# Reporting Instrument

> OMB Control Number: 1820-0606
>
> Expiration Date: July 31, 2011

**UniTed States Department of Education**

###### Office of Special Education and RehabilitatiVE Services

**Rehabilitation Services Administration**

**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:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

# 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]{.underline} CSRs |              |
| > carried over from September 30 of the preceding     |              |
| > reporting year                                      |              |
+-------------------------------------------------------+--------------+
| > \(2\) Enter the number of CSRs started since        |              |
| > October 1 of the reporting year                     |              |
+-------------------------------------------------------+--------------+
| > \(3\) Add lines (1) and (2) to get the ***total     |              |
| > number of consumers served***                       |              |
+-------------------------------------------------------+--------------+

## Section B --Number of CSRs Closed by September 30 of the Reporting Year

Include the number of consumer records closed out of the active CSR
files during the reporting year because the individual has:

+-------------------------------------------------------+--------------+
|                                                       | **\# of      |
|                                                       | CSRs**       |
+-------------------------------------------------------+--------------+
| (1) Moved                                             |              |
+-------------------------------------------------------+--------------+
| (2) Withdrawn                                         |              |
+-------------------------------------------------------+--------------+
| (3) Died                                              |              |
+-------------------------------------------------------+--------------+
| (4) Completed all goals set                           |              |
+-------------------------------------------------------+--------------+
| (5) Other                                             |              |
+-------------------------------------------------------+--------------+
| (6) Add lines (1)+(2)+(3)+(4)+(5) to get ***total     |              |
|     CSRs closed***                                    |              |
+-------------------------------------------------------+--------------+

## 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**  |
+-------------------------------------------------------+--------------+
| (1) Number of consumers who signed a waiver           |              |
+-------------------------------------------------------+--------------+
| (2) Number of consumers with whom an ILP was          |              |
|     developed                                         |              |
+-------------------------------------------------------+--------------+
| (3) ***Total number of consumers*** served during the |              |
|     reporting year                                    |              |
+-------------------------------------------------------+--------------+

## Section E -- Age

Indicate the number of consumers in each category below.

+-------------------------------------------------------+--------------+
|                                                       | **\# of      |
|                                                       | Consumers**  |
+-------------------------------------------------------+--------------+
| (1) Under 5 years old                                 |              |
+-------------------------------------------------------+--------------+
| (2) Ages 5 -- 19                                      |              |
+-------------------------------------------------------+--------------+
| (3) Ages 20 -- 24                                     |              |
+-------------------------------------------------------+--------------+
| (4) Ages 25 -- 59                                     |              |
+-------------------------------------------------------+--------------+
| (5) Age 60 and Older                                  |              |
+-------------------------------------------------------+--------------+
| (6) Age unavailable                                   |              |
+-------------------------------------------------------+--------------+

## Section F -- Sex

Indicate the number of consumers in each category below.

+-------------------------------------------------------+--------------+
|                                                       | **\# of      |
|                                                       | Consumers**  |
+-------------------------------------------------------+--------------+
| (1) Number of Females served                          |              |
+-------------------------------------------------------+--------------+
| (2) Number of Males served                            |              |
+-------------------------------------------------------+--------------+

## 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).***

**This section reflects a new OMB directive.**

**Please refer to the Instructions before completing.**

  ------------------------------------------------------ ----------------
                                                         **\# of
                                                         Consumers**

  \(1\) American Indian or Alaska Native                 

  \(2\) Asian                                            

  \(3\) Black or African American                        

  \(4\) Native Hawaiian or Other Pacific Islander        

  \(5\) White                                            

  \(6\) Hispanic/Latino of any race or Hispanic/ Latino  
  only                                                   

  \(7\) Two or more races                                

  \(8\) Race and ethnicity unknown                       
  ------------------------------------------------------ ----------------

## Section H -- Disability

Indicate the number of consumers in each category below.

+-------------------------------------------------------+--------------+
|                                                       | **\# of      |
|                                                       | Consumers**  |
+-------------------------------------------------------+--------------+
| (1) Cognitive                                         |              |
+-------------------------------------------------------+--------------+
| (2) Mental/Emotional                                  |              |
+-------------------------------------------------------+--------------+
| (3) Physical                                          |              |
+-------------------------------------------------------+--------------+
| (4) Hearing                                           |              |
+-------------------------------------------------------+--------------+
| (5) Vision                                            |              |
+-------------------------------------------------------+--------------+
| (6) Multiple Disabilities                             |              |
+-------------------------------------------------------+--------------+
| (7) Other                                             |              |
+-------------------------------------------------------+--------------+

##  

## 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

**Subpart III contains new data requests. 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 | *Consumers |
|                                            | Re         | Receiving  |
|                                            | questing** | Services** |
|                                            |            |            |
|                                            | **         |            |
|                                            | 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 | **Goals | **In    |
|                                      | Set**   | Ach     | Pro     |
|                                      |         | ieved** | gress** |
+======================================+=========+=========+=========+
| (A) Self-Advocacy/Self-Empowerment   |         |         |         |
+--------------------------------------+---------+---------+---------+
| (B) Communication                    |         |         |         |
+--------------------------------------+---------+---------+---------+
| (C) Mobility/Transportation          |         |         |         |
+--------------------------------------+---------+---------+---------+
| (D) Community-Based Living           |         |         |         |
+--------------------------------------+---------+---------+---------+
| (E) Educational                      |         |         |         |
+--------------------------------------+---------+---------+---------+
| (F) Vocational                       |         |         |         |
+--------------------------------------+---------+---------+---------+
| (G) Self-care                        |         |         |         |
+--------------------------------------+---------+---------+---------+
| (H) Information Access/Technology    |         |         |         |
+--------------------------------------+---------+---------+---------+
| (I) Personal Resource Management     |         |         |         |
+--------------------------------------+---------+---------+---------+
| (J) Relocation from a Nursing Home   |         |         |         |
|     or Institution to                |         |         |         |
|     Community-Based Living           |         |         |         |
+--------------------------------------+---------+---------+---------+
| (K) Community/Social Participation   |         |         |         |
+--------------------------------------+---------+---------+---------+
| (L) 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          **\# of          **\# of
                         Consumers        Consumers        Consumers Whose
                         Requiring        Achieving        Access is in
                         Access**         Access**         Progress**
  ---------------------- ---------------- ---------------- ----------------
  \(A\) Transportation                                     

  \(B\) Health Care                                        
  Services                                                 

  \(C\) Assistive                                          
  Technology                                               
  -------------------------------------------------------------------------

[Note:]{.underline} 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 **FTEs Filled by **FTEs Filled
                             Of FTEs**      Individuals with by Individuals
                                            Disabilities**   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)

**This section contains new data requests. 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   **Activity   **Hours   **Objective(s)**      **Outcomes(s)**
  Area**    Type**       Spent**                         

                                                         

                                                         

                                                         

                                                         

                                                         

                                                         
  --------- ------------ --------- --------------------- ---------------------

### 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
  ------------------------------------------------------ ----------------