UNITED STATES DEPARTMENT OF EDUCATION

OFFICE OF SPECIAL EDUCATION AND REHABILITATIVE SERVICES

REHABILITATION SERVICES ADMINISTRATION

WASHINGTON, D.C. 20202-2531

> POLICY DIRECTIVE
>
> RSA-PD-00-05
>
> DATE: February 1, 2000

ADDRESSEES: STATE VOCATIONAL REHABILITATION AGENCIES (GENERAL)

> STATE VOCATIONAL REHABILITATION AGENCIES (BLIND)
>
> CLIENT ASSISTANCE PROGRAMS
>
> PROTECTION & ADVOCACY OF INDIVIDUAL RIGHTS
>
> STATE REHABILITATION COUNCILS
>
> AMERICAN INDIAN VOCATIONAL REHABILITATION SERVICE PROGRAMS
>
> RSA SENIOR MANAGEMENT TEAM

SUBJECT: Promulgation of Report Form RSA-509, Annual Protection and
Advocacy of Individual Rights (PAIR) Program Performance Report.

POLICY

STATEMENT: The Office of Management and Budget (OMB) has approved Form
RSA-509, Annual Protection and Advocacy of Individual Rights (PAIR)
Program Performance Report, as a data collection instrument. OMB has
approved the RSA-509 until January 31, 2003 under the Paperwork
Reduction Act of 1995. The OMB number is 1820-0627.

> RSA uses the form to meet specific data collection requirements of
> Section 509 of the Rehabilitation Act of 1973, as amended (Act), and
> its implementing Federal regulations at 34 CFR Part 381. RSA modeled
> this form after the unnumbered form, which was developed by the
> National Association of Protection and Advocacy Systems (NAPAS), that
> the PAIR programs have used in past years. In developing this form,
> RSA sought guidance from PAIR grantees.
>
> PAIR programs must report annually using Form RSA-509 (copy attached).
> Information on transmittal of the form, including electronic
> transmission, is found on pages 22-24 of the reporting instructions.
> The form is due on or before December 30 each year, which is 90 days
> after the end of each fiscal year for which the information is
> reported.

CITATIONS

IN LAW: Section 509 of the Rehabilitation Act of 1973, as amended; and
Paperwork Reduction Act of 1995

CITATIONS IN

REGULATIONS: 34 CFR Part 381

EFFECTIVE

DATE: Immediately upon issuance

EXPIRATION

DATE: January 31, 2003

INQUIRIES: Please direct any questions concerning this Policy Directive
to the Chief, Basic State Grants Branch, Rehabilitation Services
Administration, 330 C St., SW, Washington, D.C. 20202-2574, (202)
245-7488.

> Commissioner
>
> Rehabilitation Services Administration

ATTACHMENTS

cc: CSAVR

NAPAS

NCIL

**FORM RSA-509 OMB NO. 1820- 0627**

**EXPIRES: January 31, 2003**

**ANNUAL PROTECTION & ADVOCACY OF INDIVIDUAL RIGHTS (PAIR) PROGRAM
PERFORMANCE REPORT**

**[Fiscal Year]{.underline}**

+-----------------------------------+------------------------+---------+
| **DESIGNATED AGENCY               |                        |         |
| IDENTIFICATION**                  |                        |         |
+-----------------------------------+------------------------+---------+
| Name:                             |                        |         |
+-----------------------------------+------------------------+---------+
| Address:                          |                        |         |
+-----------------------------------+------------------------+---------+
|                                   |                        |         |
+-----------------------------------+------------------------+---------+
| E-mail Address (if applicable):   |                        |         |
+-----------------------------------+------------------------+---------+
| Website Address (if applicable):  |                        |         |
+-----------------------------------+------------------------+---------+
| Phone: ( )                        | TTY: ( )               |         |
+-----------------------------------+------------------------+---------+
| Toll-free Phone: ( )              | Toll-free TTY: ( )     |         |
+-----------------------------------+------------------------+---------+
| Fax: ( )                          |                        |         |
+-----------------------------------+------------------------+---------+
| Name of P&A Executive Director:   |                        |         |
+-----------------------------------+------------------------+---------+
| Name of PAIR                      |                        |         |
| Director/Coordinator:             |                        |         |
+-----------------------------------+------------------------+---------+
| Person to contact regarding       |                        |         |
| report:                           |                        |         |
+-----------------------------------+------------------------+---------+
| Contact Person\'s phone: ( )      |                        |         |
+-----------------------------------+------------------------+---------+
| **PART I. NON-CASE SERVICES:**    |                        |         |
+-----------------------------------+------------------------+---------+
| **A. Individual Information and   |                        |         |
| Referral Services (I&R):\         |                        |         |
| **(Multiple responses are not     |                        |         |
| permitted.)                       |                        |         |
+-----------------------------------+------------------------+---------+
| > 1\. Individuals receiving I&R   |                        |         |
| > [within]{.underline} PAIR\'s    |                        |         |
| > priority areas                  |                        |         |
+-----------------------------------+------------------------+---------+
| > 2\. Individuals receiving I&R   |                        |         |
| > [outside]{.underline} of        |                        |         |
| > PAIR\'s priority areas          |                        |         |
+-----------------------------------+------------------------+---------+
| > 3\. Total individuals receiving |                        |         |
| > I&R (lines A1+A2)               |                        |         |
+-----------------------------------+------------------------+---------+
| **B. Training Activities:**       |                        |         |
+-----------------------------------+------------------------+---------+
| > 1\. Number of trainings         |                        |         |
| > presented by PAIR staff         |                        |         |
+-----------------------------------+------------------------+---------+
| > 2\. Number of individuals who   |                        |         |
| > attended these trainings        |                        |         |
| > (approximate)                   |                        |         |
+-----------------------------------+------------------------+---------+
| Describe the trainings presented  |                        |         |
| by PAIR staff. Be sure to include |                        |         |
| information about the topics      |                        |         |
| covered, the training methods     |                        |         |
| used, and the purpose for the     |                        |         |
| training. Use separate sheets if  |                        |         |
| necessary.                        |                        |         |
+-----------------------------------+------------------------+---------+
| **C. Information Disseminated to  |                        |         |
| the Public:**                     |                        |         |
+-----------------------------------+------------------------+---------+
| > 1\. Radio and TV appearances by |                        |         |
| > PAIR staff                      |                        |         |
+-----------------------------------+------------------------+---------+
| > 2\. Newspaper/magazine/journal  |                        |         |
| > articles                        |                        |         |
+-----------------------------------+------------------------+---------+
| > 3\. PSAs/videos aired           |                        |         |
+-----------------------------------+------------------------+---------+
| > 4\. Hits on the PAIR/P&A        |                        |         |
| > website                         |                        |         |
+-----------------------------------+------------------------+---------+
| > 5\.                             |                        |         |
| > Publications/booklets/brochures |                        |         |
| > disseminated                    |                        |         |
+-----------------------------------+------------------------+---------+
| > 6\. Other (specify on separate  |                        |         |
| > sheet)                          |                        |         |
+-----------------------------------+------------------------+---------+

