UNITED STATES DEPARTMENT OF EDUCATION

OFFICE OF SPECIAL EDUCATION AND

REHABILITATIVE SERVICES

REHABILITATION SERVICES ADMINISTRATION

WASHINGTON, DC 20202-2741

[POLICY DIRECTIVE]{.underline}

RSA-PD-99-02

RSM-0501

DATE: 12/10/98

ADDRESSEES: STATE VOCATIONAL REHABILITATION AGENCIES (GENERAL)

> STATE VOCATIONAL REHABILITATION AGENCIES (BLIND)

STATEWIDE INDEPENDENT LIVING COUNCILS

> CENTERS FOR INDEPENDENT LIVING
>
> CLIENT ASSISTANCE PROGRAMS

RSA SENIOR MANAGEMENT TEAM

SUBJECT: Section 704 Annual Performance Report

POLICY

STATEMENT: This transmits the Section ()704 Annual Performance Report
consisting of two parts and instructions for the completion and
submittal of the Reports for the State Independent Living Services
(SILS), and Centers for Independent Living (CIL) programs. OMB approval
number for this report form is 1820-0606.

The purpose of this report is to:

> o Serve as a performance measuring instrument of independent living
> (IL) programs, both quantitatively and qualitatively;
>
> o Determine the training and technical assistance needs of Statewide
> Independent Living Councils (SILCs) and Centers for Independent Living
> (CILs) as required by section 721(b)(3) of the Act;
>
> o Determine CIL compliance with the standards, assurances, and
> indicators of compliance with the standards in section 725 of the Act
> and 34 CFR Part 366;
>
> o Collect information necessary for issuance of continuation awards
> for qualified CILs funded under the CIL program;
>
> o Collect the data required by sections 13, 706, 721, and 725 of the
> Rehabilitation Act of 1973, as amended (Act) for the State Independent
> Living Services (SILS) program and the Centers for Independent Living
> (CIL) programs;
>
> o Serve as the basis for on-site reviews of the Chapter 1, Title VII
> of the Act program grantees; and
>
> o Obtain a report from Statewide Independent Living Councils and
> Designated State Units regarding their activities in the State plan
> for independent living development, administration, monitoring, and
> evaluation, including an assessment of consumer satisfaction with the
> IL programs in the States.
>
> Several significant changes have been made in the Report from the
> prior version. These changes include: 1. Numerous small wording
> changes designed to increase the readability of the form; 2.
> Additions: a question to measure how many individuals were assisted in
> leaving nursing homes and other institutions, a question to measure
> how many individuals received services that prevented them having to
> move into a nursing home or other institution, a consumer satisfaction
> reporting requirement, a requirement for CILs to report how many
> individuals received services, by county; 3. Deletions: reporting the
> length of time a consumer service record is open, reporting consumer
> living arrangements, and the question related to funding sources for
> personal assistance. 4. There are two OMB approved versions of the 704
> Report, Part II, one with Statutory and regulatory citations and
> another without citations. The version without citations was created
> in response to requests from several CILs.

CITATIONS

IN LAW: Title VII of the Rehabilitation Act of 1973, as amended,
Sections 13, 704(m)(4)(D), 705(c)(5), 706(d), 722, 723, 725(c)(8), and
725(c)(13)

CITATIONS IN

REGULATIONS: 34 CFR Parts 364, 365, and 366

EFFECTIVE

DATE: Upon Issuance

EXPIRATION

DATE: November 30, 1999

INQUIRIES: RSA Regional Commissioners

> [Fred Schroeder (signed)]{.underline}
>
> Frederic K. Schroeder, Ph.D.
>
> Commissioner
>
> Rehabilitation Services Administration

**UNITED STATES DEPARTMENT OF EDUCATION**

**Office of Special Education and Rehabilitative Services**

**REHABILITATION SERVICES ADMINISTRATION**

**SECTION 704 PERFORMANCE REPORT**

**INDEPENDENT LIVING PROGRAMS**

**CHAPTER 1**

**TITLE VII**

**PART I**

**Instructions and Pre-Print**

**With Citations**

According to the Paperwork Reduction Act of 1995, no persons are
required to respond to a collection of information unless such
collection displays a valid OMB control number. The valid OMB control
number for this information collection is 1820-0606. The time required
to complete this information collection is estimated to average [38
hours]{.underline} 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: Merri Pearson, Independent Living Program, Independent Living
Branch, U.S. Department of Education, MES Bldg., Room 3316, 330 C St.
S.W., Washington, D.C. 20202-2741

**11/30/98 Rehabilitation Act of 1973, as Amended**

**INSTRUCTIONS**

PURPOSE 5

GLOSSARY of TERMS 7

CONTENTS of the 704 PART ONE REPORT .9

WHO MUST COMPLETE 704 REPORTS 10

WHERE SHOULD the 704 REPORTS be SUBMITTED 10

WHEN SHOULD the 704 REPORTS be SUBMITTED 11

RECORD RETENTION 11

INSTRUCTIONS for COMPLETING the REPORT 12

Sources and Amounts of Resources 12

Staffing 12

Numbers and Types of Individuals Receiving Services 13-16

Types of Services Provided and Numbers of Individuals Receiving 15

Definitions of Services 16

ATTACHMENTS in the 704 [PART ONE]{.underline} REPORT 18

Attachment I-A Grants and Contracts 18

Attachment I-D(a) SILC Activities 18

Attachment I-D(b) Training and Technical Assistance Needs 18

Attachment I-E DSU Activities 18

Attachment I-F Narrative 18

REGIONAL and CENTRAL OFFICE DIRECTORY 19

**THE REPORT Pre-Print**

**SUBPART I-A ADMINISTRATIVE DATA.**

> I - RESOURCES 22
>
> II - ALLOCATION OF Part B, Ch. 1 funds 23
>
> III - DIRECT SERVICE ACTIVITY by DSUs 23
>
> IV - GRANTS, CONTRACTS, or other Arrangements for Use of Part B FUNDS
> 24
>
> V - STAFFING 24

**SUBPART I-B NUMBERS and TYPES of INDIVIDUALS with SIGNIFICANT**

> **DISABILITIES receiving SERVICES either DIRECTLY from the DSU or
> THROUGH GRANTS, CONTRACTS, or other ARRANGEMENT**
>
> I - CONSUMERS SERVED DURING THE YEAR 25
>
> II - CSRs INACTIVE @ Sept. 30^th^ 25

III - CSRs Active \@Sept. 30^th^ 25

> IV - CONSUMER ACHIEVEMENTS 25

V - CONSUMER GOALS ESTABLISHED AND ACHIEVED 25

VI - AGE 26

> VII - GENDER 26

VII I - RACE/ETHNICITY 26

> IX - DISABILITY 26

X - COMMUNITY BASED LIVING 26

**SUBPART I-C TYPES of STATE INDEPENDENT LIVING SERVICES**

**PROVIDED either DIRECTLY or through GRANTS, CONTRACTS,**

**or OTHER ARRANGEMENT**

> I - COMMUNITY SERVICES (total hours) 27
>
> II - INDIVIDUAL SERVICES (number of persons served) 27

**SUBPART I-D STATEWIDE INDEPENDENT LIVING COUNCIL**

**(SILC) REPORT**

> I - GENERAL ACTIVITIES 28
>
> II - DESIGN for NETWORK of CENTERS 28
>
> III -MONITORING and EVALUATION by SILC 28
>
> IV - COMPOSITION of the SILC 29
>
> V - PLACEMENT of the SILC 29

**SUBPART I-D(b) TRAINING AND TECHNICAL ASSISTANCE NEEDS 30**

**SUBPART I-E DSU ACTIVITIES**

> I - DSU ACTIVITIES .30
>
> II - DSU MONITORING 30

**SUBPART I-F NARRATIVE - A Comparison of Activities with the Prior
Year 31**

**SIGNATURES 32**

**OMB Number: 1820-0606**

**Expiration Date: November 30, 1999**

**UNITED STATES DEPARTMENT OF EDUCATION**

**Office of Special Education and Rehabilitative Services**

**Rehabilitation Services Administration**

**Washington, DC 20202-2741**

**INSTRUCTIONS**

for

**COMPLETION and SUBMISSION**

of the

**SECTION I 704 ANNUAL PERFORMANCE REPORT**

**PURPOSE OF THE REPORT**

The purpose of this report is to:

\(A\) Serve as a performance activity measuring instrument of
independent living (IL) programs including both quantitative and
qualitative information;

\(B\) Determine the training and technical assistance needs of Centers
for Independent Living (CILs) as required by section 721(b)(3) of the
Rehabilitation Act of 1973, as amended (Act);

\(C\) Determine CIL compliance with the standards, assurances, and
indicators of compliance with the standards in Section 725 of the Act
and 34 of the Code of Federal Regulations (CFR) Part 366;

\(D\) Collect information necessary for issuance of continuation awards
for qualified CILs funded under the CIL program;

\(E\) Collect the data required by Section 13, 706, 721, and 725 of the
Act for the State Independent Living Services (SILS) and the Centers for
Independent Living (CIL) programs;

\(F\) Serve as the basis for on-site reviews of the Chapter 1, Title VII
of the Act grantees; and

\(G\) Obtain a report on SILC and DSU activities.

