University Center on Excellence for Developmental Disabilities
University
Other

_____________________________________________________________

b. Funded Partner 1

i. Name of organization ___________________

ii. Type of organization (select all the designations below that apply to this organization):

State Medicaid Agency
State Vocational Rehabilitation Agency,
State Department of Education
State Department of Criminal Justice/Corrections
State Unit on Aging
State Department for Developmental Disabilities
State Behavioral and/or Mental Health Agency
State Department of Public Health
Tribal Council/Organization
Other State Agency
University Center on Excellence for Developmental Disabilities.
University
State Independent Living Council
State I/DD Council
Affiliate of National Brain Injury Organization
County or Local Government Entity,
Community-Based Services Organization (e.g. CAA, ADRC, AAA, CIL),
Public Health Department or Clinic
Recovery or Substance Abuse Treatment Center
VA Medical Center
Other Health Care Provider
University
Private Business/Employer
Other __________

iii. Is this partner new this reporting period? Y/N

Add another Funded Partner Grantees can add as many funded partners as they need.

Which types of organizations are program partners and support program activities but did not receive program funds during this reporting period?

GUIDANCE: You may have a dozen or more organizations represented on your Advisory Council. For this question, please include only those organizations you see as key or strategic partners in your recent and current systems change work. Organizations should be listed as partners if you work with them regularly to coordinate grant-related activities, co-sponsor activities with them, and/or routinely collaborate with them (outside of Advisory Council meetings) in furtherance of your grant goals.

a. Types of Unfunded Partners

Select all the types of organizations that are unfunded partners and indicate if this type of organization is new (as of this reporting period) or a continuing partner)

State Medicaid Agency
State Vocational Rehabilitation Agency,
State Department of Education
State Department of Criminal Justice/Corrections
State Unit on Aging
State Department for Developmental Disabilities
State Behavioral and/or Mental Health Agency
State Department of Public Health
Protection and Advocacy Programs
Tribal Council/Organization
Other State Agency
University Center on Excellence for Developmental Disabilities.
University
State Independent Living Council
State I/DD Council
Affiliate of National Brain Injury Organization
County or Local Government Entity
Community-Based Services Organization (e.g. CAA, ADRC, AAA, CIL),
Public Health Department or Clinic
Recovery or Substance Abuse Treatment Center
VA Medical Center
Other Health Care Provider
University
Private Business/Employer
Other __________

8. Is there anything else you would like to let ACL know about your Partnership activities during this reporting period?

This question is not mandatory.

Planning and Infrastructure Development (all grantees respond)

Please list your advisory council members for this project period and place a check by their affiliations. You may check all that apply if a person represents two or more affiliated entities.

Person who has experienced a TBI (Survivor)
Family member of person who has experienced a TBI
Center for Independent Living/State Independent Living Council representative
Aging and Disability Resource Center representative
Protection & Advocacy agency representative
Long-term care ombudsman representative
TBI Model Systems representative
Representative from an Affiliate of National Brain Injury Organization
Other (describe) _____

Estimate the number of people in your state who have experienced a TBI and are getting some kind of home and community-based services or supports.
1. Estimate how many people living in your state have experienced a TBI: ______________
  1. Of the total in a above, estimate how many people who have experienced a TBI are currently receiving HCBS through a Medicaid TBI waiver: ______________
  2. Of the total in a above, estimate how many people who have experienced a TBI are in your grant’s target population (e.g. based on where they live in the state, their age, setting in which they live or some other demographic or criteria): _______________
    1. Of the total in aii above, estimate how many people in your target population are currently receiving services or supports that help them live in a home or community setting through a Medicaid waiver or some other kind of publicly funded program (e.g. state HCBS program, Rehabilitation Services Act, Older Americans Act).

GUIDANCE: ACL hopes that TBI State Partnership Program grantees will work to calculate these estimates to inform their planning and infrastructure development activities. ACL recognizes grantees may not have access to all the potential data sources needed to make precise estimates. Grantees should use the data sources they can feasibly access to make estimates and use the space below to describe the data sources used, their associated dates, and the methodology used to calculate these estimates:

____________________________________________________________________________________________________________________________________________________________

Notes about data provided: (e.g., unknown because none of our partners collect this information, data are incomplete because only some of our partners collect this information. Please describe.)
____________________________________________________________________________________________________________________________________________________________

What planning and infrastructure accomplishments or activities of the last six months do you think have been or will be most impactful? Consider how you are working toward systems change and what progress you are seeing.

