0169 PAIMI _PPR_ Mark-up

OMB Approval: 0930-0169 Expiration Date: X/XX/XXXX

Protection and Advocacy for Individuals with Mental Illness (PAIMI)

Annual Program Performance Report (PPR)

Substance Abuse and Mental Health Services Administration (SAMHSA)

U.S. Department of Health and Human Services

Table of Contents Section A: General Program Information

1. P&A Identification

2. Main Office

3. Other Offices (if any)

4. Executive Director/Chief Executive Officer Contact Information

5. PPR Preparer Contact Information

6. Governing Authority President/Chair

7. PAIMI Advisory Council President/Chair

8. Name of P&A Chief Financial Officer/Accountant

9. Governor’s Liaison

10. Commissioner/Director of the state Mental Health Agency Name

11. Demographic composition of Governing Board, Advisory Council and PAIMI staff

12. Number of mental health professionals (social workers, psychologists, psychiatric nurses, psychiatrists, psychiatric nurse practitioners, peer support specialists, other) on the Advisory Council.

13. Governing Board (GB) Type and Number of Members

14. Governing Board Information

15. Governing Board Composition

16. PAIMI Advisory Council

17. Staff charging time to the PAIMI Program

Section B: Demographics - Interventions on behalf of Individuals

1. Age of PAIMI-eligible Individuals Served

2. Gender Identity of PAIMI-eligible Individuals Served

3. Ethnicity and Race of Individuals Served

4. PAIMI-eligible Individuals served with PAIMI Program funds

5. Living Arrangements of PAIMI-eligible Individuals at Intake

Section C: Complaints/Problems of PAIMI-eligible Individuals

1. Complaints/Problems of PAIMI-eligible Individuals - Abuse

2. Abuse Complaints Disposition

3. Complaints/Problems of PAIMI-eligible Individuals – Neglect

4. Neglect Complaints Disposition

5. Complaints/Problems of PAIMI-eligible Individuals - Rights Violations

6. Rights Violations Complaints Disposition

7. Reasons for Closing Individual Advocacy Case Files

8. Intervention Strategies

9. Death Investigation Activities

   1. The number of deaths of individuals reported to the P&A for investigation by category

   2. All Death investigations conducted involving PAIMI-eligible individuals by category.

   3. Brief summary examples of an individual’s death, P&A involvement, and outcome.

10. Intervention on Behalf of Groups of PAIMI-eligible Individuals (count by type).

11. Intervention on Behalf of Groups of PAIMI-eligible Individuals (number and outcome by type of intervention).

12. End Outcomes of P&A Activities

Section D: Non-Client Directed Advocacy Activities

1. Individual Information and Referral

2. State Mental Health Planning Activities

3. Education, Public Awareness Activities and Events

4. Technical Assistance

Section E: Grievance Procedures Section F: Other Services and Activities

Section G: Actual PAIMI Budget/Expenditures for FY Section H: Statement of Goals and Priorities

1. Report on previous FY Statement of Priorities and Objectives (SPO)

Section A: General Program Information for FY

1. P&A Identification

Name of state/jurisdiction
Name of P&A system

2. Main Office

Mailing address of main office
Phone number of main office
Toll free Phone Number
E-mail address
Website address
TTY phone number or Relay
County or Main Office

3. Other Offices (if any - add rows, if needed)

Mailing address (each satellite office)
County of each satellite office (location)

4. Executive Director/Chief Executive Officer Contact Information

Name
Address
Phone number & extension
E-mail address

5. PPR Preparer Contact Information

Name
Title
Phone number & extension
E-mail address

6. Governing Board President/Chair

Name
Mailing address
County of residence

E-mail address
Current term started
Current term expires

7. PAIMI Advisory Council President/Chair Name

Name
Mailing address
County of residence
E-mail address
Current term started
Current term expires