The report is structured to:

\(A\) Establish a uniform reporting system to compile an accurate
national report on independent living;

\(B\) Enable each State to have information on **all** funds expended
for IL in the State for what the funds paid, who was served, what
services were provided, and for RSA to be able to compare State and CIL
performance with other States and other CILs.

> (Authority Section 13, 704(m)(4)(D); 705(c)(5); 706(d); 721, 722, 723,
> 725(c)(8); 725(c)(13) of the Act; 34 CFR Parts 364, 365, and 366)

*\*\*\*\*\*Each State receiving funds under Part B or part C of Chapter
1 of Title VII of the Act must complete the Part I report. A list of RSA
regional and central office contacts, addresses, telephone numbers, and
electronic mail addresses, is included at the end of these
instructions.*

**GLOSSARY OF TERMS**

Act The Rehabilitation Act of 1973, as amended.

CIL A Center for Independent Living meeting the definition in Section
702 of the Act, and the standards in Section 725 of the Act.

CIL Program The Centers for Independent Living program funded under
part C, Chapter 1 (Ch. 1) of Title VII of the Act (part C).

Consumer Any individual with a significant disability who is eligible
for IL services under 34 CFR 364.40(a) and is currently receiving or has
been provided with any IL service(s) under the program, other than
information and referral.

Core Services IL services defined in Section 7(29) of the act;
including: information and referral; IL skills training; peer counseling
(including cross-disability peer counseling); and, individual and
systems advocacy.

CSR A Consumer Service Record maintained for an eligible consumer
receiving IL services and meeting the requirements of 34 CFR 364.53.
Where IL services are provided to the parent or guardian of a consumer,
the CSR is established for the consumer and the services provided are
reflected in that CSR.

DSU The Designated State Unit, or Units identified under Section
101(a)(1) of the Act, to jointly with the Statewide Independent Living
Council (SILC) develop and sign the State plan for Ch. 1 of Title VII
under Section 704 of the Act. The term includes a State agency solely
designated under State law to provide IL services to individuals who are
blind. In such State, the State agency for the blind may administer the
provisions in the attachments to the State plan providing for services
to individuals who are blind. In a 723\" State, the DSU receiving,
accounting for, and disbursing the funds for the CIL program is always
the general agency.

Earmarked Funds Funds appropriated by the State and expressly or clearly
identified as State expenditures in the relevant fiscal year for the
sole purpose of funding the general operation of CILs meeting the
requirements of Sections 702 and 725 of the Act.

Section 722 State A State where RSA issues grants under Part C directly
to eligible agencies (CILs).

Section 723 State A State where the DSU issues grants or assistance
contracts under part C to eligible entities for the planning,
establishment, and operation of CILs.

IL Independent Living

ILP An Independent Living Plan for the provision of IL services
mutually agreed upon by an appropriate staff member of a service
provider and an individual with significant disabilities.

Minority Alaskan Natives, American Indians, Asian Americans, Black
(African Groups) Americans, Hispanic Americans, Native Hawaiians, and
Pacific Islanders.

Reporting Year The most recent Federal fiscal project year completed -
October 1 to September 30.

RSA The Rehabilitation Services Administration in the United States
Department of Education, Office of Special Education and Rehabilitative
Services.

Service Provider (i) A DSU that directly provides IL services to
consumers; or

> \(ii\) A CIL; or
>
> \(iii\) An entity that:
>
> \(A\) provides IL services under a grant or contract; and
>
> \(B\) is delegated responsibility for the determination of eligibility
> for IL services.

SILC The Statewide Independent Living Council established in each
State as required by Sections 704 and 705 of the Act.

SILS The State Independent Living Services program funded under part
B, Chapter 1 of Title VII of the Act.

SPIL The State Plan for Independent Living which governs and provides
the context for State IL Services and Centers for Independent Living
programs and describes the services to be provided under the IL Services
for Older Individuals Who Are Blind program.

STATE Wherever the term State is used, it refers to the State in its
sovereign sense. For purposes of Title VII, the DSU(s) and the SILC
jointly represent the State, except where otherwise noted.

**CONTENTS OF THE REPORT**

The annual 704 report consists of two parts. Part I contains the reports
of the SILCs and DSUs activities for the reporting year. It also
contains data from consumer service records where those records are
maintained outside of a CIL reporting in Part II. Part II contains a
CILs self-evaluation of compliance with the requirements of Section 725
of the Act, a comparison of the CILs activities during the reporting
year with its work plan for that year, and data from consumer service
records maintained by the CIL. It also contains the CILs work plan and
any necessary budget amendments for the next fiscal year.

**[704 REPORT, PART I contains:]{.underline}**

\(A\) [Subpart IAI - Administrative Data]{.underline}: Subpart IAI
provides information on resources, including part B, Chapter 1 of Title
VII of the Act (part B), other Federal, State, and other funds received
by the DSU during the reporting year;

\(B\) [Subpart IAII - Allocation of part B funds]{.underline}: This
subpart provides information on the amounts of part B funds obligated
during the reporting year for the allowable purposes defined in the
State Plan for Independent Living (SPIL) approved for the reporting
year;

\(C\) [Subpart IAIII - Provision of Services]{.underline}: Requires that
the State provide the information in Subparts IB and IC for IL service
providers other than CILs reporting in Part II;

\(D\) [Subpart IB - Demographics on Individuals with Significant
Disabilities Receiving Services]{.underline}: Provides information from
CSRs controlled by the State (not maintained in a CILs and reported in
Part II reports) on the numbers and types of individuals with
significant disabilities receiving IL services either directly from the
DSU or through grants, contracts, or other agreements with the State;

\(E\) [Subpart IC - Types and Amounts of Services Provided]{.underline}:
A report of community (Subpart ICI) and individual (Subpart ICII) IL
services provided either directly by the DSU or

through State grants or contracts. Information on individual services is
reported only

**from CSRs controlled by the State** (and not maintained in a CIL
required to report this

information in a 704 Part II report);

\(F\) [Subpart ID - Report of the SILCs Activities]{.underline}
(including the SILC survey of its technical

assistance and training needs for next fiscal year);

\(G\) [Subpart IE - DSU Activities]{.underline}: A report on activities
of the DSU(s); and

\(H\) [Subpart IF - Narrative and Comparison with Prior Year
Activities]{.underline}: This subpart provides

additional information, jointly developed by both the DSU and the SILC,
of significant

activities not reported in other subparts, program accomplishments, goal
achievements,

difficulties encountered, and a comparison with prior years.

**WHO MUST COMPLETE PART I?**

\(A\) Each DSU and SILC will jointly complete Part I. However, the SILC
must be given the freedom by the DSU to independently prepare its
portions of the 704 report and the DSU must be given the freedom by the
SILC to independently prepare the portions of the 704 for which the DSU
is responsible. Subpart F is designed to be a cooperative venture of all
parties (DSU(s) and SILC) preparing the 704 report, Part I. In this
manner, a complete report of activities that is jointly developed and
shared within the State is assured.

\(B\) Only a single Part I report, with data aggregated from the States
reporting entities will be accepted by RSA.

\(C\) [Subparts IB and ICII]{.underline}. These subparts report
information from CSRs. The DSU reports

in Part I only information from CSRs maintained by a service provider
other than a CIL

reporting in Part II.

**WHERE MUST THE 704, PART I REPORT BE SUBMITTED?**

**[Section 722 State]{.underline}:**

> \(A\) The DSU and the SILC will jointly submit Part I to RSA Regional
> Offices.
>
> \(B\) CILs funded solely with part B or State funds will submit their
> Part II reports to the DSU and the SILC. The DSU will then transmit
> the CIL reports (other than those from CILs receiving part C funds) to
> RSA with their Part I report.

**[Section 723 State]{.underline}:**

> All CILs will file their Part II reports with the DSU and the SILC.
> The State will aggregate the data and summarize other information in
> the Part II reports with their Part I report and attach the incoming
> reports from the CILs for reference, including the States
>
> Technical Assistance and Training Needs Survey. The aggregate Part I
> report will be forwarded to RSA (one copy to the regional office, and
> one copy to RSA central office).