Is there anything else you would like to let ACL know about your planning and infrastructure activities during this reporting period? These activities may include needs assessments, state plans, and registries
This question is not mandatory.

Information and Referral/Assistance (if applicable to grant activities)

How many I&R/A contacts were made in this reporting period (across all funded partners providing grant-related I&R/A

GUIDANCE: An I&R/A contact is generally defined as an individual contact made by a consumer, caregiver, or professional by telephone or in-person. One person may contact the I&R/A provider multiple times in the reporting period so Total Contacts is likely to be a significantly larger number than total number of individuals served. “Funded partners” refers to partners receiving program funds as well as using funds that have been designated state matching funds. I&R/A providers generally track total number of contacts overall. They may or may not track the number of contacts that related to an individual who has experienced a TBI unless this is a requirement for them. Please enter a positive number, zero, or unknown.

a. How many people live in the collective service areas of the organization or organizations providing I&R/A with grant funding?

Total number of contacts made to organizations that use program funds to support some or all of their I&R/A activities:

Total number of contacts made to these funded partners regarding TBI in reporting period # _______

13. How often are different types of services referred for I&R/A callers who have experienced a TBI, their family members, or other professionals and service providers during this reporting period across all funded partners providing grant-related I&R/A? Please select an option for each type of referral.

ANSWER OPTIONS: COMMONLY/OCCASIONALLY/NEVER/UNKNOWNTBI

Grant-funded resource facilitation, service coordination
Other type of resource facilitation, service coordination (provided by other unfunded partners or other organizations such as an affiliate of national brain injury organization, ADRC, CIL, other ABI association, or other organization)
Older Americans Act services (e.g., nutrition services, LTC Ombudsman)
Behavioral health services
Brain injury support groups
Caregiver supports
Independent living services
Domestic violence help services
Employment counseling
Educational counseling or school disability services
Health insurance information or counseling (e.g. SHIP, Medicaid eligibility)
General medical services
Specialized TBI/ABI services
Homeless services provider
Housing supports
Medicaid waiver services
Physical, occupational, recreational or speech therapy
Legal or advocacy services
Transportation services
Social Security
Veteran’s hospital or clinic
Vocational rehabilitation services
In-home services and supports
Other: ____________________

14. Is there anything else you would like to let ACL know about your I&R/A activities during this reporting period?
This question is not mandatory.

Screening and Assessments (if applicable to grant activities)

15. How many unduplicated people did you and your funded partners screen or assess to identify their likelihood of TBI during this reporting period (across all funded partners providing grant-related screening and assessment)? Please enter a positive number, zero or unknown in every field.

a. Total number of unduplicated people screened or assessed this reporting period # ______

b. Number of people screened who were identified as having a history of TBI: #_______

Number of people under age 22 #_______
Number of people between 22-59 #_______
Number of people 60 or older #_______
Number of veterans of any age #_______

16. Select which standardized instruments you or your partners used for screening and assessment procedures during this reporting period. (Select all that apply)

The Ohio State University Traumatic Brain Injury Identification Method (OSU TBI-ID) A modified version of the OSU TBI-ID	YES___	NO___
The Brain Injury Screening Questionnaire (BISQ)	YES___	NO___
Defense and Veterans Brain Injury Center TBI Screening Tool (DVBIC TBI), also called The Brief Traumatic Brain Injury Screen (BTBIS)	YES___	NO___
The Traumatic Brain Injury Screening Instrument (TBISI)	YES___	NO___
HELPS	YES___	NO___
Military Acute Concussion Evaluation (MACE)	YES___	NO___
Automated Neuropsychological Assessment Metrics (ANAM)	YES___	NO___
Others: __________________________________________________	YES___	NO___

17. Of the people who have experienced a TBI whom you screened in this reporting period, how many were living in these following settings at the time of their screening? Please enter a positive number, zero or unknown in every field.

