1 Section 704 APA Part II

Reporting Instrument

OMB Control Number: 0985-0043

Expiration Date: xxxx, xx xxxx

UniTed States Department of Health and Human Services

Administration for community Living

Administration on Disabilities

Section 704

annual performance report

For

Centers for Independent Living Program

(Title VII, Chapter 1, Part C of the Rehabilitation Act of 1973, as amended)

Part II

INSTRUMENT

(To be completed by Centers for Independent Living)

Fiscal Year: ____________________________________

Grant #: _______________________________________

Name of Center: ________________________________

Acronym for Center (if applicable): ________________

State: _________________________________________

Counties Served: _______________________________

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. 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 U.S. Department of Health and Human Services, 330 C Street, SW, Washington, DC 20201, Attention Elizabeth Akinola, Administration on Disabilities, Mary E. Switzer Room 1109B or email ICDocketMgr@hhs.gov and reference the OMB Control Number 985-0043. Note: Please do not return the completed 704 Report to this address.

SUBPART I – ADMINISTRATIVE DATA

Section A– Sources and Amounts of Funds and Resources

Section 725(c)(8)(D) of the Act; 34 CFR 366.50(i)(4)

Indicate the amount received by the CIL 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	$
(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) Foundations, Corporations, or Trust Grants	$
(H) Donations from Individuals	$
(I) Membership Fees	$
(J) Investment Income/Endowment	$
(K) Fees for Service (program income, etc.)	$
(L) Other resources (in-kind, fundraising, etc.)	$

Item 4 - Total Income

Total income = (A)+(B)+(C)+(D)+(E)+(F)+(G)+(H)+(I)+(J)+(K)+(L)

$

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, or Medicaid funds)

$

Item 6 - Net Operating Resources

[Total Income (Section 4)<minus> amount paid out to Consumers (Section 5) = Net Operating Resources

$

SubPart II – Number and Types of Individuals with significant disabilities receiving services

Section 725(c)(8)(B) of the Act; 34 CFR 366.50(i)(2)

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
Moved
Withdrawn
Died
Completed all goals set
Other
Add lines (1)+(2)+(3)+(4)+(5) to get total CSRs closed

Section C –Number of CSRs Active on September 30 of the Reporting Year

Indicate the number of CSRs active on September 30^th of the reporting year.

	# of CSRs
Section A(3) <minus> Section (B)(6) = Section C

Section D – IL Plans and Waivers

Indicate the number of consumers in each category below.

	# of Consumers
Number of consumers who signed a waiver
Number of consumers with whom an ILP was developed
Total number of consumers served during the reporting year

Section E – Age

Indicate the number of consumers in each category below.

	# of Consumers
Under 5 years old
Ages 5 – 19
Ages 20 – 24
Ages 25 – 59
Age 60 and Older
Age unavailable

Section F – Sex

Indicate the number of consumers in each category below.

	# of Consumers
Number of Females served
Number of Males served

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 704 Report, even if the consumer reported more than one race and/or Hispanic/Latino ethnicity).

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
Cognitive
Mental/Emotional
Physical
Hearing
Vision
Multiple Disabilities
Other

Section I – Individuals Served by County During the Reporting Year

Section 704(m)(4)(D) of the Act

List each county within the CIL’s service area, as indicated in the CIL’s application for Part C funds and the approved SPIL. Add additional rows as necessary. For each county, indicate how many individuals residing in that county were served by the CIL during the reporting year.

County Name	Number of County Residents Served

SubPart III – Individual Services and Achievements

Sections 13 and 725(c)(8)(C) of the Act; 34 CFR 366.50(i)(3); Government Performance Results Act (GPRA) Performance Measures

Please refer to the Instructions before completing.

Section A – Individual Services

For the reporting year, indicate in the table below how many consumers requested and received each of the following IL services.

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
(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
Self-Advocacy/Self-Empowerment
Communication
Mobility/Transportation
Community-Based Living
Educational
Vocational
Self-care
Information Access/Technology
Personal Resource Management
Relocation from a Nursing Home or Institution to Community-Based Living
Community/Social Participation
Other

Item 2 – Improved Access To Transportation, Health Care Services, 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 four 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 report that follow-up contacts with these consumers showed access to previously unavailable transportation, health care and assistive technology.

(B) I&R Information

To inform RSA 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.

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.

SUBPART IV – Extent of CIL Compliance with the Six Evaluation Standards

Section 725(b) and section 725(c)(8)(A) of the Act; 34 CFR 366.63

Section A – Compliance Indicator 1: Philosophy

Item 1 - Consumer Control

34 CFR 366.63(a)(1); 34 CFR 366.50(i)(5) and (6)

(A) Board Member Composition

Enter requested governing board information in the table below:

Total Number of Board Members	Number of Board Members with Significant Disabilities

(B) Staff Composition

Enter requested staff information in the table below:

	Total Number of FTEs	FTEs Filled by Individuals with Disabilities	FTEs Filled by Individuals From Minority Populations
Decision-Making Staff
Other Staff

Item 2 - Self-Help and Self-Advocacy

34 CFR 366.63(a)(2)

Briefly describe how the CIL has promoted self-help and self-advocacy among individuals with significant disabilities during the reporting year.

Item 3 - Peer Relationships and Peer Role Models

34 CFR 366.63(a)(3)

Briefly describe how, during the reporting year, the CIL has promoted the development of peer relationships and peer role models among individuals with significant disabilities.