+-----------------------------------------------------------+----------+
| **PART II. INDIVIDUALS SERVED:**                          |          |
+-----------------------------------------------------------+----------+
| **A. Individuals Served:** (An individual is counted only |          |
| once per fiscal year. Multiple counts are not permitted   |          |
| for lines A1 through A3.)                                 |          |
+-----------------------------------------------------------+----------+
| > 1\. Individuals who were still being served as of       |          |
| > October 1 (carryover from prior fiscal year)            |          |
+-----------------------------------------------------------+----------+
| > 2\. Additional individuals who were served during the   |          |
| > year                                                    |          |
+-----------------------------------------------------------+----------+
| > 3\. Total individuals served (lines A1+A2)              |          |
+-----------------------------------------------------------+----------+
| > 4\. Individuals who had more than one case file         |          |
| > opened/closed during the fiscal year. (This number is   |          |
| > not added to the total on line A3 above.)               |          |
+-----------------------------------------------------------+----------+
| **B. Individuals still served as of September 30**        |          |
| (carryover to next year) (May not exceed total on line    |          |
| II.A.3 above.)                                            |          |
+-----------------------------------------------------------+----------+
| **C. Problem Areas/Complaints of Individuals Served:**    |          |
+-----------------------------------------------------------+----------+
| > 1\. Architectural accessibility                         |          |
+-----------------------------------------------------------+----------+
| > 2\. Employment                                          |          |
+-----------------------------------------------------------+----------+
| > 3\. Program access                                      |          |
+-----------------------------------------------------------+----------+
| > 4\. Housing                                             |          |
+-----------------------------------------------------------+----------+
| > 5\. Government benefits/services                        |          |
+-----------------------------------------------------------+----------+
| > 6\. Transportation                                      |          |
+-----------------------------------------------------------+----------+
| > 7\. Education                                           |          |
+-----------------------------------------------------------+----------+
| > 8\. Assistive technology                                |          |
+-----------------------------------------------------------+----------+
| > 9\. Voting                                              |          |
+-----------------------------------------------------------+----------+
| > 10\. Health care                                        |          |
+-----------------------------------------------------------+----------+
| > 11\. Insurance                                          |          |
+-----------------------------------------------------------+----------+
| > 12\. Non-government services                            |          |
+-----------------------------------------------------------+----------+
| > 13\. Privacy rights                                     |          |
+-----------------------------------------------------------+----------+
| > 14\. Access to records                                  |          |
+-----------------------------------------------------------+----------+
| > 15\. Abuse                                              |          |
+-----------------------------------------------------------+----------+
| > 16\. Neglect                                            |          |
+-----------------------------------------------------------+----------+
| > 17\. Other                                              |          |
+-----------------------------------------------------------+----------+
| **D. Reasons for Closing Individual\'s Case Files:**      |          |
+-----------------------------------------------------------+----------+
| > 1\. Issues resolved partially or completely in the      |          |
| > individual\'s favor                                     |          |
+-----------------------------------------------------------+----------+
| > 2\. Other representation found                          |          |
+-----------------------------------------------------------+----------+
| > 3\. Individual withdrew complaint                       |          |
+-----------------------------------------------------------+----------+
| > 4\. Appeals were unsuccessful                           |          |
+-----------------------------------------------------------+----------+
| > 5\. PAIR services not needed due to individual\'s       |          |
| > death, relocation, etc.                                 |          |
+-----------------------------------------------------------+----------+
| > 6\. PAIR withdrew from case                             |          |
+-----------------------------------------------------------+----------+
| > 7\. PAIR unable to take case because of lack of         |          |
| > resources                                               |          |
+-----------------------------------------------------------+----------+
| > 8\. Individual\'s case lacks legal merit                |          |
+-----------------------------------------------------------+----------+
| > 9\. Other (Please explain on separate sheet.)           |          |
+-----------------------------------------------------------+----------+
| **E. Intervention Strategies Used in Serving              |          |
| Individuals:** (List the [highest level]{.underline} of   |          |
| intervention used by PAIR prior to closing each case      |          |
| file.)                                                    |          |
+-----------------------------------------------------------+----------+
| > 1\. Technical assistance in self-advocacy               |          |
+-----------------------------------------------------------+----------+
| > 2\. Short-term assistance                               |          |
+-----------------------------------------------------------+----------+
| > 3\. Investigation/monitoring                            |          |
+-----------------------------------------------------------+----------+
| > 4\. Negotiation                                         |          |
+-----------------------------------------------------------+----------+
| > 5\. Mediation/alternative dispute resolution            |          |
+-----------------------------------------------------------+----------+
| > 6\. Administrative hearings                             |          |
+-----------------------------------------------------------+----------+
| > 7\. Litigation (including class actions)                |          |
+-----------------------------------------------------------+----------+
| > 8\. Systemic/policy activities                          |          |
+-----------------------------------------------------------+----------+
| **F. Satisfaction of Individuals Served:**                |          |
+-----------------------------------------------------------+----------+
| > 1\. Number of satisfaction surveys distributed          |          |
+-----------------------------------------------------------+----------+
| > 2\. Number of satisfaction surveys returned             |          |
+-----------------------------------------------------------+----------+
| > 3\. Of the total number of surveys returned, indicate   |          |
| > how many individuals rated their overall satisfaction   |          |
| > with PAIR in the following ways:                        |          |
+-----------------------------------------------------------+----------+
| > a\. very satisfied                                      |          |
+-----------------------------------------------------------+----------+
| > b\. satisfied                                           |          |
+-----------------------------------------------------------+----------+
| > c\. not satisfied                                       |          |
+-----------------------------------------------------------+----------+
| > 4\. Of the total number of surveys returned, indicate   |          |
| > whether the individual served would use PAIR again:     |          |
+-----------------------------------------------------------+----------+
| > a\. yes                                                 |          |
+-----------------------------------------------------------+----------+
| > b\. no                                                  |          |
+-----------------------------------------------------------+----------+
| **PART III. STATISTICAL INFORMATION ON INDIVIDUALS        |          |
| SERVED:**                                                 |          |
+-----------------------------------------------------------+----------+
| **Age of Individuals Served:** (as of October 1)\         |          |
| (Multiple responses not permitted.)                       |          |
+-----------------------------------------------------------+----------+
| > 1\. 0 - 4                                               |          |
+-----------------------------------------------------------+----------+
| > 2\. 5 - 22                                              |          |
+-----------------------------------------------------------+----------+
| > 3\. 23 - 59                                             |          |
+-----------------------------------------------------------+----------+
| > 4\. 60 - 64                                             |          |
+-----------------------------------------------------------+----------+
| > 5\. 65 and over                                         |          |
+-----------------------------------------------------------+----------+
| **B. Gender of Individuals Served:** (Multiple responses  |          |
| not permitted)                                            |          |
+-----------------------------------------------------------+----------+
| > 1\. Females                                             |          |
+-----------------------------------------------------------+----------+
| > 2\. Males                                               |          |
+-----------------------------------------------------------+----------+
| **C. Race/Ethnicity of Individuals Served:** (Multiple    |          |
| responses permitted)                                      |          |
+-----------------------------------------------------------+----------+
| > 1\. White                                               |          |
+-----------------------------------------------------------+----------+
| > 2\. Black or African American                           |          |
+-----------------------------------------------------------+----------+
| > 3\. American Indian or Alaska Native                    |          |
+-----------------------------------------------------------+----------+
| > 4\. Asian                                               |          |
+-----------------------------------------------------------+----------+
| > 5\. Native Hawaiian or other Pacific Islander           |          |
+-----------------------------------------------------------+----------+
| > 6\. Hispanic or Latino                                  |          |
+-----------------------------------------------------------+----------+
| > 7\. Race/ethnicity unknown                              |          |
+-----------------------------------------------------------+----------+
| **D. Living Arrangements of Individuals Served:**         |          |
| (Multiple responses not permitted)                        |          |
+-----------------------------------------------------------+----------+
| > 1\. Independent                                         |          |
+-----------------------------------------------------------+----------+
| > 2\. Parental or other family home                       |          |
+-----------------------------------------------------------+----------+
| > 3\. Community residential home                          |          |
+-----------------------------------------------------------+----------+
| > 4\. Foster care                                         |          |
+-----------------------------------------------------------+----------+
| > 5\. Nursing home                                        |          |
+-----------------------------------------------------------+----------+
| > 6\. Public institutional living arrangement             |          |
+-----------------------------------------------------------+----------+
| > 7\. Private institutional living arrangement            |          |
+-----------------------------------------------------------+----------+
| > 8\. Jail/prison/detention center                        |          |
+-----------------------------------------------------------+----------+
| > 9\. Homeless                                            |          |
+-----------------------------------------------------------+----------+
| > 10\. Other living arrangements                          |          |
+-----------------------------------------------------------+----------+
| > 11\. Living arrangements not known                      |          |
+-----------------------------------------------------------+----------+
| **E. Primary Disability of Individuals Served:**          |          |
| (Identify the individual\'s primary disability, namely    |          |
| the one directly related to the issues/complaints raised  |          |
| by the individual.)                                       |          |
+-----------------------------------------------------------+----------+
| > 1\. Blind/visual impairment                             |          |
+-----------------------------------------------------------+----------+
| > 2\. Deaf/hard of hearing                                |          |
+-----------------------------------------------------------+----------+
| > 3\. Deaf-blind                                          |          |
+-----------------------------------------------------------+----------+
| > 4\. Orthopedic impairment                               |          |
+-----------------------------------------------------------+----------+
| > 5\. Mental illness                                      |          |
+-----------------------------------------------------------+----------+
| > 6\. Substance abuse                                     |          |
+-----------------------------------------------------------+----------+
| > 7\. Mental retardation                                  |          |
+-----------------------------------------------------------+----------+
| > 8\. Learning disability                                 |          |
+-----------------------------------------------------------+----------+
| > 9\. Neurological impairment                             |          |
+-----------------------------------------------------------+----------+
| > 10\. Respiratory impairment                             |          |
+-----------------------------------------------------------+----------+
| > 11\. Heart/other circulatory impairment                 |          |
+-----------------------------------------------------------+----------+
| > 12\. Muscular/skeletal impairment                       |          |
+-----------------------------------------------------------+----------+
| > 13\. Speech impairment                                  |          |
+-----------------------------------------------------------+----------+
| > 14\. AIDS/HIV                                           |          |
+-----------------------------------------------------------+----------+
| > 15\. Traumatic brain injury                             |          |
+-----------------------------------------------------------+----------+
| > 16\. Other disability                                   |          |
+-----------------------------------------------------------+----------+
| **PART IV. SYSTEMIC ACTIVITIES AND LITIGATION:**          |          |
+-----------------------------------------------------------+----------+
| **A. Systemic Activities:**                               |          |
+-----------------------------------------------------------+----------+
| > 1\. Number of policies/practices changed as a result of |          |
| > non-litigation systemic activities                      |          |
+-----------------------------------------------------------+----------+
| > 2\. Number of individuals potentially impacted by       |          |
| > policy changes                                          |          |
+-----------------------------------------------------------+----------+
| Describe your systemic activities. Be sure to include     |          |
| information about the policies that were changed and how  |          |
| these changes benefit individuals with disabilities.      |          |
| Include case examples of how your systemic activities     |          |
| impacted individuals served. (Attach separate sheets if   |          |
| necessary.)                                               |          |
+-----------------------------------------------------------+----------+
|                                                           |          |
+-----------------------------------------------------------+----------+
|                                                           |          |
+-----------------------------------------------------------+----------+
|                                                           |          |
+-----------------------------------------------------------+----------+
|                                                           |          |
+-----------------------------------------------------------+----------+
|                                                           |          |
+-----------------------------------------------------------+----------+
| **B. Litigation/Class Actions:**                          |          |
+-----------------------------------------------------------+----------+
| > 1\. Number of individuals potentially impacted by       |          |
| > changes as a result of PAIR\'s litigation/class action  |          |
| > efforts                                                 |          |
+-----------------------------------------------------------+----------+
| > 2\. Number of individuals named in class actions        |          |
+-----------------------------------------------------------+----------+
| Describe your litigation/class action activities. Explain |          |
| how individuals with disabilities benefited from your     |          |
| litigation activities. Be sure to include case examples   |          |
| that demonstrate the impact of your litigation. (Attach   |          |
| separate sheets if necessary.)                            |          |
+-----------------------------------------------------------+----------+
|                                                           |          |
+-----------------------------------------------------------+----------+
|                                                           |          |
+-----------------------------------------------------------+----------+
|                                                           |          |
+-----------------------------------------------------------+----------+
|                                                           |          |
+-----------------------------------------------------------+----------+
| **PART V. PAIR\'S PRIORITIES AND OBJECTIVES:**            |          |
+-----------------------------------------------------------+----------+
| For [each]{.underline} of your PAIR program priorities    |          |
| for the fiscal year covered by this report, please        |          |
| provide the following information:                        |          |
|                                                           |          |
| > 1\. Identify and describe the priority.                 |          |
| >                                                         |          |
| > 2\. Identify the need, issue or barrier addressed by    |          |
| > this priority.                                          |          |
| >                                                         |          |
| > 3\. Identify and describe indicators PAIR used to       |          |
| > determine successful outcome of activities pursued      |          |
| > under this priority.                                    |          |
| >                                                         |          |
| > 4\. Explain whether pursuing this priority involved     |          |
| > collaborative efforts by other entities. If so,         |          |
| > describe this collaboration.                            |          |
| >                                                         |          |
| > 5\. Provide the number of cases handled under the       |          |
| > priority. Indicate how many of these, if any, were      |          |
| > class actions.                                          |          |
| >                                                         |          |
| > 6\. Provide at least one case summary that demonstrates |          |
| > the impact of the priority.                             |          |
+-----------------------------------------------------------+----------+
| **PART VI. NARRATIVE:**                                   |          |
+-----------------------------------------------------------+----------+
| At a minimum, you must include all of the information     |          |
| requested. You may include any other information, not     |          |
| otherwise collected on this reporting form that would be  |          |
| helpful in describing the extent of PAIR activities       |          |
| during the prior fiscal year. Please limit the narrative  |          |
| portion of this report, including attachments, to 20      |          |
| pages or less.                                            |          |
|                                                           |          |
| The narrative should contain the following information.   |          |
| The instructions for this form outline the information    |          |
| that should be contained in each section.                 |          |
|                                                           |          |
| > A. Sources of funds received and expended               |          |
| >                                                         |          |
| > B. Budget for the fiscal year covered by this report    |          |
| >                                                         |          |
| > C. Description of PAIR staff (duties and person-years)  |          |
| >                                                         |          |
| > D. Involvement with advisory boards (if any)            |          |
| >                                                         |          |
| > E. Grievances filed under the grievance procedure       |          |
| >                                                         |          |
| > F. Coordination with the Client Assistance Program      |          |
| > (CAP) and the State long-term care program, if these    |          |
| > programs are not part of the P&A agency                 |          |
+-----------------------------------------------------------+----------+