**WHEN MUST THE REPORT BE SUBMITTED TO RSA?**

**[704 Part I:]{.underline}** Part I is due to RSA regional offices by
February 12, 1999, except as noted\*.

**[Section 722 States]{.underline}:**

> Part II reports from part C funded CILs are due to RSA regional
> offices by February 12, 1999.

**[Section 723 States]{.underline}:**

> The information from the Part II reports is included in the aggregate
> Part I report, which is due to RSA regional offices by \*February 26,
> 1999.

**RECORD RETENTION**

The information provided in this report by Federal grantees is subject
to confirmation at an on-site compliance review; therefore, financial
records, statistical records, and all supporting documents and other
records pertinent to the grant award, adequate to document the accuracy
of the information and statements in the 704 Annual Performance Report,
must be kept for five years (Authority: 34 CFR 74.53).

**INSTRUCTIONS for COMPLETING the 704 ANNUAL PERFORMANCE REPORT**

**[SOURCES AND AMOUNTS OF RESOURCES]{.underline}** (Part I, Subpart IA)

\(A\) [Section IAI - Report on the Amounts of Expended
Resources]{.underline}: This section indicates the amount of resources
received by the State or CIL from each of the sources indicated during
the reporting year.

\(B\) [Section IAII - Grants, Contracts, or other Arrangements for Part
B funds]{.underline}.

\(1\) Name of the grantee or contractor.

\(2\) Use for funds. Enter the identifier from Section IAII. For
example, II(d) would

signify a grant to a CIL for the general operation of the CIL.

\(C\) [Section IAIII - Staffing]{.underline}

\(1\) The term FTE means one person working full-time for one year.
Part time

employees and employees who worked for any fraction of the year are
counted

as a fraction of an FTE to the nearest tenth. To compute FTE, determine
the

number of hours (excluding overtime) for which [all
employees]{.underline} were actually paid

[during the last six months]{.underline} of the reporting year.
[Multiply the hours worked]{.underline} by

2\" [(two]{.underline}), [divide by 2080]{.underline} (approximate
number of hours worked by a FTE), the

> subsequent total is the equivalent fraction of the FTE. Please do not
> include contract staff in this count.

\(2\) Categories of positions are:

\(I\) Decisionmaking - e.g., executive director, supervisors, and any
other

policy position as determined by the CIL or other entity;

> \(II\) Staff - e.g., counselors, teachers, trainers, and other
> non-contract employees.

**NUMBERS and TYPES of INDIVIDUALS with SIGNIFICANT DISABILITIES
RECEIVING SERVICES either DIRECTLY from the DSU**

**or**

**THROUGH GRANTS or CONTRACTS (Subpart IB)**

**I** [Active Consumer Service Records]{.underline} This is a count of
individuals who were determined eligible for IL services during any part
of the year, and for whom a CSR was initiated.

> \(A\) Enter the number of active CSRs carried over from September 30
> of the preceding year;
>
> \(B\) Enter the number of new CSRs initiated during the year; and
>
> \(C\) Enter the total number of consumers served during the year.

**II** [Inactive Consumers at Year End]{.underline} This is a count of
consumer records that have been purged from the active CSR file because
the individual has moved, stated that he or she had no further interest
in the program, died, achieved all goals set, or for any other reason is
no longer an active consumer of the CIL.

**III** [Active Consumers at Year End]{.underline} This is a count of
the total number of consumers remaining active on September 30 of the
reporting year.

**\*\*\*For the remaining sections of this subpart, RSA intends that the
demographic information include [all]{.underline} consumers served
during the year.**

**IV** [Consumer Achievements]{.underline} Report the total number of
goals set by consumers and the number of goals achieved by consumers
during the reporting year (goals may be set in one year and met in a
following year). Please classify goals in the following categories:

> \(A\) Self-Care - Goals to improve/maintain a consumers autonomy with
> respect to activities of daily living such as personal grooming and
> cleaning, toileting, meal preparation, shopping, eating, etc.
>
> \(B\) Communication - Goals involving either improvement in the
> consumers ability to understand and acknowledge communication by
> others (receptive skills), or improvement in ones ability to
> communicate ones thoughts to others (expressive skills).
>
> \(C\) Mobility - Goals to improve a consumers access to their life
> space, environment, and community. This may occur by improving the
> individuals own ability to move or transport themselves, or by
> others.
>
> \(D\) Residential - Goals that provide for a change in living
> situations with increased autonomy for the consumer. This may include
> movement from a nursing home or other institution to another more
> independent residential situation.
>
> \(E\) Educational - Goals of an academic or training nature that are
> expected to improve the consumers basic knowledge or increase their
> ability to perform certain skills deemed to increase their
> independence consistent with IL philosophy.
>
> \(F\) Vocational - IL goals related to obtaining, maintaining, or
> advancing in employment.
>
> \(G\) Other - IL goals not included in the above categories.

**IV** [Age]{.underline} - Enter the number of consumers in each age
category at the end of the reporting years. For CSRs put in inactive
status during the year, use the consumers age reached during the
reporting year.

**V** [Gender]{.underline} - Enter the number of males and females
served during the fiscal year.

**VI** [Race/Ethnicity]{.underline} - Enter a count of individuals by
race or ethnicity. Information should be solicited on a voluntary basis.
If unavailable, consumers should be included in the group to which they
appear to belong. If unknown, do not enter a count. For persons who are
of mixed racial origin, use the category which reflects the individuals
choice. The racial categories are:

> \(A\) White - (non-Hispanic) - A person having origins in any of the
> original peoples of Europe, North Africa, or the Middle East.
>
> \(B\) Black (non-Hispanic) - A person having origins in any of the
> black peoples of Africa.
>
> \(C\) American Indian or Alaskan Native (including Native Hawaiians) -
> A person having origins in any of the original peoples of North
> America or Hawaii, and who maintains cultural identification through
> affiliation or community identification.
>
> \(D\) Asian or Pacific Islander - A person having origins in any of
> the original peoples of the Far East, Southeast Asia, the Indian
> subcontinent, or the Pacific Islands, and Samoa.
>
> \(E\) Hispanic - A person of Mexican, Puerto Rican, Cuban, Central or
> South American, or other Spanish culture or origin.

**VII** [Disability]{.underline} -

> Enter a count of individuals with a significant cognitive, mental,
> physical, vision, hearing, or multiple disability.

**VIII** [Community-Based Living]{.underline} -

> \(A\) Indicate the number of consumers who have received IL services
> in the reporting year who successfully relocated from nursing homes or
> other institutions to community-based living arrangements.
> Community-based living arrangements include privately owned housing,
> apartments, self-directed assisted living, or self-directed with
> family/friends.
>
> \(B\) Indicate the number of consumers for whom IL services prevented
> the necessity of entering nursing homes or other institutions. These
> individuals were therefore continued living in a community-based
> living arrangements.

**TYPES of SERVICES PROVIDED and NUMBER of INDIVIDUALS**

**RECEIVING SERVICES either DIRECTLY by the DSU**

**or**

**THROUGH GRANTS, CONTRACTS, or OTHER ARRANGEMENTS** (Subpart IC)

**I** [Community Services]{.underline} - A yes or no response is
required. Reporting entities are encouraged but not required to report
the number of hours of community service provided. The intent is to
obtain a count of the types and hours of all services being provided.
Please round to the nearest whole hour. Even incomplete data has proven
impressive in reflecting degree of effort in creating/advocating for
community improvements and services to groups.

> \(A\) Information and Referral \-- this is a service that does not
> necessarily entail the creation of a CSR and may include such things
> as group presentations or telephone referrals.
>
> \(B\) Community and Systems Advocacy \-- this includes efforts to
> develop and implement local policy and legislation changes to make
> facilities, services, and opportunities available and accessible to
> individuals with disabilities.
>
> \(C\) Outreach Efforts \-- this entails the location of and provision
> of services to individuals with significant disabilities in the
> community.
>
> \(D\) Publications \-- these may include accessibility guides,
> disability awareness brochures, ADA information, etc..
>
> \(E\) Community Education \-- activities and information programs to
> enhance the communitys awareness of disabilities and disability
> issues, e.g. local TV, radio, or newspaper campaigns.
>
> \(F\) Maintaining Registries \-- includes activities related to
> creating and maintaining directories for personal assistants,
> recreation opportunities, accessible transportation, accessible
> housing, and other support services.
>
> \(G\) Other \-- activities that do not fit in any of the above.