8. Name of P&A Chief Financial Officer/Accountant

Name
Title
Phone
E-mail address

9. Governor’s Liaison

Name
Official title
Mailing address
Phone number
E-mail address

10. Commissioner/Director of the State Mental Health Agency

Name
Mailing address
Phone number
E-mail address

11. Demographic Composition of PAIMI Governing Board, Advisory Council, and Program Staff

		Governing Board	Advisory Council	Program Staff
Ethnicity	Hispanic/Latino
	Non-Hispanic/Latino
	Ethnicity Unknown
Race	American Indian/ Alaska Native
	Asian
	Native Hawaiian or Other Pacific Islander
	Black/African American
	White
	Two or more races
	Some other race
	Race unknown
Gender	Female
	Male
	Transgender (Trans Women)	This was added.
	Transgender (Trans Man)	This was added.
	Two-Spirit (if Client is AIAN)
	Gender Non-Conforming	This was added.
	Other (if use a different term)
	Prefer not to say
Sexual Orientation	Lesbian or gay
	Straight (not lesbian or gay)
	Bisexual
	Two-Spirit (if Client is AIAN)	This was deleted.
	Other (if use a different term)
	Prefer not to say

12. Number of Mental Health Professionals on the Advisory Council (social workers, psychologists, psychiatric nurses, psychiatrists, psychiatric nurse practitioners).

Professional Category	Number on Advisory Council
Social Worker
Psychologist
Psychiatric Nurse
Psychiatrist
Psychiatric Nurse Practitioner
Peer Support Specialist
Other (Identify the professional in the Footnotes)
Total:

12. Governing Board (GB) Type and Number of Members Included in Governing Board Information

    Governing board	Minimum number of members	Maximum number of members
    Private, non-profit with multi- Member
    State-operated with governing Board
    State-operated with no governing board

13. Governing Board Information

Total seats available
Total members serving as of 9/30/
Total vacancies on 9/30/
Term of appointment (number of years)
Term maximum
Meeting frequency
Number of meetings held this fiscal year (FY)
Percentage of members present at meetings during the FY

12. Governing Board Composition

	Number of individuals with mental illness who are recipients/former recipients (R/FR) of mental health services or have been eligible for services.
	Number of family members of individuals with mental illness who are R/FR of mental health services, guardians, advocates or authorized representatives or other persons who broadly represent or are knowledgeable about the needs of clients served by the P&A system.
Total

12. PAIMI Advisory Council (PAC)

PAC Chair
Sits on the governing board	Yes	No
Appointment date
	MM/DD/YYYY
Other PAC member(s) sit on governing board	Yes	No
If yes, number serving

12. Staff charging time to the PAIMI Program

	Number of Attorneys	Full-time	Part-time	Male	Female	Number of Advocates	Full-time	Part-time	Male	Female
Ethnicity
Hispanic/Latino (of any race)
Non-Hispanic/ Latino
Race
American Indian/ Alaska Native
Asian
Black/African American
Native Hawaiian/ Pacific Islander
White
Two or more races
Some other race
Race unknown

Section B: Demographics

1. Age of PAIMI-eligible Individuals Served

Age	Number
0 – 2
3-5
6-10
11-22
23-64
65+
Prefer not to say
Total

2. Gender and Sexual Orientation of PAIMI-eligible Individuals Served

Gender	Number
Female
Male
Transgender (Trans Woman)
Transgender (Trans Man)
Two-Spirit (if Client is AIAN)
Gender Non-Conforming
Other (if use a different term)
Prefer not to say
Total
Sexual Orientation	Number
Lesbian or gay
Straight (not lesbian or gay)
Bisexual
Other (if use a different term)
Prefer not to say
Total

2. Ethnicity and Race of Individuals Served

Ethnicity	Number	PAIMI%	State%
Hispanic/Latino (of any race)
Non-Hispanic/Latino
Ethnicity unknown
Total

Race	Number	PAIMI%	State%
American Indian/Alaska Native
Asian
Black/African American
Native Hawaiian/Pacific Islander
White
Two or more races
Some other race
Race unknown
Total