On their own/independent #______
Homeless #______
With parent or grandparent #______
With immediate family #______
With friends or other extended family #______
Group home #_______
Prison or Jail/Justice involved setting #______
Transitional living program or temporary housing #______
Community Based Neurobehavioral Rehabilitation Services
Nursing facility or in-patient rehab setting
Supervised living program #______
Assisted-living settings #______
Other: ___________________ #______

18. Of the people who have experienced a TBI whom you screened during this reporting period how many were in competitive, integrated employment and/or in school at the time of the screening? Please enter a positive number, zero (0), or unknown in every field.

Competitive, integrated employment #______
In school or training #______

19. Is there anything else you would like to let ACL know about your screening and assessment activities this reporting period?

This question is not mandatory.

Resource Facilitation (if applicable to grant activities)

20. For how many unduplicated people who have a TBI did you or your partners provide resource facilitation in this reporting period (across all funded partners providing grant-related resource facilitation)? Please enter a positive number, zero (0), or unknown in every field.

Total number of unduplicated people who have experienced a TBI who were provided with resource facilitation in this reporting period #_______

Number of people under age 22 #_______
Number of people between 22-59 #_______
Number of people 60 or older #_______
Number of veterans of any age #_______

21. What types of referrals did those providing Resource Facilitation make for people who have experienced a TBI and who received resource facilitation during this reporting period? Please select a response for each type of referral

ANSWER OPTIONS: COMMONLY/OCCASIONALLY/NEVER/UNKNOWN

Grant-funded resource facilitation, service coordination
Other type of resource facilitation, service coordination (provided by other unfunded partners or other organizations such as a Brain Injury Alliance or Association, ADRC, CIL, TBI association or other)
Older Americans Act services (e.g., nutrition services, LTC Ombudsman)
Behavioral health services
Brain injury support groups
Caregiver supports
Independent living services
Domestic violence help services
Employment counseling
Educational counseling or school disability services
Health insurance information or counseling (e.g. SHIP, Medicaid eligibility)
General medical services
Specialized TBI services
Homeless services provider
Housing supports
Medicaid waiver services
Physical, occupational, recreational or speech therapy
Legal or advocacy services
Transportation services
Social Security
Veteran’s hospital or clinic
Vocational rehabilitation services
In-home services and supports

Other: ____________________

22. Of the people who have experienced a TBI for whom you provided resource facilitation this reporting period, how many were living in these different settings at the time you worked with them? Please enter a positive number, zero (0), or unknown in every field.

On their own/independent #______
Homeless #______
With parent or grandparent #______
With immediate family #______
With friends or other extended family #______
Group home #_______
Prison or Jail/Justice involved setting #______
Transitional living program or temporary housing #______
Community Based Neurobehavioral Rehabilitation Services
Nursing facility or in-patient rehab setting
Supervised living program #______
Assisted-living settings #______
Other: ___________________ #______

23. Of the people who have experienced a TBI for whom you provided resource facilitation this reporting period, how many were in competitive, integrated employment and/or in school while receiving resource facilitation? Please enter a positive number, zero (0), or unknown in every field.

Competitive, integrated employment #______
In school or training #______

24. Of the people who have experienced a TBI for whom you provided resource facilitation this reporting period, how many did you support through a transition from an institutional setting (e.g. criminal justice system, nursing facility) into the community? Please enter a positive number, zero (0), unknown, or not applicable in every field.

Number transitioning from criminal justice system to community (with or without HCBS) #______
Number transitioning from nursing facility/medical facility to community (with or without HCBS) #______
Number transitioning from another setting to community (with or without HCBS) (describe) #______

____________________________________________________________________________________________________________________________________________________________

25. Is there anything else you would like to let ACL know about your resource facilitation efforts during this period?
This question is not mandatory.

Training, Outreach and Awareness (if applicable to grant activities)

26. How many different types of people received grant-supported training in this reporting period (across all funded partners that provide training with program funds)? Please enter a positive number, zero (0), unknown or not applicable in every field.

GUIDANCE: One individual person may serve in different capacities and may have received different kinds of training for different reasons. If one person received training you offered for EMS providers and a different training you offered for athletic coaches, they may be counted in both places.