**II** [Individual Services]{.underline} - The number of consumers
receiving each of the following services offered during the reporting
year. This number is not expected to equal the number of consumers
served, as a single individual may receive a number of different
services during the reporting year. Individual IL services include, but
are not limited to the following areas:

> \(A\) Advocacy/Legal Services \-- assistance and/or representation in
> obtaining access to those benefits, services and programs to which a
> consumer may be entitled.
>
> \(B\) Assistive Devices/Equipment \-- provision of specialized devices
> and equipment such as TDDs, wheelchairs and lifts, or the provision of
> assistance to obtain these devices and equipment from other sources.
>
> \(C\) Childrens Services \-- the provision of IL services to
> individuals with significant disabilities under the age of six.
>
> \(D\) Communication Services \-- services directed to enable consumers
> to better communicate such as: interpreter services; training in
> communication equipment use; Braille instruction; and reading
> services.
>
> \(E\) Counseling Services \-- these include psychological,
> psychotherapeutic, and related services.
>
> \(F\) Family Services \-- these are provided to the family members of
> an individual with significant disabilities when necessary for
> improving the individuals ability to live and function more
> independently, or their ability to engage or continue in employment.
> Such services may include respite care. CILs should record the service
> in the consumers CSR on behalf of whom services were provided to the
> family.
>
> \(G\) Housing or Shelter Services \-- these are related to securing
> housing or shelter, adaptive housing services (including appropriate
> accommodations to and modifications of any space used to serve, or
> occupied by individuals with significant disabilities). A CIL shall
> not provide nor manage housing or shelter as an IL service on either a
> temporary or long term basis unless the housing or shelter is
> incidental to the overall operation of the CIL and is provided to any
> one individual for a period not to exceed eight weeks during any
> six-month period.
>
> \(H\) IL Skills Training and Life Skills Services and Training
> \--these [may]{.underline} include instruction to develop independent
> living skills in areas such as personal care, coping, financial
> management, social skills, and household management. This may also
> include education and training necessary for living in the community
> and participating in community activities.
>
> \(I\) Information and Referral Services \-- individual services
> provided to a consumer. Some CILs record this service using strokes on
> an answering pad when answering a telephone call, others create a CSR
> or other such files for future contact and outreach.
>
> \(J\) Mental Restoration \-- psychiatric restoration services
> including maintenance on psychotropic medication, psychological
> services, and treatment management for substance abuse.
>
> \(K\) Mobility Training \-- a variety of services involving assisting
> consumers to get around their homes and communities.
>
> \(L\) Peer Counseling \-- counseling, teaching, information sharing,
> and similar kinds of contact provided to consumers by peers (other
> people with disabilities).
>
> \(M\) Personal Assistance Services \-- these include attendant care
> and the training of such personnel providing these services.
>
> \(N\) Physical Restoration \-- restoration services including medical
> services; therapeutic treatments, such as physical therapy,
> occupational therapy, speech, language, and hearing therapy; health
> maintenance; eyeglasses and visual services; and prosthetic, orthotic
> and other assistive appliances and devices.
>
> \(O\) Preventative Services \-- these are intended to prevent
> additional disabilities, or to prevent an increase in the severity of
> an existing disability.
>
> \(P\) Prosthesis and other Appliances (See Rehab technology)
>
> \(Q\) Recreational Services \-- provision or identification of
> opportunities for the involvement of consumers in meaningful leisure
> time activities. These may include such things as participation in
> community affairs and other recreation activities that may be
> competitive, active or quiet.
>
> \(R\) Rehabilitation Technology \-- assistance to obtain through other
> sources or provision of the systematic application of technologies,
> engineering methodologies, or scientific principles to address the
> barriers confronted by individuals with significant disabilities with
> respect to education, rehabilitation, employment, transportation, IL
> and/or recreation.
>
> \(S\) Therapeutic Treatment \-- services provided by registered
> occupational, physical, recreational, or speech therapists.
>
> \(T\) Transportation \-- provision of or arrangements for
> transportation.
>
> \(U\) Youth Services \-- these are provided to youth with significant
> disabilities, ages 6-17, and may include training to develop skills
> specifically designed for youths to promote self-awareness and esteem,
> develop advocacy and personal power skills, and the exploration of
> career options.
>
> \(V\) Vocational Services \-- any of the services defined in Section
> 103 of the Act.
>
> \(W\) Other \-- any IL service not listed above.

**ATTACHMENTS**

**In preparing the various attachments, please insure that the States
name**

**and report year appear at the top of each page.**

[Attachment I-A Grants and Contracts]{.underline}:

> This attachment identifies where eligibility for services is
> determined and where the CSR is maintained; for other grants and
> contracts, the attachment describes the objectives, activities, and
> results achieved. Address exemplary or innovative practices that are
> considered useful or worthy of replication in Subpart IF.

[Attachment I-D(a) SILC Activities]{.underline}: This attachment
contains:

> 1\. A summary of activities of the SILC (including AND NOT LIMITED TO
> collaboration efforts for communication, coordination, and cooperation
> with the CILs, DSU(s) and other agencies and groups);
>
> 2\. A report on solutions to the problems encountered (address
> exemplary activities or major problems not included in Subpart IF);
>
> 3\. A report on the development and implementation of the design for
> the CIL network;
>
> 4\. A report on SILCs activities related to monitoring and evaluating
> the implementation of the SPIL;
>
> 5\. A report on consumer satisfaction with Chapter 1 services and
> programs consistent with Section 16 of the SPIL; and,

6\. Descriptions of the composition and placement of the SILC

[Attachment I-D(b) Training and Technical Assistance Needs]{.underline}:

> This attachment describes the SILCs training and technical assistance
> needs for the next fiscal year. It may also contain TA and training
> needs for CILs in the State, identified by the SILC in its evaluation
> and monitoring activities. Please be specific rather than general and,
> where appropriate, put needs in priority order.

[Attachment I-E DSU Activities]{.underline}:

> This attachment contains a summary of DSU activities (including AND
> NOT LIMITED TO collaboration efforts for communication, coordination,
> and cooperation with the CILs, SILC and other agencies and groups),
> results of DSU evaluations, joint evaluation activities with the SILC,
> monitoring activities, and, in 723 States, the results of periodic and
> on-site reviews of at least 15% of the part C CILs in the State.

[Attachment I-F DSU and SILC Narrative]{.underline}:

> This attachment contains a narrative with additional information,
> significant activities, exemplary practices, program accomplishments,
> goal achievements, difficulties experienced and how they were
> addressed, and how these compare with the immediately preceding year.
> Please do not report information in this subpart that is included in
> another attachment.

**[RSA REGIONAL OFFICE DIRECTORY]{.underline}**

> REGION I REGION II

Regional Commissioner: Mr. John Szufnarowski Regional Commissioner: Mr.
John Szufnarowski

Dept. Of Education, OSERS Dept. Of Education, OSERS

J.W. McCormack Post Office and Court House Rm 232 75 Park Place, Rm 1208

Boston, MA 02109 New York, NY 10007

(617)223-4086 VOICE (212)264-4016 VOICE

(617)223-4573 TDD (212)264-4028 TDD

(617)223-4573 FAX (212)264-3029 FAX

IL Program: Richard Anderson IL Program: Richard Anderson

> Illeana Prancan Janice Plumer

\*CT, ME, NH, RI, VT, MA \*NJ, PR, VI, NY

> REGION III REGION IV

Regional Commissioner: Dr. Ralph Pacinelli Regional Commissioner: Dr.
Ralph Pacinelli

Dept. Of Education, OSERS Dept. Of Education, OSERS

The Wanamaker Building Suite 512

100 Penn Square East 61 Forsyth St. SW Suite 18T91

Philadelphia, PA 19107 Atlanta, GA 30303-3104

(215)656-8531 VOICE (404)562-6330 VOICE

(215)656-6186 TDD (404)562-6347 TDD

(215)656-6188 FAX (404)562-6346 FAX

IL Program: Keith Beichner IL Program: Sue Rankin-White

> Margurite Pinkney Dan Hunsberger

\*DC, DE, MD, VA, WVA, PA \*AL, FL, KY, NC, SC, TN, GA, MS

> REGION V REGION VI

Regional Commissioner: Dr. Douglas Buleigh Regional Commissioner: Mr.
Loerance Deaver

Dept. Of Education, OSERS Dept. Of Education, OSERS

111 N. Canal Rm. 1048 1999 Bryan St. Rm. 2740

Chicago, IL 60606 Dallas, TX 75201-6817

(312)886-8630 VOICE (214)880-4927 VOICE

(312)353-9694 TDD (214)880-4833 TDD

(312)353-8623 FAX (214)880-4931 FAX

IL Program: Zilpha Hibner IL Program: Mike McGill

> Kathy Neimi Loretta Thomas

\*IN, MI, MN, OH, WI, IL \*AK, LA, NM, OK

> REGION VII REGION VIII

Regional Commissioner: Dr. Douglas Burleigh Regional Commissioner: Mr.
Loerance Deaver