2. PAIMI-eligible Individuals Served with PAIMI Program Funds

What to Count	Number
1. Number of PAIMI-eligible individuals continued to be served with PAIMI program funds, including any program income resulting from legal actions supported by PAIMI program funds as of October 1, from the previous FY into the reporting year.
2. Number of new PAIMI-eligible individuals served during the reporting year.
3. Total number of PAIMI-eligible individuals served during this FY (add lines 4.1 and 4.2).
4. Individuals with more than one intervention opened/closed during the reporting year
5. Individuals with a co-occurring mental illness and Intellectual and Developmental Disability (IDD).
6. Total number of PAIMI-eligible individuals who requested program related advocacy services during the reporting year, but were not served within 30-days of initial contact due to:
a. insufficient PAIMI program resources
b. non-priority areas.
7. Individuals served as of September 30 and will be carried over to next reporting year (This should equal ≤ item 3 above).

2. Living Arrangements of PAIMI-eligible Individuals at Intake

Living Arrangement	Number
Community residential home for children/youth up to age 18 yrs.
Community residential home for adults
Non-medical community-based residential facility for children/youth
Foster care
Nursing homes, including skilled nursing facilities
Intermediate care facilities
Public and Private general hospitals including emergency rooms
Public institutional living arrangement
Private institutional living arrangement
Psychiatric hospitals (public/private)
a. public/state b. private
Jails
State prison
Federal detention center
Federal prison
Veterans’ administration hospital/Clinic
Other federal facility
Homeless
Independent (in the community & PAIMI-eligible)
Parental or other family home & PAIMI-eligible
Unknown
Total

Section C: Complaints/Problems of PAIMI-eligible Individuals

1. Areas of Alleged Abuse

Number of complaints/problems (Make every effort to report within the following categories)	Number from Closed Cases only	Outcomes (will add col. J & K
	Total	A	B	C	D	E	F	G	H	I
a. Inappropriate or excessive medication
b. Inappropriate or excessive restraint and seclusion
c. Involuntary medication
d. Involuntary electrical convulsive therapy
e. Involuntary aversive behavioral therapy
f. Involuntary sterilization
g. Physical assault
h. Sexual assault
i. Threats of retaliation or verbal abuse by facility staff
j. Coercion
k. Financial exploitation
l. Suspicious death
m. Other - Specify type of complaint (describe on a separate sheet)
Total

*Expanded authorities under the Children’s Health Act of 2000, Part H, section 592(a) and Part I Section 595, as codified respectively under Title V. Public Health Service Act, 42 U.S.C., at 290ii- 290ii and 290jj-1 -290jj-2 (See also, the PAIMI

Act 42 U.S.C. 10802(1)(A) - (D)).

2.Abuse Complaints Disposition

For total closed cases listed in Table C.1., provide the number of abuse complaints/problems for each disposition category.
Total number of Abuse complaints/problem addressed from closed cases.
a. Number of complaints/problems determined after investigation not to have merit.
b. Number complaints/problems withdrawn or terminated by client.
c. Number of complaints/problems resolved in the client’s favor.
d. Number of complaints/problems not resolved in the client’s favor.

e. Other indicators of success or outcomes that resulted from P&A involvement.
f. Other representation found.
g. Services not needed due to client death or relocation.
h. P&A withdrew due to conflict of interest or other reasons.
i. Lost Contact
j. Outcome Unknown
k. Lack of Resources

3. Areas of Alleged Neglect

[Failure to provide for appropriate. . .] - Number of complaints/problems:	Number from Closed Cases Only	Outcomes (will add col. K)
	Total	A	B	C	D	E	F	G	H	I	J
a) Failure to provide necessary or appropriate medical (other than psychiatric) treatment
b) Failure to provide necessary or appropriate mental health treatment, including access to prescribed medication
c) Failure to provide necessary or appropriate personal care and safety
d) Failure to provide appropriate discharge planning or release from a residential care or treatment facility
e) Mental health diagnostic or other evaluation (does not include treatment)
f) Medical (non-mental health related) diagnostic or physical examination
g) Other [Describe and make every effort to report within the above categories]