Within 90 days after the end of the fiscal year covered by this report,
mail one copy of this report to the RSA Regional Office and one copy to
the RSA Central Office specified in the instructions.

Signature of agency official Date

**ANNUAL PROTECTION AND ADVOCACY OF INDIVIDUAL RIGHTS**

**(PAIR) PROGRAM PERFORMANCE REPORT**

**INSTRUCTIONS**

**Paperwork Reduction Act Notice:**

According to the Paperwork Reduction Act of 1995, no persons are
required to respond to a collection of information unless it displays a
valid OMB control number. The valid OMB control number for this
information collection is 1820-0627; approval for this information
collection expires on January 31, 2003. The time required to complete
this information collection is estimated to average six hours per
response, including the time to review instructions, search existing
data resources, gather the data needed, and complete and review the
information collection. If you have any comments concerning the accuracy
of the time estimate(s) or suggestions for improving this form, please
write to: U.S. Department of Education, Washington, D.C. 20202-4651. If
you have comments or concerns regarding the status of your individual
submission of this form, write directly to: Division of Program
Administration, U.S. Department of Education, 330 C Street, S.W., Mary
E. Switzer Building, Room 3211, Washington, D.C. 20202-2716.

**FISCAL YEAR:** Enter the fiscal year covered by this report.

**DESIGNATED AGENCY IDENTIFICATION:** Enter the name, address,
telephone, TTY and fax numbers (including area codes), and e-mail and
website addresses (if applicable) of the agency designated to administer
the PAIR program. Also, enter the names of the Executive Director of the
Protection and Advocacy (P&A) agency, the PAIR director/coordinator (if
applicable), and the person to contact (including telephone number) in
the event questions arise regarding the report.

**[DEFINITIONAL GUIDELINES FOR THIS REPORT]{.underline}**

**I&R SERVICES:** I&R services are those services that include responses
to individuals at meetings, one-time telephone discussions, and
follow-up mailings of letters, brochures and/or pamphlets per an
individual\'s request. These services generally take less than one hour
of service time. PAIR generally would not have personal identifying
information about the individuals who request and/or receive I&R
services, except for possibly the name, address and telephone number.
For purposes of this section of the report, individuals who receive I&R
services are those who do not meet the definition of \"individual
served\" (see definition below).

**INDIVIDUAL SERVED:** To be considered an \"individual served\" (aka a
\"client\" of PAIR), the individual must meet three criteria:

1\. the individual is eligible for PAIR services according to section
509(a) of the Rehabilitation Act of 1973, as amended (Act);

2\. PAIR has opened a case file/service record, which includes at least
the individual\'s name, address, age, race, disability, signed release
of information form (if appropriate), the individual\'s concern or
complaint, and the action taken by PAIR; and

3\. PAIR provided at least one \"significant service,\" such as:

a\. at least one hour of case service time;

b\. a supervised referral that allows follow-up to assure that the
referral was appropriate and completed;

c\. the completion of a second telephone call to the client when the
time between telephone calls was used to obtain additional information
about appropriate programs; or

d\. the provision of any allowable service beyond I&R services, as
defined above.