Dept. Of Education, OSERS Dept. Of Education, OSERS

10220 N. Executive Hills Blvd FOB Suite 310- 1244 Speer Blvd

Kansas City, MO 64153-1367 Denver, CO 80204-3582

(816)880-4107 VOICE (303)844-2135 VOICE

(816)891-0985 TDD (303)844-2890 TDD

(816)891-0807 FAX (303)844-6269 FAX

IL Program: Rodney King IL Program: Mike McGill

> Mari Kierstein Patty Burrows

\*IA, KS, NB, MO \*MT, ND, SD, UT, WY, CO

> REGION IX REGION X

Regional Commissioner: Mr. Gilbert Williams Regional Commissioner: Mr.
Gilbert Williams

Dept. Of Education, OSERS Dept. Of Education, OSERS

FOB, Rm 215 - 50 United Nations Plaza 915 Second Ave Rm 2848

San Francisco, CA 94102 Seattle, WA 98174-1099

(415)437-7840 VOICE (206)220-7840 VOICE

(415)556-3323 TDD (206)220-7849 TDD

(415)437-7848 FAX (206)220-7842 FAX

IL Program: Gilbert Williams IL Program: Chris Smith

> Gayle Palumbo Diana Koreski

\*AZ, HI, NV, GU, AS, CA, CNMI \*AK, ID, OR, WA

**[CENTRAL OFFICE DIRECTORY]{.underline}**

IL Team Leader: Mr. John Nelson CIL Program Officer: Ms. Merri Pearson

Office of Development Programs Office of Developmental Programs

Rehabilitation Services Administration Rehabilitation Services
Administration

330 C St. SW Rm. 3326 330 C St. SW Rm. 3316

Washington, DC 20202-2741 Washington, DC 20202-2741

(202)205-9362 VOICE (202)205-8484 VOICE

(202)260-9424 FAX (202)260-9424 FAX

(202)205-8243 TDD (202)205-8243 TDD

E-mail: john_nelson@ed.gov E-mail: merri_pearson@ed.gov

**REPORTING INSTRUMENT**

**UNITED STATES DEPARTMENT of EDUCATION**

**Office of Special Education and Rehabilitative Services**

**REHABILITATION SERVICES ADMINISTRATION**

**ANNUAL PERFORMANCE REPORT**

**for**

**STATE INDEPENDENT LIVING SERVICES PROGRAMS**

**PART I**

The Centers for Independent Living Program

Chapter 1, Title VII of the Rehabilitation Act, as Amended

FISCAL YEAR 1998

With Citations

**STATE\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_GRANT
#\_\_\_\_\_\_\_\_\_\_\_\_**

**COUNTIES
SERVED\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**STATE\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Report YR\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**SUBPART I A - ADMINISTRATIVE DATA**

(704(m)(4)(D) of the Act; 34 CFR Parts 74 and 75)

I - [Resources]{.underline}

\(A\) Federal Funds

\(1\) Ch. 1, part B, Title VII \$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\(2\) Ch. 1, part C, Title VII (723 States)
\$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\(3\) Ch. 2, Title VII \$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\(4\) Other Federal Funds \$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\(B\) Other Government Funds

\(5\) State Government funds \$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\(6\) Local Government funds \$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\(C\) Private Resources

\(7\) Foundation, corporation, or trust grants
\$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\(8\) Donations from Individuals \$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\(9\) Memberships \$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\(10\) Investment Income/Endowment
\$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\(11\) Fees for Service (program income)
\$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\(12\) Other resources (in-kind items, etc.)
\$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\(D\) Total Resources (sum of lines 1 - 12)
\$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\(E\) Amount of total resources that pass through to

Consumers, e.g., personal assistance service funds
\$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\(F\) Net operating resources

(Line D minus line E) \$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

II - [Allocation of Funds Part B, Ch. 1 Funds]{.underline} (from SPIL
developed under 704, 713 of the Act; 34 CFR 365.20)

  ------------------------ ------------- ---------------- ----------------
  **PURPOSE**              **\$**        **Direct by      **Grant or
                                         DSU**            Contract**

  \(a\) Fund the resource  \$            Yes No           Yes No
  plan for the SILC                                       

  \(b\) Provide IL         \$            Yes No           Yes No
  services directly                                       
  through grant or                                        
  contract                                                

  \(c\) Demonstrate ways   \$            Yes No           Yes No
  to expand IL services                                   

  \(d\) Support the        \$            Not Applicable   Yes No
  general operation of                                    
  CILs                                                    

  \(e\) Support activities \$            Yes No           Yes No
  to increase capacity to                                 
  develop approaches or                                   
  systems for providing IL                                
  services                                                

  \(f\) Conduct studies    \$            Yes No           Yes No
  and analysis, gather                                    
  information, develop                                    
  model policies, and                                     
  present information in                                  
  order to enhance IL                                     
  services                                                

  \(g\) Train regarding IL \$            Yes No           Yes No
  philosophy                                              

  \(h\) Provide outreach   \$            Yes No           Yes No
  to unserved or under                                    
  served populations,                                     
  including minority                                      
  groups and urban and                                    
  rural populations                                       
  ------------------------ ------------- ---------------- ----------------

III - [Provision of Services]{.underline} (704(e) of the Act; 34 CFR
365.20.21)

> \(A\) If the DSU provides community IL services using part B funds,
> directly or though grant or contract to a service provider ***other
> than a CIL reporting in 704 Part II\****, complete Subpart IC(I) of
> this part.

\(B\) If the DSU directly provides IL services to individuals with
significant disabilities; directly determines eligibility for such
individuals; and the CSRs for those individuals are maintained
***outside a CIL reporting in 704 Part II***,\* enter

information on such individuals in Subpart IB of this part and complete
Subpart

IC(II) of this part.

***\*Basically, RSA does not want you to report to us information that
we will already receive from CILs submitting the Part II report - this
will help us to avoid redundancy of information collected.***

IV - [Grants, Contracts, or other Arrangements for Use of Part B
Funds]{.underline} (704(f), 713 of the Act;

34 CFR 365.23)

+---------------------+-----------+----------+-------------+----------+
| **(a)               | **Use of  | **Part B | **Other     | **Non    |
| G                   | Funds**   | Ch. 1    | Federal     | Fed      |
| rantee/Contractor** |           | Funds**  | Funds**     | S        |
|                     | **(table  |          |             | ources** |
|                     | IA-II)**  |          |             |          |
+---------------------+-----------+----------+-------------+----------+
| \(1\)               |           | [\$]{.un | [\$]{       | [\$]{.un |
|                     |           | derline} | .underline} | derline} |
+---------------------+-----------+----------+-------------+----------+
| \(2\)               |           | [\$]{.un | [\$]{       | [\$]{.un |
|                     |           | derline} | .underline} | derline} |
+---------------------+-----------+----------+-------------+----------+
| \(3\)               |           | [\$]{.un | [\$]{       | [\$]{.un |
|                     |           | derline} | .underline} | derline} |
+---------------------+-----------+----------+-------------+----------+
| \(4\)               |           | [\$]{.un | [\$]{       | [\$]{.un |
|                     |           | derline} | .underline} | derline} |
+---------------------+-----------+----------+-------------+----------+
| \(5\)               |           | [\$]{.un | [\$]{       | [\$]{.un |
|                     |           | derline} | .underline} | derline} |
+---------------------+-----------+----------+-------------+----------+
| **[Total Amount of  | **\*\*\*  | [\$]{.un | [\$]{       | [\$]{.un |
| Grants and          | \*\*\*\*\ | derline} | .underline} | derline} |
| Contr               | *\*\*\*** |          |             |          |
| acts]{.underline}** |           |          |             |          |
+---------------------+-----------+----------+-------------+----------+

> **Attachment I - A (**34 CFR 364.43(e)): (\*If all grants/contracts
> for services are for the general operation of CILs, skip this section)

\(A\) If the purpose of any grant or contract is to provide IL services
to individuals:

\(1\) Who determines eligibility for these individuals?

\(2\) Where is the CSR for each individual maintained?

> \(B\) For grants or contracts for purposes other than services, please
> provide a brief narrative description of the objectives to be achieved
> by each agreement, what activities were conducted during the year; and
> what results were achieved.

V - [Staffing]{.underline} (21, 701, 704(m) (2) of the Act; 34 CFR
364,35, 34 CFR 364.36)

> Report the total number of FTE employed in the SILS and CIL programs
> administered by the DSU(s) and by service providers other than CILs
> reporting in 704 Part II reports submitted to RSA. Report the total
> decision making and other staff, the number of FTE filled by
> individuals with disabilities, and the number of minority FTE who are
> employed.

