Alzheimer's Disease Supportive Services Program (ADSSP) Data Collection

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Overview

PWD Charac
CG Characteristics
Svcs, Exp, Participation

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Sheet 1: PWD Charac

Person with Dementia	Age of Person with Dementia
	Under 60	60+	Totals
Gender
Female			0
Male			0
Gender Missing			0
Geographic Location
Urban			0
Rural			0
Geographic Location Missing			0
Relationship to Caregiver
Spouse			0
Unmarried Partner			0
Parent			0
Other relative			0
Non-relative			0
Relationship Missing			0
Person with Dementia by Ethnicity
Hispanic or Latino			0
Not Hispanic or Latino			0
Ethnicity Missing			0
Person with Dementia by Race
White (Alone) -- Non-Hispanic			0
White (Alone) -- Hispanic			0
American Indian or Alaska Native (Alone)			0
Asian (Alone)			0
Black or African-American (Alone)			0
Native Hawaiian or Other Pacific Islander (Alone)			0
Persons Reporting Some Other Race			0
Persons Reporting 2 or More Races			0
Race Missing			0
Veteran Status
Veteran Status			0
Non-Veteran			0
Veteran Status Missing			0
Gray boxes are not to be filled out.

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Sheet 2: CG Characteristics

Caregiver	Age of Primary Caregiver
	Under 60	60+	Totals
Gender
Female			0
Male			0
Gender Missing			0
Geographic Location
Urban			0
Rural			0
Geographic Location Missing			0
Relationship to Person with Dementia
Spouse			0
Unmarried Partner			0
Child			0
Other Relative			0
Other Non-Relative			0
Relationship Missing			0
Person with Dementia by Ethnicity
Hispanic or Latino			0
Not Hispanic or Latino			0
Ethnicity Missing			0
Primary Caregiver by Race
White (Alone) -- Non-Hispanic			0
White (Alone) -- Hispanic			0
American Indian or Alaska Native (Alone)			0
Asian (Alone)			0
Black or African-American (Alone)			0
Native Hawaiian or Other Pacific Islander (Alone)			0
Persons Reporting Some Other Race			0
Persons Reporting 2 or More Races			0
Race Missing			0
Veteran Status
Veteran			0
Non-Veteran			0
Veteran Status Missing			0
Gray boxes are not to be filled out.

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Sheet 3: Svcs, Exp, Participation

Services & Expenditures	Total Units of Direct Service Delivered	Total ADSSP Expenditures	Total Federal Funds Spent on Direct Services	Total Federal Funds Spent on Administrative Services	Percentage of Federal Funds Spent on Direct Service Expenses	Percentage of Federal Funds Spent on Administrative Expenses
Narrative
It is a statutory requirement for the Alzheimer’s Disease Supportive Services Program that at least 50% of federal grant funds spent be spent on direct service costs and that no more than 10% of federal funds be spent on administrative costs. If your project has not met these requirements by the end of this reporting period (reflected in the numbers above), please describe -- in the box to the right -- why the project has not met these requirements and confirm that the project will meet these requirements by the end of the grant.
Participantion*	Program Entrants	Program Completers
*Only complete for Evidence-Based Projects