To satisfy the first criterion above, an individual is eligible for PAIR
services if he/she:

1\. is ineligible for the Protection and Advocacy for Developmental
Disabilities (PADD) program because the individual does not meet the
definition of having a \"developmental disability\" as defined in the
Developmental Disabilities Assistance and Bill of Rights Act;

2\. is ineligible for the Protection and Advocacy for Individuals with
Mental Illness (PAIMI) program because the individual is not an
\"individual with a mental illness\" as defined in the Protection and
Advocacy for Mentally Ill Individuals Act; and

3\. needs services that are beyond the scope of services authorized to
be provided by the Client Assistance Program (CAP) under section 112 of
the Act.

**CASE FILE/SERVICE RECORD:** This is the compilation of personal
identifying information about the individual, documents, letters,
complaints/issues raised, advocate\'s notes, etc., used in working with
an \"individual served\" (as defined above). It may contain many issues
at any one time, In fact, many individuals served will present several
issues to PAIR during the course of the PAIR/client relationship. The
case file/service record is opened at the time PAIR determines that it
will provide at least one \"significant service\" (as defined above) for
the individual. New issues may arise while still working with the
individuals. These new issues, if appropriate for PAIR intervention,
should be added to the existing case file/service record.

**[PART I. NON-CASE SERVICES]{.underline}:**

**A. Individual Information and Referral (I&R) Services:** Include in
this category the number of times that PAIR provided I&R services to
individuals during the fiscal year. Be sure to include only numbers that
reflect I&R services provided by only the PAIR program [not]{.underline}
the P&A agency as a whole. Estimated counts are not acceptable for this
section. All PAIRs should maintain logs to respond accurately to this
section. Such routine requests should not require maintenance of client
confidential information, extensive research by PAIR staff, or extended
contact with the individual. For purposes of this section of the report,
do not include any data regarding I&R services provided to individuals
who meet the definition of \"individual served\" (as defined above).
Services provided to those individuals are recorded in another section
of this report.

When counting follow-up mailings of letters, brochures or pamphlets, be
sure to count only the number of individuals who actually requested the
information, not the number of letters, brochures or pamphlets sent. Do
not include the number of brochures, pamphlets or newsletters that are
routinely distributed en masse or the number of individuals who attend
workshops or trainings presented by PAIR staff. This data will be
collected in another section of this report.

**Line A1:** Enter the number of individuals who received I&R services
from PAIR on issues that were **within** the priorities set by PAIR for
the fiscal year covered by this report. In other words, PAIR was able to
meet these individuals\' needs by providing I&R services only and did
not open a case file/service record for these individuals.

**Line A2:** Enter the number of individuals who received I&R services
from PAIR on issues that were **not** within PAIR\'s priorities for the
fiscal year covered by this report.

**Line A3:** Add lines A1 and A2. This is the total number of
individuals who received I&R services from PAIR during the fiscal year
covered by this report.

**B. Training Activities:** Include in this category information about
the trainings offered by the PAIR program. PAIR staff frequently offer
trainings for individuals with disabilities, their families, and various
community groups. The purpose of these trainings generally is to educate
individuals with disabilities, their families, and members of the
community about the laws protecting individuals with disabilities. These
trainings also often are used to teach self-advocacy skills to
individuals with disabilities and their families.

**Line B1:** Enter the number of trainings and workshops presented by
PAIR staff during the fiscal year covered by this report.

**Line B2:** Enter the number of individuals who attended these
trainings. If PAIR did not maintain registration logs of these trainings
and workshops, it is acceptable to provide an estimate of the number of
individuals who attended the trainings and workshops.

**Descriptive Information:** Describe the trainings and workshops
presented by PAIR staff as completely as possible. For each of the
trainings and workshops presented, be sure to include information
about: 1) the topics and issues covered by the trainings; 2) the
training methods used (i.e., lecture, hands-on learning, etc.); and 3)
the purpose of the training. Please use additional sheets as necessary
to provide this information.

**C. Information Disseminated to the Public:** Include in this category
information that PAIR disseminated to the public at large. In many of
these circumstances, PAIR will be unable to provide the number of
individuals who received the information. Therefore, this data will not
be requested for many of the following items.

**Line C1:** Enter the number of radio and/or TV appearances that PAIR
staff made during the fiscal year covered by this report.

**Line C2:** Enter the number of articles that PAIR staff wrote and had
published in the newspaper, magazines, journals or other periodicals.
Also include on this line the number of articles that were written by
others but that highlighted the work done by PAIR during the fiscal year
covered by this report.

**Line C3:** Enter the number of videos or public service announcements
(PSAs) that were aired pursuant to efforts by PAIR. Do not include the
number of times the videos or PSAs were aired. Instead, count only the
actual number of PSAs or videos that were aired during the fiscal year
covered by this report. For example, the local radio station aired two
of PAIR\'s PSAs about architectural barriers thirty times each. For
purposes of this line entry, there were 2 PSAs aired.

**Line C4:** Enter the number of hits that were made on PAIR\'s (or the
P&A\'s) website (if applicable) during the fiscal year covered by this
report.

**Line C5:** Enter the number of publications, booklets or brochures
that PAIR disseminated during the fiscal year covered by this report.
Include on this line, those brochures, booklets and publications that
were disseminated en masse at trainings or via regular mailings to
PAIR\'s mailing list. Do not include on this line those brochures,
booklets or publications that were disseminated to individuals at the
individual\'s request. This information was collected in category A
above.

**Line C6:** Enter the number of other information, not otherwise
collected in this section of the report, that was disseminated to the
public at large during the fiscal year covered by this report. Be sure
to specify the types of information and the method used to disseminate
this information on a separate sheet.

**[PART II. INDIVIDUALS SERVED]{.underline}:**

**A. Individuals Served:** Include in this category, the number of
individuals to whom PAIR provided advocacy services during this fiscal
year. As stated in the definitional guidelines section above, an
\"individual served\" is someone who is eligible for PAIR services; who
has a case file/service record with PAIR; and who received one or more
significant services from PAIR. All concerns noted in the case
file/service record should have required some type of intervention (even
if it is only brief) that goes beyond the definition of \"I&R\"
services.

An \"individual served\" is counted only once during a fiscal year,
regardless of how many case files/service records were opened/closed for
that individual during the year. Estimated counts are not acceptable.
All PAIRs should maintain logs to respond accurately to this item. Do
[not]{.underline} include in this section any \"I&R services\" provided
to individuals who do not meet the definition of \"individuals served.\"
I&R services provided to those individuals are recorded in an earlier
section of this report.

**Line A1:** Enter the number of individuals who had open case
files/service records on hand at the beginning of the fiscal year, which
were carried over from the prior fiscal year.

**Line A2:** Enter the number of individuals who had new case
files/service records opened during this fiscal year.

**Line A3:** Add lines A1 + A2 and enter the total number here. This is
the total number of individuals served during this fiscal year.
Remember, no individual may be counted more than once in a fiscal year.

**Line A4:** Of the number of individuals accounted for on Line A3
above, enter here the number of those individuals who had more than one
case file/service record opened/closed during the fiscal year.

**Example:** An individual may have received legal advice for one issue
early in the fiscal year. However, a new and unrelated issue arose
several months later (in the same fiscal year) for this individual and
PAIR agreed to represent him/her. Depending on the PAIR program\'s case
management program, this individual may have had two cases opened/closed
during the fiscal year. Thus, this individual would be counted on Line
A4 as having multiple case files/service records during the fiscal year.
If this were the only such individual for PAIR this fiscal year, PAIR
should enter a \"1\" on Line A4.

**B. Individuals Still Served as of September 30:** Enter here the
number of individuals served who still had open case files/service
records with PAIR as of September 30. These are the individuals who need
PAIR intervention to continue into the next fiscal year (carryover) in
order to resolve the problems/issues raised this fiscal year. This
number may not exceed the total number of \"individuals served\" listed
on Line II.A3 above. This number will equal the \"number of individuals
who were still being served as of October 1\" (Line II.A1) on next
fiscal year\'s annual report.

**C. Problem Areas/Complaints of Individuals Served:** Include in this
category the types of problems/complaints that \"individuals served\"
presented to PAIR during this fiscal year. Be sure to include only those
problems/complaints that were directly related to the individual\'s
disability.

**Example:** An individual with a disability may have a housing problem
that is not related in any way to the individual\'s disability. Although
that individual with a disability might otherwise be eligible for PAIR
services, PAIR cannot represent that individual on the housing problem
if that housing problem is not related to the individual\'s disability.
PAIR could, however, represent that same individual on a different
issue, such as employment, that is related to the individual\'s
disability.