  -------------------- -------------- ----------------- -----------------
  **SILS/CIL Program** **Total FTE**  **Persons with    **Number of
                                      Disabilities**    Persons who are
                                                        Minority**

  \(a\) Decision                                        
  making Staff                                          

  \(b\) Other Staff                                     
  -------------------- -------------- ----------------- -----------------

.

**SUBPART IB: NUMBERS AND TYPES OF INDIVIDUALS WITH SIGNIFICANT
DISABILITIES RECEIVING SERVICES EITHER DIRECTLY**

> **FROM THE DSU OR THROUGH GRANTS OR CONTRACTS** (Section 13,
> 704(m)(4)(b)(d) of the Act; 34 CFR 364.53)

I - Consumers served during the reporting year:

> \(A\) CSRs carried from previous year \_\_\_\_\_\_\_\_\_\_
>
> \(B\) CSRs started since Oct. 1 of the reporting year
> \_\_\_\_\_\_\_\_\_\_
>
> \(C\) Total consumers served \_\_\_\_\_\_\_\_\_\_

II - Consumers inactive on September 30^th^ of the reporting year

> \(A\) Moved \_\_\_\_\_\_\_\_\_\_
>
> \(B\) Withdrew \_\_\_\_\_\_\_\_\_\_
>
> \(C\) Died \_\_\_\_\_\_\_\_\_\_
>
> \(D\) Inactive because goals were met \_\_\_\_\_\_\_\_\_\_
>
> \(E\) Other \_\_\_\_\_\_\_\_\_\_
>
> \(F\) Total \_\_\_\_\_\_\_\_\_\_

III - Consumers (CSRs) active on September 30^th^ of the reporting year

> \[line I-c minus line I-f\] \_\_\_\_\_\_\_\_\_\_

IV - Consumer Achievements (725(c)(14) of the Act; CFR 364.43)

> \(A\) Number of individuals declining offer to develop ILP
> \_\_\_\_\_\_\_\_\_\_
>
> \(B\) Number of individuals with whom an ILP was developed
> \_\_\_\_\_\_\_\_\_\_

V - Consumer Goals and Objectives Established and Achieved:

> **Goals Set Goals Met**
>
> \(A\) Self-care \_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_
>
> \(B\) Communication \_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_
>
> \(C\) Mobility \_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_
>
> \(D\) Residential \_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_
>
> \(E\) Educational \_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_
>
> \(F\) Vocational \_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_
>
> \(G\) Other \_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_

VI - Age Information

> \(A\) Under 6 \_\_\_\_\_\_\_\_\_\_
>
> \(B\) 6 - 17 \_\_\_\_\_\_\_\_\_\_
>
> \(C\) 18 - 22 \_\_\_\_\_\_\_\_\_\_
>
> \(D\) 23 - 54 \_\_\_\_\_\_\_\_\_\_
>
> \(E\) 55 & Over \_\_\_\_\_\_\_\_\_\_

VII - Gender

> \(A\) Female \_\_\_\_\_\_\_\_\_\_
>
> \(B\) Male \_\_\_\_\_\_\_\_\_\_

VIII - Race/ethnicity

> \(A\) White (non-Hispanic) \_\_\_\_\_\_\_\_\_\_
>
> \(B\) Black (non-Hispanic) \_\_\_\_\_\_\_\_\_\_
>
> \(C\) American Indian or Alaskan Native (including Native Hawaiian)
> \_\_\_\_\_\_\_\_\_\_
>
> \(D\) Asian or Pacific Islander \_\_\_\_\_\_\_\_\_\_
>
> \(E\) Hispanic \_\_\_\_\_\_\_\_\_\_

IX - Disability

> \(A\) Cognitive \_\_\_\_\_\_\_\_\_\_
>
> \(B\) Mental/Emotional \_\_\_\_\_\_\_\_\_\_
>
> \(C\) Physical \_\_\_\_\_\_\_\_\_\_
>
> \(E\) Hearing \_\_\_\_\_\_\_\_\_\_
>
> \(F\) Vision \_\_\_\_\_\_\_\_\_\_
>
> \(G\) Multiple Disability \_\_\_\_\_\_\_\_\_\_

X - Community-Based Living

> \(A\) Individuals successfully relocated from nursing homes or other
> institutions to community-based living arrangements
> \_\_\_\_\_\_\_\_\_\_
>
> \(B\) Individuals for whom IL services prevented the necessity of
> entering nursing homes or other institutions and therefore continued
> living in a community-based living arrangements\_\_\_\_\_\_\_\_\_\_

**SUBPART IC: TYPES OF SERVICES PROVIDED AND THE NUMBER OF INDIVIDUALS
WITH SIGNIFICANT DISABILITIES RECEIVING SERVICES EITHER DIRECTLY BY THE
DSU(s) OR THROUGH GRANTS, CONTRACTS, OR OTHER ARRANGEMENTS**
(704(m)(4)(D), 725 (c)(8)(C) of the Act; 34 CFR 364.43, 366.50(i)(3))

I - Community Services (this section is optional)

> **Total Hours**
>
> \(A\) Information and Referral \_\_\_\_\_\_\_\_\_\_
>
> \(B\) Community and Systems Advocacy \_\_\_\_\_\_\_\_\_\_
>
> \(C\) Outreach \_\_\_\_\_\_\_\_\_\_
>
> \(D\) Publications \_\_\_\_\_\_\_\_\_\_
>
> \(E\) Community Education \_\_\_\_\_\_\_\_\_\_
>
> \(F\) Maintaining Registries \_\_\_\_\_\_\_\_\_\_
>
> \(G\) Other \_\_\_\_\_\_\_\_\_\_
>
> \(H\) Total \_\_\_\_\_\_\_\_\_\_

II - Individuals Services **Number of Individuals**

> \(A\) Advocacy \_\_\_\_\_\_\_\_\_\_
>
> \(B\) Legal \_\_\_\_\_\_\_\_\_\_
>
> \(C\) Childrens \_\_\_\_\_\_\_\_\_\_
>
> \(D\) Communication \_\_\_\_\_\_\_\_\_\_
>
> \(E\) Counseling and Related \_\_\_\_\_\_\_\_\_\_
>
> \(F\) Family \_\_\_\_\_\_\_\_\_\_
>
> \(G\) Housing, Home Modifications,

and Shelter (e.g. moving people out

> of nursing homes/institutions into integrated housing)
> \_\_\_\_\_\_\_\_\_\_
>
> \(H\) Information and Referral \_\_\_\_\_\_\_\_\_\_
>
> \(I\) IL Skills Training and Life Skills Training \_\_\_\_\_\_\_\_\_\_
>
> \(J\) Mental Restoration \_\_\_\_\_\_\_\_\_\_
>
> \(K\) Mobility Training \_\_\_\_\_\_\_\_\_\_
>
> \(L\) Peer Counseling (including Cross-disability Peer Counseling)
> \_\_\_\_\_\_\_\_\_\_
>
> \(M\) Personal Assistance Services \_\_\_\_\_\_\_\_\_\_
>
> \(N\) Physical Rehabilitation \_\_\_\_\_\_\_\_\_\_
>
> \(O\) Preventative Services \_\_\_\_\_\_\_\_\_\_
>
> \(P\) Prostheses and other \_\_\_\_\_\_\_\_\_\_
>
> \(Q\) Recreational \_\_\_\_\_\_\_\_\_\_
>
> \(R\) Rehabilitation Technology \_\_\_\_\_\_\_\_\_\_
>
> \(S\) Therapeutic Treatment \_\_\_\_\_\_\_\_\_\_
>
> \(T\) Transportation \_\_\_\_\_\_\_\_\_\_
>
> \(U\) Youth \_\_\_\_\_\_\_\_\_\_
>
> \(V\) Vocational \_\_\_\_\_\_\_\_\_\_
>
> \(W\) Other \_\_\_\_\_\_\_\_\_\_

**SUBPART ID: STATEWIDE INDEPENDENT LIVING COUNCIL (SILC) REPORT**

(705(c)(5) of the Act; 34 CFR 364.21(g))

**[ATTACHMENT I - D(a)]{.underline}** - Please address the following, as
appropriate:

I. [General Activities]{.underline}. Please provide a summary of
activities the SILC has been involved

in during the reporting year such as:

\(A\) Major accomplishments and problems encountered and how they were
addressed;

\(B\) Relations with the DSU(s), activities, successes, problems,
solutions;

\(C\) Allocation of resources and development of the State plan;

\(D\) Other information that the SILC believes would be helpful

or informative to RSA, the Congress, and other CILs and

State agencies.

