Title VI PPR

OMB No. 0985-0007
Expiration Date: MM/DY/YR
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 0985-0007). Public
reporting burden for this collection of information is estimated to average 3.49 hours per response,
including time for gathering, maintaining, 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 42 U.S. Code § 3057e.

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.__________
------------------------------------------------------------------------------------------------------------------------------------------

TITLE VI, PART A/B REPORT
A. 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

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Person(s)

B. NUTRITION SERVICES
Congregate Meals
Unduplicated number of eligible persons who received one
or more Congregate Meal(s).
Total number of Congregate Meals served.

Enter number here

Person(s)

Enter number here

Meal(s)

Enter number here

Person(s)

Enter number here

Meal(s)

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

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)

C. SUPPORTIVE SERVICES
Access Services
Total number of contacts of Information/Assistance.
Total number of Outreach activities.
Unduplicated number of persons receiving Case
Management.
Total number of hours of Case Management.
Unduplicated number of persons receiving Transportation.

Enter number here
Enter number here

Contact(s)
Activities

Enter number here

Person(s)

Enter number here
Enter number here

Total one-way trips of Transportation.

Enter number here

Hour(s)
Person(s)
One-way
trip(s)

In-home Services
Unduplicated number of persons receiving Homemaker
Services.
Total number of hours of Homemaker Services.
Unduplicated number of persons receiving Personal
Care/Home Health Aid Services.
Total number of hours of Personal Care/Home Health Aid
Service.
Unduplicated number of persons receiving Chore Services.
Total number of hours spent on Chore Services.
Total number of contacts of Visiting.
Total number of contacts of Telephoning.

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Enter number here

Person(s)

Enter number here

Hour(s)

Enter number here

Person(s)

Enter number here

Hour(s)

Enter number here
Enter number here
Enter number here
Enter number here

Person(s)
Hour(s)
Contact(s)
Contact(s)

Other Supportive Services
Total number of Social Events held.
Total number of persons receiving Health Promotion and
Wellness activities.
Total number of visits to persons in nursing facilities/homes
or residential care communities.

Enter number here

Event(s)

Enter number here

Person(s)
Visit(s)

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

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D. FINANCE
Part A/B Spending
Total amount of funds spent on Congregate and Homedelivered Meals.
Total amount of funds spent on Supportive Services
Programming.

Enter number here

Dollars

Enter number here

Dollars

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
State funds
Title III funds
Other grants
Donations

Yes or No
Yes or No
Yes or No
Yes or No
Yes or No

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

E. 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.

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TITLE VI, PART C REPORT
A. 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)

Enter number here

Person(s)

Part-time staff
Part-time staff

B. 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
Enter number here
Person(s)
related disorders.
Unduplicated number of Elder caregivers caring for
Enter number here
Person(s)
children under the age of 18.
Unduplicated number of Elder caregivers providing care
Person(s)
to adults 18-59 years old with disabilities.

C. CAREGIVER SUPPORT SERVICES
Services for Caregivers
Total number of activities of Information Services
provided.
Total number of contacts of Information and Assistance
provided.
Unduplicated number of caregivers receiving Counseling
(e.g. formal and/or informal counselors).
Total number of hours of Counseling.
Total number of sessions of Support Group.
Unduplicated number of caregivers served in Caregiver
Training.
Total number of hours of Caregiver Training.

Activities
Contact(s)
Enter number here

Person(s)

Enter number here
Enter number here

Hour(s)
Session(s)

Enter number here

Person(s)

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.

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

D. 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
Total amount of funds spent on Respite Care.
Enter number here

Report Certified By ________________________________________________
(Tribal Official or other authorized personnel)
Report Prepared by: ____________________________________________________________
Telephone: _______________________________ Email address: _______________________

Date Submitted: _________________________________________________

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Dollars
Dollars