The following list contains broad categories of the common types of
complaints/problems individuals served present to PAIR. Please account
for each problem/complaint in the most appropriate category. Multiple
counts are permitted in case one individual presents more than one
problem/complaint for PAIR intervention.

**Line C1:** Enter on this line the number of individuals who sought
PAIR assistance for complaints related to architectural barriers or
other building accessibility problems. These complaints could relate to
any aspect of accessibility to the building or structure, including the
adjoining parking lot or garage, building entrance, interior rooms,
signage, etc. Include on this line complaints for both public and
private buildings/structures.

**Line C2:** Enter on this line the number of individuals who sought
PAIR assistance for complaints related to employment. These employment
complaints may involve such issues as hiring or termination, reasonable
accommodations, supported employment, or employment benefits.

**Line C3:** Enter on this line the number of individuals who sought
PAIR assistance for complaints related to program access. Include on
this line the number of individuals who were denied equal access to a
program due to their disabilities. Examples might an include an
individual who is not allowed to participate in a YMCA program due to a
particular disability or a child who is not allowed to attend camp due
to a disability. Do not enter on this line those complaints that relate
to the accessibility of the building in which the program is housed.

**Line C4:** Enter on this line the number of individuals who sought
PAIR assistance for complaints related to housing. These housing
complaints may involve such issues as contracts/property ownership,
zoning or restrictive covenants, reasonable accommodations,
landlord/tenant, and subsidized or section 8 housing.

**Line C5:** Enter on this line the number of individuals who sought
PAIR assistance for complaints related to government benefits or
services. Include on this line those individuals who had difficulty
securing equal access to a government service or who have problems with
government financial benefits programs, welfare-to-work programs, and
other government programs.

**Line C6:** Enter on this line the number of individuals who sought
PAIR assistance for complaints related to transportation. These
complaints may involve such issues as the accessibility or availability
of accessible public transportation.

**Line C7:** Enter on this line the number of individuals who sought
PAIR assistance for complaints related to education. These education
complaints may involve such issues as IEP planning, development or
implementation; inclusive settings in the schools; availability of
assistive technology and interpreter services and devices in the
schools; discipline, suspension or expulsion; and other
education-related issues. Do not include on this line those complaints
that relate to building accessibility or program access of the school
program. These issues should be counted on lines C1 or C3 above.

**Line C8:** Enter on this line the number of individuals who sought
PAIR assistance for complaints related to assistive technology. These
complaints generally will involve the individual\'s access to needed
assistive technology, such as augmentative communication devices,
durable medical equipment, vehicle modifications, etc.

**Line C9:** Enter on this line the number of individuals who sought
PAIR assistance for complaints related to voting, such as the
accessibility of the voting process for individuals with disabilities.

**Line C10:** Enter on this line the number of individuals who sought
PAIR assistance for complaints related to health care. These complaints
may involve such issues as medicaid problems; access to or denial of
coverage for medical insurance; access to medical or treatment services
or managed care, etc.

**Line C11:** Enter on this line the number of individuals who sought
PAIR assistance for complaints related to insurance. These issues may
include denial of private disability or life insurance coverage due to
the individual\'s disability. Do not include on this line issues related
to medical insurance because those complaints are accounted for on Line
C10 above.

**Line C12:** Enter on this line the number of individuals who sought
PAIR assistance for complaints related to an inability to receive
non-government services. These complaints may involve such issues as
problems with obtaining interpreter services for medical visits; access
to menus in an alternative format; obtaining needed personal assistance
services; etc. This line is distinguished from Line C5 above which
captures all complaints regarding services paid for with government
(Federal, State or local) funds.

**Line C13:** Enter on this line the number of individuals who sought
PAIR assistance for complaints related to privacy rights. These issues
involve some invasion of the individual\'s right of privacy, such as the
release of medical information without the individual\'s consent.

**Line C14:** Enter on this line the number of individuals who sought
PAIR assistance for complaints related to access to records. Include on
this line the number of individuals who were denied access to their
records for some reason related to their disabilities.

**Line C15:** Enter on this line the number of individuals who sought
PAIR assistance for complaints related to abuse. These complaints may
involve such issues as inappropriate or excessive physical restraint,
isolation or seclusion; inappropriate or excessive medication;
involuntary sterilization; failure to provide appropriate medical
treatment; physical or sexual assault; threats of retaliation by
facility staff; coercion; suspicious death; etc.

**Line C16:** Enter on this line the number of individuals who sought
PAIR assistance for complaints related to neglect. These complaints may
involve such issues as the failure to provide appropriate diagnostic
evaluations, personal care, written habilitation plan, adequate
discharge planning, etc.

**Line C17:** Enter on this line the number of individuals who sought
PAIR assistance for complaints not otherwise covered by the above list.
Examples of complaints that PAIR might address, but are not included in
the above listing, are issues related to criminal actions, commitment to
institutions, guardianship/conservatorship, wills, etc. You do
[not]{.underline} need to itemize these \"other\" complaints/problem
areas for purposes of this report.

**D. Reasons for Closing Individual\'s Case Files:** Following is a list
of the various reasons PAIR might give for closing the case file/service
record of an \"individual served.\" Please choose **one** primary (most
appropriate) reason for closing each case file/service record (defined
in the definitional guidelines section of these instructions). Do
[not]{.underline} itemize a reason for resolving each issue raised. This
item asks you to choose one overall reason for closing the entire case
file/service record after PAIR has done all it can for the individual in
terms of resolving the issues/problems/complaints raised by the
individual. The number of case files/service records may, in some
situations, be greater than the total number of individuals served (Line
II.A3) in order to account for those situations, referred to in Line
II.A4, when an individual had multiple case files/service records closed
during the fiscal year. Estimated counts are not acceptable. PAIRs
should maintain records to respond accurately to this item.

**Line D1:** Enter the number of case files/service records that were
closed by PAIR in which all or some of the issues were resolved in the
individual\'s favor.

**Line D2:** Enter the number of case files/service records that were
closed by PAIR because the individual obtained other representation.
Include on this line those times when PAIR referred the individual to
another advocate/attorney, as well as those times when the individual
decided to seek representation by someone other than a PAIR
advocate/attorney.

**Line D3:** Enter the number of case files/service records that were
closed by PAIR because the individual withdrew the complaint because
he/she did not want to pursue resolution of the problem at this time. In
these situations, the individual simply wanted to \"forget it.\"

**Line D4:** Enter the number of case files/service records that were
closed by PAIR because the individual had exhausted all available or
appropriate formal appeal procedures and did not prevail. The appeal
procedures relevant to this item include formal administrative hearings
and legal remedies. For example, PAIR may choose to close a case
file/service record for this reason if the individual served did not
prevail at the formal administrative hearing and the case lacks merit
for judicial review. PAIR also may choose to close a case file/service
record for this reason if the individual served did not prevail at the
formal administrative hearing and judicial review is not allowed under
the State\'s Administrative Procedures Act (APA).

**Line D5:** Enter the number of case files/service records that were
closed by PAIR because the individual no longer needed PAIR services due
to the individual\'s death, relocation, etc. In other words, the
individual is no longer available for representation by PAIR.

**Line D6:** Enter the number of case files/service records that were
closed by PAIR because PAIR withdrew from the case. Generally, a
withdrawal occurs when the consumer-advocate relationship has
deteriorated to the point that PAIR cannot continue effective
representation. Some of the reasons might have been that the individual
refused to: a) give PAIR access to all necessary information; b) follow
or accept PAIR\'s advice; or c) follow through on the individual\'s
obligations in some way.

**Line D7:** Enter the number of case files/service records that were
closed by PAIR because the PAIR lacks sufficient staff or resources to
represent the individual.

**Line D8:** Enter the number of case files/service records that were
closed by PAIR because PAIR has determined, after exploring the facts
and the law further, that the individual\'s complaint lacked legal
merit.

**Line D9:** Enter the number of case files/service records that were
closed by PAIR for a reason that is not listed above. RSA has attempted
to list all of the possible reasons PAIR could cite for closing a case
file/service record. However, we realize there may be some circumstances
not encompassed in this listing. This response should be reserved for
rare instances when a reason for closure clearly does not fit into any
of the above categories. Be sure to attach a separate explanation of the
circumstances for the case closure if you use this response.