Total

3. Neglect Complaints Disposition

For total closed cases listed in Table C.3., provide the numbers of neglect complaints or problem areas for each disposition category.
Total number of Neglect complaints/problem addressed from closed cases.
a. Number of complaints/problems determined after investigation not to have merit.
b. Number complaints/problems withdrawn or terminated by the client.
c. Number of complaints/problems resolved in the client’s favor.
d. Number of complaints/problems not resolved in the client’s favor.
e. Other indicators of success or outcomes that resulted from P&A involvement.
f. Other representation found,
g. Services not needed due to client death or relocation
h. P&A withdrew due to conflict of interest or other reasons.
i. Lost Contact
j. Outcome Unknown
k. Lack of Resources

3. Areas of Alleged Rights Violations

Number of Complaints/Problems	Number from Closed Cases only	Outcomes (will add col. K)
	Total	A	B	C	D	E	F	G	H	I
a. Failure to provide an individualized, written treatment or service plan
b. Failure to provide written discharge plan, including a description of mental health services needed upon discharge from such program or facility
c. Failure to allow ongoing participation, appropriate to such person’s capabilities, in the planning of mental health services (including the right to participate in the development and periodic revision of the plan)
d. The right to refuse treatment
e. The right to refuse to take prescribed medications
f. The denial of financial benefits/entitlements (e.g., SSI, SSDI, Insurance)
g. Guardianship/conservator problems
h. The denial of rights protection information or legal assistance, including adequate and appropriate representation during commitment hearings
i. The denial of privacy rights (e.g., congregation, telephone calls, receiving mail)
j. The denial of recreational opportunities (e.g., grounds access, television, and smoking)
k. The denial of visitors
l. The denial of access to or correction of records
m. Breach of confidentiality of records (e.g., failure to obtain consent before disclosure)
n. Failure to obtain informed consent
o. Advance directives issues
p. The denial of parental/family rights
q. Housing Discrimination
r. The denial of access to administrative or judicial process;
s. Failure to provide educational services in the least restricted environment for PAIMI-eligible individuals
t. The denial of access to community-based rehabilitation services and/or treatment
u. The denial of access to transportation
v. Employment Discrimination
w. The denial of access to personal possessions
x. Failure to comply with commitment regulations
y. Failure to comply with commitment time frames
z. Other [Please, make every effort to report within the above categories]
Total

3. Rights Violations Disposition

For closed cases listed in this Table, provide the number of rights complaints or problem areas for each disposition category.
Total number of Rights Violation complaints/problems addressed from closed cases.
a. Number of complaints/problems determined after investigation not to have merit.
b. Number complaints/problems withdrawn or terminated by client.
c. Number of complaints/problems resolved in the client’s favor.
d. Number of complaints/problems not resolved in the client’s favor.
e. Other indicators of success or outcomes that resulted from P&A involvement.
f. Other representation found.
g. Services not needed due to client death or relocation.
h. P&A withdrew due to conflict of interest or other reasons.
i. Lost Contact
j. Outcome Unknown
k. Lack of Resources

3. Reasons for Closing Individual Advocacy Case File

	Number
Client’s objective was partially or fully met.
Case or investigation lacked merit.
Case withdrawn or terminated by the client.
Issue favorably resolved.
Issue not favorably resolved.
Other success or outcomes due to P&A involvement (i.e., provided self-advocacy assistance)
Other representation found.
Services not needed due to client’s death or relocation.
P&A withdrew due to conflict of interest or other reasons (i.e., client would not cooperate).
Appeal(s) unsuccessful.
Other appropriate entity investigating.
Lost Contact.
Lack of Resources.
Total