Staff providing grant-related services # _______

Staff providing, I&R/A # _____
Staff conducting Screenings/Assessments # _______
Staff providing Resource Facilitation # _______

Clinical/medical providers # _______

Physicians # _______
Emergency medical services providers/first responders # _______
Other clinical/medical providers # _______

Coaches or other athletics personnel
Domestic violence services staff # _______
Family, friends, informal caregivers # _______
Homeless services organization staff # _______
Individuals who have experienced a TBI # _______
In-home services and supports staff # _______
Law enforcement personnel # _______
Prison or criminal justice system staff # _______
Protection and advocacy staff # _______
Residential rehabilitation center staff # _______
Nursing home staff # _______
Universities, colleges, or school staff (excluding school coaches) # _______
Veterans & military organization staff # _______
Other:______________________ # _______
Other:______________________ # _______

27. Please provide the number of grant-sponsored trainings took place this reporting period, by topic area and number of attendees. Please enter a positive number, zero (0), unknown, or not applicable in every field. Note: “grant-sponsored trainings” refers to those using program funds or state matching funds.

GUIDANCE: If you offered the same TBI Basics training four different times for different groups of grantees, enter 4 as the # of trainings offered and the total number of attendees across all 4 trainings as the # attendees.

TBI Basics #______ # attended: _____
Aging and TBI #______ # attended: _____
Assistive technology #______ # attended: _____
Athletics #______ # attended: _____
Behavioral health and TBI #______ # attended: _____
Caregiving #______ # attended: _____
Children and TBI #______ # attended: _____
Concussions & mild TBI #______ # attended: _____
Criminal justice and TBI #______ # attended: _____
Diagnosis #______ # attended: _____
Educational issues #______ # attended: _____
Employment and training of people with TBI #______ # attended: _____
Identification, screening, assessment #______ # attended: _____
Independent living #______ # attended: _____
Substance Use and TBI #______ # attended: _____
Neurobehavioral aspects of TBI #______ # attended: _____
Public Policy #______ # attended: _____
Person Centered Planning/Counseling #______ # attended: _____
Community-based services and support resources #______ # attended: _____
Treatment and therapies #______ # attended: _____
Other: ______________ #______ # attended: _____
Other: ______________ #______ # attended: _____

28. Please list and describe any training materials, outreach materials, fact sheets or other products you produced during this reporting period.

29. Is there anything else you would like to let ACL know about your training activities during this reporting period?

This question is not mandatory.

Other (if applicable to grant activities)

30.Describe what activities you undertook in this area this reporting period.

31. How many unduplicated people did you work with or support through ____ activity during this reporting period? Please enter a positive number, zero (0), or unknown in every field.

Total number of people who have experienced a TBI who participated in __activity # ______

Number of people under age 22 #_______
Number of people between 23-59 #_______
Number of people 60 or older #_______

Narrative Responses (all grantees respond)

Please describe the TBI mentoring and work group activities your program led or participated in during this reporting period.

Please describe the extent to which the mentoring and work group activities you participated in added value to your program, the national program, and/or any other aspect of your TBI work.

Did you use the services of the TBI Technical Assistance and Resource Center (TARC) during this reporting period? [Yes/No] If yes, please describe these services. If you did not use the services of the TBI TARC during this reporting period, please explain why not.

How would you describe the quality of services you received from the TBI TARC during this reporting period?

Is there anything else you would like to let ACL know about your project or the TBI State Partnership Program?

Public Burden Statement:

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-NEW). Public reporting burden for this collection of information is estimated to average [8] 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 or maintain benefits under the statutory authority [Traumatic Brain Injury Reauthorization Act of 2018 (P.L. 115-377)].

File Type	application/msword
Author	Kurt Moore
Last Modified By	SYSTEM
File Modified	2020-01-14
File Created	2020-01-14

TBI State Partnership Program Performance Measures

Traumatic Brain Injury (TBI) State Partnership Program

0985-New TBI Instrument_Perf Measures 010820

Traumatic Brain Injury (TBI) State Partnership Program

OMB: 0985-0066

OMB Control Number: 0985-xxxx

ACL Traumatic Brain Injury State Partnership Grants Performance Measurement Reporting –

TABLE OF CONTENTS

Grant Activities (all grantees respond)

Partnership Activities (all grantees respond)

Planning and Infrastructure Development (all grantees respond)

Information and Referral/Assistance (if applicable to grant activities)

Screening and Assessments (if applicable to grant activities)

Resource Facilitation (if applicable to grant activities)

Training, Outreach and Awareness (if applicable to grant activities)

Other (if applicable to grant activities)

Narrative Responses (all grantees respond)