**E. Intervention Strategies Used in Serving Individuals:** PAIRs engage
in a variety of intervention strategies to resolve complaints raised by
the individuals served. Following is a listing of the categories of
services that PAIR can provide to an individual served in attempting to
resolve a complaint. Although PAIRs generally provide more than one type
of service during the PAIR/client relationship, this report form asks
you to choose **one** primary service that PAIR provided to the
individual before closing the case file/service record. Choose the
**highest** level of intervention strategy used by PAIR on behalf of the
individual served to resolve the complaint.

As stated in earlier sections of these instructions, the number of case
files/service records may be greater than the total number of
individuals served (Line II.A3) in order to account for those
situations, referred to in Line II.A4, when an individual had multiple
case files/service records closed during the fiscal year. Estimate
counts are not acceptable. PAIRs should maintain records to respond to
this item accurately.

> **Example 1:** PAIR may have engaged in investigation, negotiation,
> and ADR activities on behalf of an individual served in order to
> resolve the complaint. PAIR provided all three of these services
> during the course of one case file/service record. PAIR should account
> for this individual on Line E5 (Mediation/ADR) since this was the
> highest level of service provided to this particular individual.
>
> **Example 2:** PAIR may have opened and closed two different case
> files/service records on behalf of an individual served during the
> fiscal year. During the course of working with the individual in the
> first case file/service record, PAIR provided only short-term
> assistance and advice. However, in the second case file/service
> record, PAIR represented the individual at a formal administrative
> hearing. PAIR should account for this individual on Line E2
> (short-term assistance) for the first case file/service record **and**
> Line E6 (administrative hearings) for the second case file/service
> record.

**Line E1:** Enter the number of case files/service records closed in
which the highest level of service (intervention strategy) provided by
PAIR was technical assistance to the individual to enable him/her to
engage in self-advocacy.

**Line E2:** Enter the number of case files/service records closed in
which the highest level of service (intervention strategy) provided by
PAIR was short-term assistance. In these cases, PAIR was able to assist
the individual simply by providing legal advice or extended I&R
services. The individual did not need other PAIR services.

**Line E3:** Enter the number of case files/service records closed in
which the highest level of service (intervention strategy) provided by
PAIR was investigating or monitoring a particular situation. In these
cases, PAIR was able to assist the individual by merely investigating
the complaint or monitoring a situation or facility. No other services
were needed by PAIR.

**Line E4:** Enter the number of case files/service records closed in
which the highest level of service (intervention strategy) provided by
PAIR was negotiation. In these cases, PAIR was able to effect a
resolution for the individual by engaging in negotiation with the
adverse party in an informal environment. No other PAIR services were
needed.

**Line E5:** Enter the number of case files/service records closed in
which the highest level of service (intervention strategy) provided by
PAIR was mediation or another form of alternative dispute resolution
(ADR) procedure. In these cases, PAIR assisted the individual by
engaging in mediation or another form of ADR to resolve the dispute
between the individual and another party.

**Line E6:** Enter the number of case files/service records closed in
which the highest level of service (intervention strategy) provided by
PAIR was representation at a formal administrative hearing. In these
cases, PAIR may have assisted the individual in requesting, preparing
for, or participating in a formal administrative hearing. Do not include
any legal services provided (i.e., in a judicial setting).

**Line E7:** Enter the number of case files/service records closed in
which the highest level of service (intervention strategy) provided by
PAIR was representation in litigation. In these cases, PAIR assisted the
individual in pursuing legal recourse in the judicial system to resolve
the individual\'s complaint. Include on this line any case files/service
records that were part of a class action.

**Line E8:** Enter the number of case files/service records closed in
which the highest level of service (intervention strategy) provided by
PAIR was to engage in systemic or other policy-making activities to
resolve the individual\'s complaint. For example, PAIR may have been
successful in changing an agency policy on a particular issue, raised by
many individuals, without resorting to formal administrative or legal
remedies. Case files/service records that were closed because PAIR was
able to resolve the matter through these systemic efforts should be
counted on this line.

**F. Satisfaction of Individuals Served:** The Government Performance
and Results Act (GPRA) requires Federal agencies to focus on outcomes
and results regarding the programs they fund. In light of these new GPRA
standards, RSA has identified client satisfaction as one indicator it
will examine when analyzing the effectiveness of PAIR. Therefore, RSA
has added this new data element to the annual PAIR report form. RSA has
drafted a very simple model survey for the convenience of PAIR programs.
You may use this model survey or adopt a similar one for your own use.
It is important that the survey used captures the data elements required
in this reporting form.

RSA is requiring that all PAIR programs send each \"individual served\"
(as defined earlier in these instructions) a \"satisfaction survey\" at
the time of closing the case file/service record. PAIRs should encourage
individuals served to respond to these surveys. RSA suggests that the
survey be made intentionally short and simple and that the respondents
be kept anonymous in order to encourage a large percentage of responses.
RSA also encourages PAIR programs to use these survey results for their
own program improvement.

**Line F1:** Enter the number of satisfaction surveys mailed. PAIRs
should send a satisfaction survey to each individual served at the time
the case file/service record is closed.

**Line F2:** Enter the number of satisfaction surveys that were returned
to the PAIR program. This is the number on which the rest of the
questions in this section are based.

**Line F3:** Enter the number of surveys returned according to how the
responded indicated his/her overall satisfaction with the PAIR program.
The total number of responses for the three categories of \"not
satisfied,\" \"satisfied,\" and \"very satisfied\" cannot exceed the
number of surveys actually returned to the PAIR and listed on Line F2
above.

**Line F4:** Enter the number of surveys returned to PAIR according to
whether the individual served would use PAIR services again. The total
for this entire question cannot exceed the total number of satisfaction
surveys actually returned to the PAIR as indicated on Line F2 above.

**[PART III. STATISTICAL INFORMATION ON INDIVIDUALS
SERVED]{.underline}:**

The items in this section are based on statistical information learned
about the \"individuals served\" (as defined earlier in these
instructions). Each individual may be counted only once during a fiscal
year, for statistical purposes, regardless of how many case
files/service records were opened/closed. Estimated counts are not
acceptable for the items in these sections. All PAIRs should maintain
records to respond to these items accurately.

**A. Age of Individuals Served:** Enter the number of individuals served
in each of the age categories listed on the form. Record the
individual\'s age as of the beginning of the fiscal year (as of October
1). No individual may be counted more than once for purposes of
reporting the age of individuals served in this section.

**B. Gender of Individuals Served:** Enter the number of individuals
served according to their gender. Do not count an individual more than
once in this section, regardless of the number of case files/service
records that were opened/closed on the individual\'s behalf.

**C. Race/Ethnicity of Individuals Served:** Enter the number of
individuals served according to their stated racial or ethnic origin. An
individual **may** be counted more than once, for purposes of reporting
his/her race/ethnicity on this form, in order to account for those
individuals who consider themselves multicultural/racial.

**Line C1:** Enter the number of individuals served who consider
themselves to be White or Caucasian.

**Line C2:** Enter the number of individuals served who consider
themselves to be Black or African-American. Include on this line
individuals who may be African, Jamaican, etc.

**Line C3:** Enter the number of individuals served who consider
themselves to be an American Indian or Alaska Native.

**Line C4:** Enter the number of individuals served who consider
themselves to be Asian. Do not include on this line those individuals
who consider themselves only to be Native Hawaiian or another Pacific
Islander. These individuals will be counted on Line C5.

**Line C5:** Enter the number of individuals served who consider
themselves to be a Native Hawaiian or other Pacific Islander.

**Line C6:** Enter the number of individuals served who consider
themselves to be Hispanic or Latino.

**Line C7:** Enter the number of individuals served whose race or
ethnicity is unknown. This line rarely should be marked. As stated in
the definitional guidelines section earlier in these instructions,
information about the individual\'s race/ethnicity should be included in
every case file/service record that PAIR opens.

**D. Living Arrangements of Individuals Served:** Include in this
category information about the living arrangements for all individuals
served by PAIR during this fiscal year. An individual served may be
counted only once, for purposes of reporting information about his/her
living arrangements.

**Line D1:** Enter the number of individuals served who live
independently. These individuals may live alone or may share housing
with a roommate, spouse or significant other. The key here is that the
individual is responsible for his/her own housing.

**Line D2:** Enter the number of individuals served who live with their
parents or with another relative.

**Line D3:** Enter the number of individuals served who live in a
community residential home, such as a group home of some kind.

**Line D4:** Enter the number of individuals served who live in a foster
care setting and are part of the State\'s foster care system.