3. Intervention Strategies (more columns will be added to match C.1., C.3. and C.5.)

Outcomes

Abuse

Neglect

Rights Violations

Strategy

Total

A

B

C

D

E

F

G

H

I

J

A

B

C

D

E

F

G

H

I

A

B

C

D

E

F

G

H

I

1. SAA

2. LA

3. TA

3. AR

4. L

5. A/N I

6. M

7. N

Total

1. SAA – Self Advocacy Assistance

2. LA – Limited Advocacy

3. TA – Technical Assistance

4. AR – Administrative Remedies

   5. A/N I – Abuse/Neglect Investigations

5. L – Litigation

6. M – Mediation

7. N – Negotiation

3. Death Investigation Activities

a). The number of deaths reported to the P&A for investigation by the following entities:
1. State
2. The Center for Medicaid & Medicare Services (Regional Offices). If zero means the P&A did not receive any death reports from CMS for investigation, please note this in the Footnotes.
3. Other Sources. Briefly list the source for each death reported in this category (e.g., newspaper, concerned citizen, relative, etc.).
Total Number of deaths investigated.
If the information requested in this section was not available, please explain.
b). All death investigations conducted involving PAIMI-eligible individuals related to the following:
1. Number of deaths investigated involving incidents of seclusion (S).
2. Number of deaths investigated involving incidents of abuse (A).
3. Number of deaths investigated involving incidents of restraint (R).
4. Number of deaths investigated not related to incidents of S & R.
5. Death investigations with a finding or determination.
6. Provision in policy added or prevented because of a death investigation
Total Number of deaths investigated [Sum of 9b 1-6].

3. Provide a brief summary example of an individual’s death, P&A involvement, and outcome.

If you reported deaths in categories B.9.b., please provide the following information on one death from each category, as appropriate:

1. A brief summary of the circumstances about the death.

2. A brief description of P&A involvement in the death investigation.

3. A summary of the outcome(s) resulting from the P&A death investigation.

(Note – limit text field to 500 words)

3. Number of Interventions on behalf of groups of PAIMI-eligible Individuals – Individuals Impacted

Multiple counts not permitted for lines 1 – 3 and 6.

What to Count	Number
1. Group cases/projects still open on October 1 (carried over from prior FY(s)).
2. New group cases/projects opened during the year.
3. Total group cases/projects worked on during the year (add items 1 and 2 above).
4. Total group cases/projects as of September 30 (carry over to next FY).
5. Group cases/projects targeted at serving the following special populations:
a. ethnicity
b. racial minorities
c. homeless
d. veterans
e. urban
f. rural/frontier
g. older adults/geriatric
6. Total number of individuals impacted by line 3.

11. Interventions on behalf of groups of PAIMI-eligible Individuals

5. E. Intervention Types (See the Instructions for Guidance)	Potential number of Individuals Impacted	Concluded Successfully	Concluded Unsuccessfully	On-going
Group Advocacy (non-litigation)
Abuse and Neglect Investigations (non-death related)
Facility Monitoring Services
Community Based Monitoring Services
Court Ordered Monitoring
Systemic Litigation
Educating Policy Makers
Other Systemic Advocacy
Total

12. Performance Measures of P&A Activities

Specific Measures:	Number from Closed Cases only
a) PAIMI-eligible individuals who access community-based mental health or health care services that resulted in community integration and independence or are better able to advocate to do so;
b) PAIMI-eligible individuals who access benefits or services or are better able to advocate to do so;
c) PAIMI-eligible individuals who live in a healthier, safer, improved, or more integrated settings or are better able to advocate to do so;
d) PAIMI-eligible individuals are able to stay in their own home or better able to advocate to do so;
e) PAIMI-eligible individuals who can secure or maintain employment and/or are not subject to workplace discrimination or are better able to advocate for to do so;
f) PAIMI-eligible individuals who receive appropriate educational services and supports and/or are not subject to discrimination in educational settings or are better able to advocate for those outcomes;
g) PAIMI-eligible individuals who go to school in safe and more humane conditions;
h) PAIMI-eligible children (individuals) who receive appropriate services in the most integrated settings;
i) PAIMI-eligible individuals who were not subject to discrimination in government benefits/services, housing, public accommodations, etc. or are better able to advocate for such outcomes;
j) PAIMI-eligible individuals who were not subject to abuse, neglect, or rights violations or are better able to advocate for to do so;
k) PAIMI-eligible individuals who can make their own decisions to the maximum extent feasible or are better able to advocate to do so;
l) PAIMI-eligible individuals who had their rights enforced, retained, restored and/or expanded or are better able to advocate for to do so; and
m) PAIMI-eligible individuals who were more able to participate in the voting process or are better able to advocate for to do so.