Item 4 - Equal Access

34 CFR 366.63(a)(4)

(A) Briefly describe how, during the reporting year, the CIL has ensured equal access of individuals with significant disabilities, including communication and physical access, to the center's services, programs, activities, resources, and facilities, whether publicly or privately funded. Equal access, for the purposes of this indicator, means that the same access is provided to any individual with a significant disability regardless of the individual’s type of significant disability.

(B) Briefly describe how, during the reporting year, the CIL has advocated for and conducted activities that promote the equal access to all services, programs, activities, resources, and facilities in society, whether public or private, and regardless of funding source, for individuals with significant disabilities. Equal access, for the purposes of this indicator, means that the same access provided to individuals without disabilities is provided in the center’s service area to individuals with significant disabilities.

Item 5 – Alternative Formats

34 CFR 366.63(a)(4)

Briefly describe how, during the reporting year, the CIL has ensured the availability in alternative formats of all of its written policies and materials and IL services, as appropriate.

Section B – Compliance Indicator 2: Provision of Services on a Cross-Disability Basis

Section 725(b)(2) of the Act; 34 CFR 366.63(b)

Briefly describe how, during the reporting year, the CIL has ensured that IL services are provided to eligible individuals with a diversity of significant disabilities and individuals who are members of populations that are unserved or underserved, without restrictions based on the particular type or types of significant disability and in a manner that is neither targeted nor limited to a particular type of significant disability.

Section C – Compliance Indicator 3: Independent Living Goals

Section 725(b)(3) of the Act; 34 CFR 366.63 (c)

Item 1 – Consumer Information

Briefly describe how, during the reporting year, the CIL has ensured that consumers have the opportunity to develop and achieve their goals (either with or without an ILP) and that the consumer has the opportunity to express satisfaction with the center and such consumer satisfaction results are evaluated by the center.

Item 2 – Consumer Service Record Requirements

Briefly describe how, during the reporting year, the CIL ensured that each consumer’s CSR contains all of the required information.

Section D – Compliance Indicator 4: Community Options and Community Capacity

Section 725(b)(4) and (6) of the Act; 34 CFR 366.63(d)

Please refer to the Instructions before completing.

Item 1 – Community Activities Table

In the table below, summarize the community activities involving the CIL’s staff and board members during the reporting year. For each activity, identify the primary disability issue(s) addressed as well as the type of activity conducted. Describe the primary objective(s) and outcome(s) for each activity. Add more rows as necessary.

Issue Area	Activity Type	Hours Spent	Objective(s)	Outcomes(s)

Item 2 – Description of Community Activities

For the community activities mentioned above, provide additional details such as the role of the CIL staff board members and/or consumers, names of any partner organizations and further descriptions of the specific activities, services and benefits.

Section E – Compliance Indicator 5: IL Core Services and Other IL Services

Section 725(b)(5) of the Act; 34 CFR 366.63(e)

In addition to the data provided in Subpart III, describe how information and referral services and the other IL core and other IL services are provided to those who request such services in formats accessible to the individual requesting the services. Describe any innovative practices (not mentioned elsewhere in this report) to enhance the availability and effectiveness of IL services.

Section F – Compliance Indicator 6: IL Resource Development Activities

Section 725(b)(7); 34 CFR 366.63(f)

Briefly describe the CIL’s resource development activities conducted during the reporting year to expand funding from sources other than chapter 1of title VII of the Act.

SUBPART V – ANNUAL PROGRAM AND FINANCIAL PLANNING OBJECTIVES

Section 725(c)(4) of the Act

Section A –Work Plan for the Reporting Year

Item 1 – Achievements

Discuss the work plan’s proposed goals and objectives and the progress made in achieving them during the reporting year.

Item 2 – Challenges

Describe any substantial challenges or problems encountered by the CIL, and the resolutions/attempted resolutions.

Item 3 – Comparison with Prior Reporting Year

34 CFR 366.50(i)(7)

As appropriate, compare the CIL’s activities in the reporting year with its activities in prior years, e.g., recent trends.

Section B – Work Plan for the Year Following the Reporting Year

Item 1 – Annual Work Plan

List the CIL’s annual work plan goals, objectives and action steps planned for the year following the reporting year.

Item 2 – SPIL Consistency

Explain how these work plan goals, objectives and action steps are consistent with the approved SPIL.

SUBPART VI - TRAINING AND TECHNICAL ASSISTANCE NEEDS

Section 721(b)(3) of the Act.

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
Assistive Technologies
General Overview
Data Collecting and Reporting
General Overview
704 Reports
Performance Measures contained in 704 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
Innovative Programs
Best Practices
Specific Examples
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
Outreach to Unserved/Underserved Populations
General Overview
Disability
Minority
Institutionalized Potential Consumers
Rural
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)

SUBPART VII – ADDITIONAL INFORMATION

Section 704(m)(4)(D) of the Act

Section A – Other Accomplishments, Activities and Challenges

Describe any additional significant accomplishments, activities and/or challenges not included elsewhere in the report, e.g. brief summaries of innovative practices, improved service delivery to consumers, etc.

Section B – Additional Information

Provide additional information, comments, explanations or suggestions not included elsewhere in the report.

SubPART VIII - signatures

Please sign and print the names, titles and telephone numbers of the CIL director and board chair.

SIGNATURE OF CENTER DIRECTOR	DATE
NAME AND TITLE OF CENTER DIRECTOR	PHONE NUMBER
SIGNATURE OF CENTER BOARD CHAIRPERSON	DATE
NAME AND TITLE OF CENTER BOARD CHAIRPERSON	PHONE NUMBER

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