\*Please be brief and concise, but complete, in your response\*

II\. [Design for Network of Centers]{.underline}. Coordinate with the
DSU(s) and report on:

\(A\) The development and implementation of the design for a

statewide network of CILs, with particular emphasis on \--

\(1\) Under served and unserved areas;

\(2\) Priorities for establishment of new centers;

\(3\) Estimated resources needed to accomplish each

step of the design.

\(B\) How the needs and resources were determined, the numbers of

individuals with significant disabilities estimated to be unserved or
under served,

and other data supported by surveys available in the State.

III\. [Monitoring and Evaluating the Implementation of the SPIL by
SILC]{.underline}

\(A\) Provide a summary of \--

\(1\) The SILCs monitoring and evaluation activities related to
implementation

of the State plan for independent living.

> \(2\) Findings and recommendations related to any problems or plans
> exceeded encountered in the implementation of the State plan for
> independent living.

\(3\) Council participation in any on-site compliance reviews of CILs or
DSU(s).

> \(4\) Involvement in development of corrective action plans addressing
> deficiencies of CILs, DSU(s), deriving from on-site or other reviews,
> etc.
>
> The summary should include positive evaluation findings as well
> negative findings. Exemplary activities, particularly those the
> council considers worthy of replication, and incidences of substantial
> deviation from provisions in the State plan should be noted.

\(B\) Describe activities and results related to evaluation of the
effectiveness of the

> State plan for independent living in meeting the objectives
> established in the plan.

IV\. [Report on Consumer Satisfaction with Chapter 1 Services and
Programs]{.underline}

> Consistent with Section 16 of the approved SPIL, for the reporting
> year:
>
> \(A\) Provide a report on consumer satisfaction with Chapter 1
> services and programs.

V. [Composition of the SILC]{.underline} (Sec. 705(b) of the Act; 34 CFR
364.21(b))

+-------------------------------------------------------------+--------+
| > \(1\) State the total number of persons on the SILC.      |        |
+-------------------------------------------------------------+--------+
| > \(2\) State the number of SILC members with disabilities, |        |
| > as defined in 34 CFR 364.4(b), and not employed by a      |        |
| > State agency or a CIL.                                    |        |
+-------------------------------------------------------------+--------+
| > \(3\) Is a representative of the DSU an ex-officio member | Y N    |
| > of the SILC?                                              |        |
+-------------------------------------------------------------+--------+
| > \(4\) State the number of voting members on the SILC.     |        |
+-------------------------------------------------------------+--------+
| > \(5\) State the number of different disability groups     |        |
| > (physical, mental, cognitive, sensory, or multiple)       |        |
| > represented by members of the SILC (up to five).          |        |
+-------------------------------------------------------------+--------+
| > \(6\) Is a CIL director chosen by CIL directors within    | Y N    |
| > the State appointed to the SILC?                          |        |
+-------------------------------------------------------------+--------+
| > \(7\) Does the SILC include representatives from other    | Y N    |
| > State agencies that provide services for individuals with |        |
| > disabilities?                                             |        |
+-------------------------------------------------------------+--------+
| > \(8\) Does the council have a voting membership that is   | Y N    |
| > knowledgeable about CILs and IL services?                 |        |
+-------------------------------------------------------------+--------+
| > \(9\) Do Council members provide statewide                | Y N    |
| > representation?                                           |        |
+-------------------------------------------------------------+--------+
| > \(10\) Is the Council Chairperson elected from among the  | Y N    |
| > voting members of the Council by the voting members of    |        |
| > the Council or the Governor, pursuant to section          |        |
| > 705(b)(5) of the Act?                                     |        |
+-------------------------------------------------------------+--------+
| > \(11\) Is there one or more section 121 (formerly 130)    | Y N    |
| > project in the State?                                     |        |
+-------------------------------------------------------------+--------+
| > \(12\) If #11 is answered as Y, does the Council        | Y N    |
| > include at least 1 representative of the directors of the |        |
| > section 121 projects?                                     |        |
+-------------------------------------------------------------+--------+

> 4.2 [Placement of the SILC]{.underline} (Sec. 705(a) of the Act; 34
> CFR 364.21(a)(2))
>
> The SILC is not established as an entity within any State agency,
> including the DSU, and is independent of the DSU and all other State
> agencies. Following is a brief description of the legal status and
> placement of the SILC:

[**ATTACHMENT I -D(b) -**]{.underline} TRAINING AND TECHNICAL ASSISTANCE
NEEDS

(Section 721(b)(3) of the Act; 34 CFR 366.13)

As the SILC reviews the performance of the entities and service
providers involved in the implementation and administration of the State
plan during the reporting year, and the needs of the SILC in carrying
out its responsibilities in the next fiscal year, please identify and
prioritize the SILCs training and technical assistance needs for the
next fiscal year. In this attachment, the SILC may also identify
training and technical assistance needs of CILs providing services in
the State, resulting from the SILCs evaluation and monitoring
activities. (721(b)(3) of the Act)

**SUBPART IE: DSU(s) ACTIVITIES** (704(M)(4)(D) of the Act; 34 CFR
364.22;

364.38)

**[ATTACHMENT I - E]{.underline}** Please address the following, as
appropriate:

I - Development of the SPIL and Provision of Administrative Support
Services.

II - Evaluation(s) Conducted by DSU(s); to include:

\(A\) Summarize results of evaluation activities conducted by the DSU(s)
during

the reporting ear, including positive and negative findings; and,

\(B\) Describe any evaluation activities jointly conducted with the SILC
related

to implementation of the Evaluation plan required by 704(n) of the Act.

> \(C\) Describe other collaborative efforts with the SILC and entities
> providing independent living services and conducting independent
> living programs in the state.

III - Monitoring; to include:

> \(A\) A summary of monitoring activities conducted by the DSU(s),
> (including involvement or coordination with the SILC) with findings of
> strengths,

weaknesses, opportunities, and threats to the implementation of
activities

conducted under the SPIL.

\(B\) ***In 723 States (only) -***

> \(1\) Identify each CIL that was the subject of a on-site compliance
> review during the reporting year and provide information on the extent
> to which the CIL complied with the standards in 725. Where a
> particular CIL has exemplary and innovative practice that may be
> replicated by other CILs, RSA encourages the DSU to describe the
> practice. (723 (g) of the Act; 34 CFR 366.38)
>
> \(2\) Provide a summary of periodic reviews, other than those in the
> preceding paragraph, i.e., on-site reviews conducted of 15% of the
> part C CILs compliance with the standards and assurances in 725.

\(3\) Provide a summary of any corrective action plans developed as a

result of findings of non-compliance. (723(f) of the Act; 34 CFR 366.38)

\(4\) Identify any CILs against which adverse action was initiated
pursuant to

723(h) of the Act.

**SUBPARTS IF: NARRATIVE - COMPARISON WITH PRIOR YEARS**

(704(m)(4)(D), 705(c)(5) of the Act; 34 CFR 366.50(I)(7))

**[ATTACHMENT IF]{.underline} -** Please provide the following:

\(A\) Additional information, comments, or explanations of the reporting
year

data compared to the previous year;

\(B\) Descriptions of the significant activities not accounted for
elsewhere in the

report, e.g., brief summaries of innovative activities or practices, not
reported

in previous years, which could be replicated and used by other States
and CILs.

\(C\) Descriptions of substantial problems or difficulties, types of
resolution methods

attempted, and the results of those attempts; and

\(D\) A comparison of program accomplishments and goal achievements
during this

reporting year.