Section D. Non-Client Directed Advocacy Activities

1. Individual Information and Referral (I&R).

Provide the number of PAIMI Program I&R services.
Total

2. State Mental Health Planning Activities

3. Education, Public Awareness Activities, and Events

List the number of public awareness activities or events and the number of individuals who received the information [Refer to Glossary].
1. Number of public awareness activities or events.
2. Number of education/training activities undertaken.
3. Number (approximate) of persons trained in 2.

4. Technical Assistance

Provide the number of PAIMI Program TA services.
Total

Section E. Grievance Procedures [42 CFR Section 51.25]

1. Do you have a systemic/program assurance grievance policy, as mandated by 42 CFR 51.25(a) (2)?

Yes ☐No (If no, please indicate the date that the developed policy is anticipated. / /

2. The number of grievances filed by PAIMI-eligible clients, including representatives or family members of such individuals receiving services during this fiscal year.
Total

3. The number of grievances filed by prospective PAIMI-eligible clients (those who were not served due to limited PAIMI program resources or because of non-priority issues).
Total [42 CFR Section 1.25(a)(1)(2)]

4. The number of grievances appealed to:
4.a. The governing authority/board
4.b. The Executive Director
Total 4.a. & 4.b.

5. The number of reports sent to the governing board and the advisory board.
Total

6. Please identify all individuals (name & title), responsible for grievance reviews.

Name & title
Name & title
Name & title
Name & title

7. What is the timetable (in days) used to ensure prompt notification of the grievance procedure process to clients, prospective clients or persons denied representation, and ensure prompt resolution?
Number of days

Section F. Other Services and Activities

2. Were the notices provided to the following persons?
a. Individuals with mental illness in residential facilities?	Yes	No
b. Family members and representatives of such individuals?	Yes	No
c. Other individuals with disabilities?	Yes	No
d. Brief explanation is required for each no answer in 2.a., b., or c.

3. Do the procedures provide for receipt of the comments in writing or in person?	Yes	No
3.a. If yes to 3, attach a copy of the agency’s policies/procedures pertaining to public comment.
3.b. If no to 2 a, b, c., explain why the agency does not have such procedures in place.

4. Was the public provided an opportunity for public comment?

Yes

No

8. List Groups (e.g., states, consumer advocacy, service providers, professional organizations, and others, including groups of current and former mental health consumers or family members of such individuals) with whom the PAIMI program coordinated systems, activities, and mechanisms [PAIMI Act 42 U.S.C. 10824 (a) (D)].

9. Briefly describe the outreach efforts/activities used to increase the numbers of ethnic and racial minority clients served or educated about the PAIMI program, this information will be evaluated by using the demographic/state profile information contained in the PAIMI Application for the same FY.

10. Did the activities described in 9; result in an increase of ethnic or minorities in the following categories?
a. Staff	Yes	No
b. Advisory Council	Yes	No
c. Governing Board	Yes	No
d. Clients	Yes	No
If you answer no to any item (10.a-d), please provide a brief explanation, such as 10.a, b., or c. – no vacancies.

11. External Impediments

Describe any problems with implementation of mandated PAIMI activities, including those activities required by Parts H and I of the Children’s Health Act of 2000 that pertain to requirements related to incidents involving seclusion and restraint and related deaths and serious injuries (e.g., access issues, delays in receiving records and documents, etc.).

12. Internal Impediments

Describe any problems with implementation of mandated PAIMI activities, including any identified

annual priorities, and objectives (e.g., lack of sufficient resources, necessary expertise, etc.).

13. Accomplishments

For this fiscal year, briefly describe the most important accomplishment(s) that resulted from PAIMI program activities. Provide copies of supporting documents (e.g., case law, news article, legislation,

etc.).

14. Recommendations

Please provide recommendations for activities and services to improve the PAIMI program. Include a

brief description of why such activities and services are needed [42 U.S.C. 10824(a) (4)].

