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REPORTING INSTRUMENT
OMB Control Number: 0985-0043
Expiration Date: January 31, 2021

UNITED STATES DEPARTMENT OF HEALTH AND HUMAN SERVICES
ADMINISTRATION FOR COMMUNITY LIVING
OFFICE OF INDEPENDENT LIVING PROGRAMS

SECTION 704
ANNUAL PERFORMANCE
REPORT
for
STATE INDEPENDENT LIVING
SERVICES PROGRAM
(Title VII, Chapter 1, Part 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 09850043. 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, Part B

$

(B) Title VII, Ch. 1, Part 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.)

$

2

Item 6 - Net Operating Resources
[Total Income (Section 4) amount paid out to Consumers
(Section 5) = Net Operating Resources

$

3

Section B – Distribution of Title VII, Chapter 1, Part B Funds
Section 713 of the Act; 45 CFR 1329.10

What Activities were
Conducted with Part B Funds?

Expenditures of
Part B Funds for
Services by DSE
Staff

Expenditures for
Services
Rendered By
Grant or
Contract

(1) Provided resources to the SILC to carry out its
functions

$

$

(2) Provided IL services to individuals with
significant disabilities

$

$

(3) Demonstrated ways to expand and improve IL
services

$

$

(4) 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

$

$

(5) Supported activities to increase capacity to
develop approaches or systems for providing
IL services

$

$

(6) Conducted studies and analyses, gathered
information, developed model policies, and
presented findings in order to enhance IL
services

$

$

(7) Provided training regarding the IL philosophy

$

$

(8) Provided outreach to unserved or underserved
populations, including minority groups and
urban and rural populations

$

$

4

Section C – Grants or Contracts Used to Distribute Title VII, Chapter 1, Part 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 Part 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-Part 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

Total Amount of Grants
and Contracts

Use of Funds
(based on the activities listed in
Subpart I, Section B)

Amount of
Part B
Funds

Amount of
Non-Part B
Funds

$

$

Consumer
Eligibility
Determined By
DSE or
Provider

Consumer
Service Records
(CSRs) Kept
With
DSE or
Provider

5

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 Part B grant or contract awarded for
purposes other than IL services or the general operation of centers.

Section E – Monitoring Title VII, Chapter 1, Part 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 Part 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 Part 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 Part C Funds to Centers
In the chart below, please provide the following information:
A) name of each center within your state that received Part C funding during the reporting
year;
B) amount of Part C funding each center received;
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C) whether the Part C funding included a cost-of-living increase;
D) whether the Part C funding included any excess funds remaining after cost-of-living
increases were provided;
E) whether any of the centers received its Part C funding pursuant to a competition for a new
center in the state; and
F) whether the center was the subject of an onsite compliance review conducted by the DSE
during the reporting year.

Name of CIL

Amount of
Subchapter C
Funding
Received

Cost of
Living
Increase?
(Yes/No)

Excess
Funds
After Cost
of Living New
Increase? Center?
(Yes/No)
(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 Part C program.
Item 3 – Monitoring and Onsite Compliance Reviews
Section 723(g), (h), and (i)
Provide a summary of the monitoring activities involving Part C centers conducted by the state
during the current reporting year, including the onsite reviews of at least 15% of centers
receiving Part C funds under section 723. The summary should include, at least, the following:
A)
B)
C)
D)

centers’ level of compliance with the standards and assurances in Section 725 of the Act;
any adverse actions taken against centers;
any corrective action plans entered into with centers; and
exemplary, replicable or model practices for centers.

Item 4 – Updates or Issues
Provide any updates to the administration of the Part 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 Part C funds. Provide a description of any issues of concern
addressed by the DSE in its administration of the Part C program.

7

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
Part B funds and who were listed in Subpart I, Section C of this report, except for the centers that
receive Part C funds. Part 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
(1) Enter the number of active CSRs carried over from September 30 of
the preceding reporting year
(2) Enter the number of CSRs started since October 1 of the reporting
year
(3) 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
(1) Moved
(2) Withdrawn
(3) Died
(4) Completed all goals set
(5) Other
(6) Add lines (1) + (2) + (3) + (4) +(5) to get total CSRs closed

8

Section C –Number of CSRs Active on September 30 of the Reporting Year
Indicate the number of CSRs active on September 30th of the reporting year.
# of CSRs
Section A(3) Section (B)(6) = Section C

Section D – IL Plans and Waivers
Indicate the number of consumers in each category below.
# of Consumers
(1) Number of consumers who signed a waiver
(2) Number of consumers with whom an ILP was developed
(3) Total number of consumers served during the reporting year

Section E – Age
Indicate the number of consumers in each category below.
# of Consumers
(1) Under 5 years old
(2) Ages 5 – 19
(3) Ages 20 – 24
(4) Ages 25 – 59
(5) Age 60 and Older
(6) Age unavailable

Section F – Sex
Indicate the number of consumers in each category below.
# of Consumers
(1) Number of Females served
(2) Number of Males served

9

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
(1) Cognitive
(2) Mental/Emotional
(3) Physical
(4) Hearing
(5) Vision
(6) Multiple Disabilities
(7) Other

10

SUBPART III – INDIVIDUAL SERVICES AND
ACHIEVEMENTS FUNDED THROUGH TITLE VII, CHAPTER
1, PART 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 Part 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 Part 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

11

Services

Consumers
Requesting
Services

Consumers
Receiving
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

(A) Self-Advocacy/Self-Empowerment
(B) Communication
(C) Mobility/Transportation
(D) Community-Based Living
(E) Educational
(F) Vocational
(G) Self-care
(H) Information Access/Technology
(I) Personal Resource Management
(J) Relocation from a Nursing Home or Institution
to Community-Based Living
12

Significant Life Area

Goals Set

Goals
Achieved

In
Progress

(K) Community/Social Participation
(L) Other
Item 2 – Improved Access to Transportation, Health Care 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 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.

13

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.

14

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 Part 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 Hours
Entity
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.

15

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 Voting or
Category
Non-Voting

Term Start
Date

Term End
Date

16

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.

17

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.

18

(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-Part 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

19

Training and Technical Assistance Needs
Assistive Technologies
General Overview

Choose up to 10
Priority Needs —
Rate items 1–10
with 1 being most
important

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

20

Training and Technical Assistance Needs
Innovative Programs
Best Practices
Specific Examples

Choose up to 10
Priority Needs —
Rate items 1–10
with 1 being most
important

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

21

Training and Technical Assistance Needs
Outreach to Unserved/Underserved Populations
General Overview
Disability
Minority
Institutionalized Potential Consumers
Rural

Choose up to 10
Priority Needs —
Rate items 1–10
with 1 being most
important

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)

22

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.

23

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

NAME AND TITLE OF SILC CHAIRPERSON

SIGNATURE OF DSE DIRECTOR

NAME AND TITLE OF DSE DIRECTOR

DATE

PHONE NUMBER

DATE

PHONE NUMBER

24