**Line D5:** Enter the number of individuals served who live in a public
or private nursing home.

**Line D6:** Enter the number of individuals served who live in some
public institution (i.e., hospital). Do not include those individuals
who live in a public nursing home because these individuals are counted
on Line D5.

**Line D7:** Enter the number of individuals served who live in a
private institution (i.e., hospital). Do not include those individuals
who live in a private nursing home because these individuals are counted
on Line D5.

**Line D8:** Enter the number of individuals served who live in a jail,
prison, or some other detention center,

**Line D9:** Enter the number of individuals served who are homeless.
These individuals may spend an occasional night with friends or
relatives or in a shelter; however, they have no real address.

**Line D10:** Enter the number of individuals served who have some other
living arrangement that is not listed in this section.

**Line D11:** Enter the number of individuals served for whom PAIR has
no information about their living arrangements.

**E. Primary Disability of Individuals Served:** Include in this
category information about the primary disabilities of the individuals
served by PAIR. The primary disability, for purposes of this report, is
the individual\'s disability that is directly related to the issues or
complaints raised by the individual served.

**Example 1:** An individual is deaf and also has an orthopedic
impairment that requires the use of a wheelchair. The individual has
come to PAIR because the local pizzeria is inaccessible for
wheelchair-users. PAIR should account for this individual on Line E4
(orthopedic impairment) because the issue raised focuses on building
accessibility problems. The fact that the individual also is deaf has no
bearing on this particular complaint.

**Example 2:** Let\'s say the same individual as described above came to
PAIR for a different problem, namely a complaint that the county
hospital refused to provide an interpreter to explain the diagnostic
testing she was to undergo. In this case, PAIR should count this
individual on Line E2 (deaf/hearing impairment) because the issue dealt
with interpreter services. The fact that the individual also has an
orthopedic impairment has no bearing on this particular complaint.

**Line E1:** Enter the number of individuals served who are blind or
have some visual impairment.

**Line E2:** Enter the number of individuals served who are deaf or are
hard-of-hearing.

**Line E3:** Enter the number of individuals served who are deaf-blind.
These individuals meet the criteria for both deafness and blindness.

**Line E4:** Enter the number of individuals served who have an
orthopedic impairment. These individuals may be missing a limb, may be
paralyzed, or may have some other functional impairment involving the
limbs, digits, trunk, back or spine.

**Line E5:** Enter the number of individuals served who have a mental
illness.

**Line E6:** Enter the number of individuals served who have alcohol
and/or drug addictions.

**Line E7:** Enter the number of individuals served with any degree of
mental retardation (i.e., mild, moderate, severe/profound).

**Line E8:** Enter the number of individuals served with any form of
learning disability.

**Line E9:** Enter the number of individuals served with any form of a
neurological impairment.

**Line E10:** Enter the number of individuals served who are disabled
from any respiratory system impairment/condition.

**Line E11:** Enter the number of individuals served who are disabled
from any cardiac or other circulatory system impairment or condition.

**Line E12:** Enter the number of individuals served with any form of a
muscular/skeletal impairment.

**Line E13:** Enter the number of individuals served with speech
impairments, such as cleft palate and harelip with speech imperfections,
laryngectomies, stuttering, etc.

**Line E14:** Enter the number of individuals served who are infected
with the human immunodeficiency virus (HIV), regardless of whether the
individual is symptomatic or asymptomatic.

**Line E15:** Enter the number of individuals served whose disabling
condition or functional limitation is caused by traumatic brain injuries
(TBI).

**Line E16:** Enter the number of individuals served who have other
impairments or disabling diseases or conditions that are not covered by
the above categories.

**[PART IV. SYSTEMIC ACTIVITIES AND LITIGATION]{.underline}:**

**A. Systemic Activities:** The information collected in this category
of the report focuses on PAIR\'s systemic activities in general. This
category goes beyond any systemic efforts made on behalf of
\"individuals served\" (as defined earlier in these instructions).
Estimated counts are appropriate for this category. However, PAIR must
be able to demonstrate a reasonable basis for the estimate.

**Line A1:** Enter the number of policies or practices that were changed
as a result of systemic activities. Do not include those policies or
practices that were changed as a result of litigation because those will
be collected in category IV.B.

**Example:** PAIR focused much of its systemic efforts this year on
discriminatory questions contained in State professional licensure
applications. PAIR successfully negotiated with the State Supreme Court
and with the State Nursing Board to change a question regarding mental
illness on their applications. For purposes of this example, PAIR would
enter \"2\" on Line A1.

**Line A2:** Enter the approximate number of individuals who will
benefit by the changes made in policy or practice, as reported in Line
A1 above.

**Example:** Let\'s say that 25 percent of the applicants for the State
bar and nursing licenses have historically been individuals with mental
illness. There generally are 600 total attorney applicants and 300 nurse
applicants in any given year. This means that 150 attorney applicants
and 75 nurse applicants could potentially benefit from the changes made
that were reported in Line A1. The PAIR would report \"225\" on Line A2,
for purposes of this example.

**Narrative regarding Systemic Activities:** Describe the systemic
activity undertaken. Identify the policies and practices that were
problematic and explain why they were problematic. Describe the systemic
activities PAIR engaged in to change these policies or practices. Be
sure to include information about how these changes will benefit
individuals with disabilities in the State. Include case examples of how
your systemic activities impacted the individuals served by PAIR. As
appropriate, provide PAIR\'s plans for continuing to address these
issues during the next fiscal year. Use additional sheets as needed.

**B. Litigation/Class Actions:** This category focuses on the changes
that PAIR effected by engaging in litigation on behalf of an individual
or in a class action on behalf of many individuals.

**Line B1:** Enter the number of individuals who potentially will
benefit from a change brought about as a result of PAIR\'s litigation
efforts.

**Example:** Let\'s say that PAIR sued the State Board of Medicine, via
a class action in which 12 plaintiffs were named, for its discriminatory
questions regarding mental illness on its physician license
applications. The plaintiffs won. The Court ruled that the Board must
modify its application to delete the offending question. Historically,
20 percent of the State\'s 200 physician applicants have been
individuals with mental illness. This means that potentially 40
individuals could benefit from this court-ordered change this year. For
purposes of this example, PAIR would report 40 on line B1.

**Line B2:** Enter the number of individuals named in any class actions
handled by PAIR during the fiscal year.

**Example:** Using the above example here, PAIR would report \"12\" on
this line because there were 12 named plaintiffs in that class action.

**Narrative regarding Litigation/Class Actions:** Describe your
litigation/class action activities. Be sure to identify the issue that
prompted the litigation and explain how individuals with disabilities
were impacted negatively. Explain how individuals with disabilities
benefited from your litigation activities. Be sure to include case
examples that demonstrate the impact of your litigation. Use additional
sheets as necessary.

**[PART V. PAIR\'S PRIORITIES AND OBJECTIVES]{.underline}:**

Be sure to provide the information requested in this category for
**each** of the priorities and objectives set by PAIR for the fiscal
year covered by this report. The information requested is as follows:

1\. Identify and describe the priority. Be sure to include enough
information so that the issue is clear.

2\. Identify the need, issue, or barrier addressed by this priority. It
is not enough to identify an issue as a priority. You must explain why
this issue is a priority and the desired effect it will have on
individuals with disabilities.

**Example:** Let\'s say that PAIR identified discriminatory questions on
State professional licensure applications as a priority. The barrier
that will be addressed by this priority is that a significant percentage
of the applicants is routinely denied a license because of a particular
disability. Thus, a significant population is denied access to certain
professional fields in the State.

3\. Identify the indicators PAIR used to determine whether it was
successful in terms of an outcome with this priority. In the above
example, one indicator could be that PAIR was successful in getting the
discriminatory questions removed from the applications.

4\. Explain whether pursuing this priority involved collaborative
efforts by other entities or programs. For example, PAIR may work with
PAIMI or PADD or CAP to bring about systemic change for one of its
priorities. Be sure to describe these joint efforts, if appropriate.
Explain the role each program played and the activities pursued by each.

5\. Provide the number of cases handled under the priority. This number
can be derived from determining the number of \"individuals served\"
(from Line II.A3) whose problem/complaint involved this priority.
Specify if any of these \"individuals served\" were part of a class
action handled by the PAIR.

6\. Provide at least one case summary that demonstrates the impact of
the priority. Identify the facts and issue of the case, the resolution
of that case, and how the individual served benefited.