15. Please identify any training & technical assistance requests [42 U.S.C. 10825].

Section G. PAIMI Budget – Actual for FY 20___

In this section, provide actual expenditures for the FY. Refer to the PAIMI Application [Appendix C] submitted to SAMHSA/CMHS for the same FY. For additional information regarding this Section, please review the PPR Instructions.

I. Personnel/Name/Title (Active for PAIMI Supervisor only) – Insert additional rows, as needed.

Personnel/Name/Title	Annual Salary A	Total PAIMI Share B	Percent/Level of Effort to PAIMI B / A = C	Comments
Staff Positions
Vacant Positions
Volunteer Positions
Total

II. Fringe Benefits – Insert additional rows, as needed.

Fringe Breakdown	Annual Salary A	Total PAIMI Share B	Percent/Level of Effort to PAIMI B / A = C	Comments
Total

III. Travel – Insert additional rows, as needed.

Travel Expenses	Actual Cost A	Total PAIMI Share B	Percent/Level of Effort to PAIMI B / A = C	Comments
Total

IV. Equipment – Insert additional rows, as needed.

Equipment	Actual Cost A	Total PAIMI Share B	Percent/Level of Effort to PAIMI B / A = C	Comments
Total

V. Supplies – Insert additional rows, as needed.

Supplies	Actual Cost A	Total PAIMI Share B	Percent/Level of Effort to PAIMI B / A = C	Comments
Total

VI. Contractual/Consultant Costs – Insert additional rows, as needed.

Contractual/Consultant	Actual Cost A	Total PAIMI Share B	Percent/Level of Effort to PAIMI B / A = C	Comments
Total

VII. Technical Assistance/Training Costs – Insert additional rows, as needed.

Technical Assistance/Training	Actual Cost A	Total PAIMI Share B	Percent/Level of Effort to PAIMI B / A = C	Comments
Total

VIII. Other Expenses – Insert additional rows, as needed.

Other Expenses	Actual Cost A	Total PAIMI Share B	Percent/Level of Effort to PAIMI B / A = C	Comments
Litigation
Total

IX. Indirect Costs

Indirect Costs	The Base A	Rate * B % Format = (.125 = 12.5%)	Total PAIMI Share A * B = C	Comments
Federally approved IDC rate
Total

X. Carryover of PAIMI Funds Only

Carryover for FY ___ $0.00

	Total Actual Costs	Total PAIMI Share
Total PAIMI Costs

Footnotes:

PAIMI Expenditures and Revenues

PAIMI Expenditures
1. Does your P&A have an approved Federal indirect cost rate? If yes, what is the approved rate?	Yes 0.05%	No
2. Total indirect costs		$
3. Total of all PAIMI program costs listed in I-VIII in the Budget.		$
Total		$

Income sources and other resources (PAIMI program only)
1. PAIMI program carryover of grant funds identified by FY.	$
Enter the last two digits of the Fiscal Year FY 20__	$
2. Program income (PAIMI only).
3. State	$
4. Other funding sources [identify each source].	$
Total of all PAIMI Program resources	$

Section H: Statement of Priorities (Goals)

1. For each Priority/Objective, please indicate the “Achieved Outcome:

Priority/Goal Description:
Objective:
Target Population:
Expected Outcome:
Actual Outcome
	B. Strategies Used to Implement Goal and Address Priorities (Check all that apply below)
	□ Collaboration	□ Systemic Litigation
	□ Rights-Based Individual Advocacy Services	□ Educating Policy Makers
	□ Investigations of Abuse and Neglect	□ Other Systemic Advocacy
	□ Monitoring	□ Training/Outreach
	□ Issuance of Public Report

3. Results narratives of P&A activities and accomplishments related to above priority.

   Priority:
   Objective:
   Target Population:
   limited to 500 characters

4. Other qualitative narrative related to the above priority

(Significant activity for which there were no quantifiable results goes here). Describe any other significant activity related to this goal (500 words maximum)

Section I: Glossary

This section contains definitions applicable to the Protection and Advocacy for Individuals with Mental

Illness (PAIMI) program.