**[PART VI. NARRATIVE]{.underline}:**

At a minimum, you must provide the information requested for the
narrative portion of this report. You may include any other information,
not otherwise collected on this reporting form, that would be helpful in
describing the extent of activities performed by the PAIR program during
the fiscal year. Please limit the narrative portion of this report,
including attachments, to 20 pages or less.

The information requested is as follows:

**A. Sources of funds received and expended: Provide** the amount of
funds the PAIR program received from each of the sources indicated
during the fiscal year covered by this report. In addition, specify the
total amount expended, from each of the sources of funds, in providing
services to PAIR-eligible individuals. Provide this information even if
the PAIR\'s only source of funding is the Federal formula grant under
section 509 of the Act. The following chart is recommended when
providing this information:

  ----------------------- ------------------------ -----------------------
  **Source of Funding**   **Amount Received**      **Amount Spent**

  Federal (section 509)                            

  State                                            

  Program income                                   

  Private                                          

  All other funds                                  

  Total (from all                                  
  sources)                                         
  ----------------------- ------------------------ -----------------------

The \"all other\" category above is broad. It includes funds from local
governments, earned income (i.e., legal fees), charitable contributions,
and other grants or contracts. This category does not include in-kind
donations. However, it is hoped that PAIRs will collect this information
separately if appropriate.

**B. Budget for the fiscal year covered by the report:** Outline the
budget for the fiscal year covered by the report (prior fiscal year), as
well as a projection for the current fiscal year. Be sure to include a
breakdown of dollars expended/allotted for: administrative costs (i.e.,
personnel salaries, equipment, etc.); services to individuals; and other
expenses (i.e., staff training, travel, etc.). The following chart is
recommended:

  ----------------------- ----------------------- -----------------------
  **Category**            **Prior Fiscal Year**   **Current Fiscal Year**

  Wages/salaries                                  

  Fringe benefits (FICA,                          
  unemployment, etc.)                             

  Materials/supplies                              

  Postage                                         

  Telephone                                       

  Rent                                            

  Travel                                          

  Copying                                         

  Bonding/insurance                               

  Equipment                                       
  (rental/purchase)                               

  Legal services                                  

  Indirect costs                                  

  Miscellaneous                                   

  Total Budget                                    
  ----------------------- ----------------------- -----------------------

**C. Description of PAIR staff:** Provide a description of the PAIR
staff in terms of \"person-years\" and duties. \"Person-years\" refer to
the actual time that positions (both professional and clerical) were
filled during the period covered by this annual report. If a position
was filled throughout the year, it counts as one person-year. For those
positions that were filled for only a fraction of the year, you will
have to calculate the \"person-year\" for that position by first
calculating the \"full-time equivalents (FTEs)\" for that position.
Person-years should be reported for all PAIR personnel whose salaries
are paid fully or partially by section 509 funds. Be sure to include an
explanation of the number of full-time part-time, and vacant positions.

**Example 1 on how to calculate person-years:** PAIR has two full-time
attorneys. Both positions were filled all year. The person-year
calculation for full-time professional staff is 2.

**Example 2:** PAIR has two full-time attorneys. One position was filled
all year; the second was filled only for 6 months. The person-year
calculation for full-time professional staff is 1 + .5 (1 FTE times 50%
of the year) = 1.5. The vacant position category would be reported as
follows: 1 FTE times 50% of the year = .5 person-years.

The following chart is recommended:

  ------------------ ----------------- ----------------- ------------------
  **Type of          **FTE**           **% of year       **Person-years**
  Position**                           filled**          

  **Professional**                                       

  Full-time                                              

  Part-time                                              

  Vacant                                                 

  **Clerical**                                           

  Full-time                                              

  Part-time                                              

  Vacant                                                 
  ------------------ ----------------- ----------------- ------------------

**D. Involvement with advisory boards:** Identify in what ways, if any,
is PAIR involved with advisory boards. Include here any information
regarding PAIR\'s involvement with the P&A\'s advisory board (if
applicable).

**E. Grievances filed:** The Act requires that PAIR establish a
grievance procedure to handle any complaints by clients regarding the
services received/not received from PAIR. Provide a description of the
issues involved in any grievances filed against PAIR during the fiscal
year covered by this report. Explain why the individual filed the
grievance and describe the outcome of the grievance process for each
complaint. You should not include personally-identifying information
regarding the individual served.

**F. Coordination with the CAP and the State long-term care program:**
In some States, the CAP and the State\'s long-term care programs are not
part of the designated P&A agency, which administers the PAIR program.
However, the Act mandates that PAIR coordinate its activities with the
CAP and the long-term care programs. If the CAP and/or the long-term
care program is not a part of your P&A, describe how PAIR coordinates
its activities with those entities.

**[END OF FORM]{.underline}:**

**Signature:** The form should be signed by a P&A official who has
responsibility for the completion of the form and who can verify its
accuracy.

**Date:** Enter the month, day and year in which you send the form to
RSA.

**Transmittal:** The PAIR annual report should be sent within 90 days
after the fiscal year covered by this report. Reports may be sent by
mail or electronically using one of the options listed below. If you
have questions regarding filling out this form, contact Roseann Eshbach
in central office at 202-205-9315.

**A. Electronic Mail addresses via Internet:**

The RSA central office internet e-mail address for PAIR annual report
form is:

gloria_sommerville@ed.gov

For information about filling out the PAIR annual report form, the RSA
central office internet e-mail address is:

roseann_eshbach@ed.gov

Regional office e-mail addresses are as follows:

  ----------------- -----------------------------------------------------
  **Regional        **Individual**
  Office**          

  I & II            john_szufnarowski@ed.gov

  III & IV          ralph_pacinelli@ed.gov

  V & VII           douglas_burleigh@ed.gov

  VI & VIII         loerance_deaver@ed.gov

  IX & X            gilbert_williams@ed.gov
  ----------------- -----------------------------------------------------

**B. Transmittal via Mail and Fax:**

If you submit the PAIR annual report by mail or fax, please send one
copy to the RSA central office and the appropriate regional office, as
listed below:

RSA Central Office:

Rehabilitation Services Administration

Financial Management & Information Systems Staff

Data Management Unit

Room 3042, MES Building

Washington, DC 20202-2703

Fax: 202-205-9772

RSA Regional Office addresses are as follows:

**Region I**

Mr. John J. Szufnarowski

RSA Regional Commissioner

Dept. of Education, OSERS

J.W. McCormack Post Office and Courthouse, Room 232

Boston, Massachusetts 02109

Fax: 617-223-4573

**Region II**

Mr. John J. Szufnarowski

RSA Regional Commissioner

Dept. of Education, OSERS

75 Park Place, Room 1236

New York, New York 10007

Fax: 212-264-3029

**Region III**

Dr. Ralph N. Pacinelli

RSA Regional Commissioner

Dept. of Education, OSERS

The Wanamaker Building, Suite 512

100 Penn Square East

Philadelphia, Pennsylvania 19107

Fax: 215-656-6188

**Region IV**

Dr. Ralph N. Pacinelli

RSA Regional Commissioner

Dept. of Education, OSERS

61 Forsyth Street, S.W., Room 18-T-91

Atlanta, Georgia 30303-3104

Fax: 404-562-6346

**Region V**

Dr. Douglas Burleigh

RSA Regional Commissioner

Dept. of Education, OSERS

111 N. Canal, Room 1048

Chicago, Illinois 60606-7204

Fax: 312-353-8623

**Region VI**

Mr. Loerance Deaver

RSA Regional Commissioner

Dept. of Education, OSERS

Harwood Center, Suite 2740

1999 Bryan Street

Dallas, Texas 75201-6817

Fax: 214-880-4931

**Region VII**

Dr. Douglas Burleigh

RSA Regional Commissioner

Dept. of Education, OSERS

10220 N. Executive Hills Boulevard

Kansas City, Missouri 64153-1367

Fax: 816-891-0807

**Region VIII**

Mr. Loerance Deaver

RSA Regional Commissioner

Dept. of Education, OSERS

Federal Office Building, Suite 310

1244 Speer Boulevard

Denver, Colorado 80204-3582

Fax: 303-844-6269

**Region IX**

Mr. Gilbert \"Doc\" Williams

RSA Regional Commissioner

Dept. of Education, OSERS

Federal Office Building, Room 215

50 United Nations Plaza

San Francisco, California 94102

Fax: 415-437-7848

**Region X**

Mr. Gilbert \"Doc\" Williams

RSA Regional Commissioner

Dept. of Education, OSERS

915 Second Avenue, Room 2848

Seattle, Washington 98174-1099

Fax: 206-220-7842