**[Report Submission Information]{.underline}**

***Mail two (2) copies of this report to your RSA Regional Office.***

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_

SIGNATURE OF STATE AGENCY OFFICIAL DATE

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

NAME AND TITLE OF STATE AGENCY OFFICIAL PHONE NUMBER

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

SIGNATURE OF STATE AGENCY OFFICIAL DATE

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

NAME AND TITLE OF STATE AGENCY OFFICIAL PHONE NUMBER

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

SIGNATURE OF SILC REPRESENTATIVE DATE

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

NAME OF SILC REPRESENTATIVE PHONE NUMBER

**UNITED STATES DEPARTMENT OF EDUCATION**

**Office of Special Education and Rehabilitative Services**

**REHABILITATION SERVICES ADMINISTRATION**

**SECTION 704 PERFORMANCE REPORT**

**INDEPENDENT LIVING PROGRAMS**

**CHAPTER 1**

**TITLE VII**

**PART II**

Instructions and Pre-Print

**Non-Cited Version**

**Centers for Independent Living**

According to the Paperwork Reduction Act of 1995, no persons are
required to respond to a collection of information unless such
collection displays a valid OMB control number. The valid OMB control
number for this information collection is 1820-0606. The time required
to complete this information collection is estimated to average [38
hrs]{.underline} 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: Merri Pearson, Independent Living Program, Independent Living
Branch, U.S. Department of Education, MES Bldg., Room 3316, 330 C St.
S.W., Washington, D.C. 20202-2741

**11/30/98 Rehabilitation Act of 1973, as Amended**

**Table of Contents**

**[Instructions Section]{.underline}**

**Purpose of the Report 5**

**Glossary of Terms 6**

**Contents of the Report 8**

**Who Completes the Report and Where is it Submitted 9**

**When is the Report Submitted 9**

**Record Retention 10**

**SELF EVALUATION**

Purpose of the Self-Evaluation 11

Staffing Information 11

Center Narrative Portion of the Report 12

Next Years Work Plan 13

Center Training and Technical Assistance Needs 14

Sources and Amounts of Resources 15

**FISCAL INFORMATION**

Other Budget Information 16

Budget Summary (Form 524) 17

**NUMBERS and TYPES of INDIVIDUALS with SIGNIFICANT**

**DISABILITIES RECEIVING SERVICES**

Active Consumer Service Records 17

Inactive Consumers at the Year End 17

Active Consumers at the Year End 17

Consumer Achievements 18

Age, Gender, and Race Informarion 18

Disability and Community-based Living Information 19

**TYPES of SERVICES PROVIDED and NUMBER OF**

**INDIVIDUALS RECEIVING SERVICES**

Community Services 19

Individual Services 19

**RSA REGIONAL and CENTRAL OFFICE DIRECTORY 22**

**[Pre-Print Section]{.underline}**

**Cover Sheet 24**

**SF 524 25**

**SUBPART II A - APPLICANT SELF EVALUATION**

Compliance Indicator 1 - Philosophy 26

Compliance Indicator 2 - Cross Disability 27

Compliance Indicator 3 - Independent Living Goals 27

Compliance Indicator 4 - Community Options and Community Capacity 28

Compliance Indicator 5 - IL Core Services and Other IL Services 29

Compliance Indicator 6 - Resource Development Activities 29

**Attachment IIB - PROGRAM ACTIVITIES**

Comparison of Activities 30

Other Activities 30

Descriptions of Problems or Difficulties 30

**SUBPART II C - PROGRAM PLANNING OBJECTIVES**

**Attachment IIC(a) - Next Federal Fiscal Years Work Plan 30**

**Attachment IIC (b) - List of Training and Technical Assistance Needs
30**

**SUBPART II D - SOURCES AND AMOUNTS OF RESOURCES**

Resources 31

**SUBPART II E - NEXT YEAR BUDGET INFORMATION**

Form 524 32

**SUBPART II F - NUMBERS AND TYPES OF INDIVIDUALS WITH SIGNIFICANT**

**DISABILITIES RECEIVING SERVICES THROUGH THE CIL**

> Consumer Information 32

**SUBPART II G - TYPES OF SERVICES PROVIDED AND THE NUMBER OF**

**INDIVIDUALS WITH SIGNIFICANT DISABILITIES**

**RECEIVING EACH TYPE OF SERVICE**

Community Services (optional) 33

Individual Services 33

**SIGNATURE SHEET 35**

**OMB Number: 1820-0606**

**Expiration Date: November 30, 1999**

**UNITED STATES DEPARTMENT OF EDUCATION**

**Office of Special Education and Rehabilitative Services**

**Rehabilitation Services Administration**

**Washington, DC 20202-2741**

INSTRUCTIONS for COMPLETION and SUBMISSION

of the 704 ANNUAL PERFORMANCE REPORT

**PURPOSE OF THE REPORT**

The purpose of this report is to:

\(A\) Serve as a performance activity measuring instrument of
independent living (IL) programs including both quantitative and
qualitative information;

\(B\) Determine the training and technical assistance needs of Centers
for Independent Living (CILs) as required by section 721(b)(3) of the
Rehabilitation Act of 1973, as amended (Act);

\(C\) Determine CIL compliance with the standards, assurances, and
indicators of compliance with the standards in Section 725 of the Act
and 34 of the Code of Federal Regulations (CFR) Part 366;

\(D\) Collect information necessary for issuance of continuation awards
for qualified CILs funded under the CIL program;

\(E\) Collect the data required by Section 13, 706, 721, and 725 of the
Act for the State Independent Living Services (SILS) and the Centers for
Independent Living (CIL) programs; and

\(F\) Serve as the basis for on-site reviews of the Chapter 1, Title VII
of the Act grantees.

The report is structured to:

\(A\) Establish a uniform reporting system to compile an accurate
national report on independent living;

\(B\) Enable each State to have information on **all** funds expended
for IL in the State for what the funds paid, who was served, what
services were provided, and for RSA to be able to compare State and CIL
performance with other States and other CILs.

**GLOSSARY OF TERMS**

Act The Rehabilitation Act of 1973, as amended.

CIL A Center for Independent Living meeting the definition in Section
702 of the Act, and the standards in Section 725 of the Act.

CIL Program The Centers for Independent Living program funded under
part C, Chapter 1 (Ch. 1) of Title VII of the Act (part C).

Consumer Any individual with a significant disability who is eligible
for IL services under 34 CFR 364.40(a) and is currently receiving or has
been provided with any IL service(s) under the program, other than
information and referral.

Core Services IL services defined in Section 7(29) of the act;
including: information and referral; IL skills training; peer counseling
(including cross-disability peer counseling); and, individual and
systems advocacy.

CSR A Consumer Service Record maintained for an eligible consumer
receiving IL services and meeting the requirements of 34 CFR 364.53.
Where IL services are provided to the parent or guardian of a consumer,
the CSR is established for the consumer and the services provided are
reflected in that CSR.

DSU The Designated State Unit, or Units identified under Section
101(a)(1) of the Act, to jointly with the Statewide Independent Living
Council (SILC) develop and sign the State plan for Ch. 1 of Title VII
under Section 704 of the Act. The term includes a State agency solely
designated under State law to provide IL services to individuals who are
blind. In such State, the State agency for the blind may administer the
provisions in the attachments to the State plan providing for services
to individuals who are blind. In a 723\" State, the DSU receiving,
accounting for, and disbursing the funds for the CIL program is always
the general agency.

Earmarked Funds Funds appropriated by the State and expressly or clearly
identified as State expenditures in the relevant fiscal year for the
sole purpose of funding the general operation of CILs meeting the
requirements of Sections 702 and 725 of the Act.

Section 722 State A State where RSA issues grants under Part C directly
to eligible agencies (CILs).

Section 723 State A State where the DSU issues grants or assistance
contracts under part C to eligible entities for the planning,
establishment, and operation of CILs.

IL Independent Living

ILP An Independent Living Plan for the provision of IL services
mutually agreed upon by an appropriate staff member of a service
provider and an individual with significant disabilities.

Minority Alaskan Natives, American Indians, Asian Americans, Black
(African Groups) Americans, Hispanic Americans, Native Hawaiians, and
Pacific Islanders.

Reporting Year The most recent Federal fiscal project year completed -
October 1 to September 30.

RSA The Rehabilitation Services Administration in the United States
Department of Education, Office of Special Education and Rehabilitative
Services.

Service Provider (i) A DSU that directly provides IL services to
consumers; or

> \(ii\) A CIL; or
>
> \(iii\) An entity that:
>
> \(A\) provides IL services under a grant or contract; and
>
> \(B\) is delegated responsibility for the determination of eligibility
> for IL services.

SILC The Statewide Independent Living Council established in each
State as required by Sections 704 and 705 of the Act.

SILS The State Independent Living Services program funded under part
B, Chapter 1 of Title VII of the Act.

SPIL The State Plan for Independent Living which governs and provides
the context for State IL Services and Centers for Independent Living
programs and describes the services to be provided under the IL Services
for Older Individuals Who Are Blind program.

STATE Wherever the term State is used, it refers to the State in its
sovereign sense. For purposes of Title VII, the DSU(s) and the SILC
jointly represent the State, except where otherwise noted.

**CONTENTS OF THE REPORT**

The annual 704 report consists of two parts. Part I contains the reports
of the SILCs and DSUs activities for the reporting year. It also
contains data from consumer service records where those records are
maintained outside of a CIL reporting in Part II. Part II contains a
CILs self-evaluation of compliance with the requirements of Section 725
of the Act, a comparison of the CILs activities during the reporting
year with its work plan for that year, and data from consumer service
records maintained by the CIL. It also contains the CILs work plan and
any necessary budget amendments for the next fiscal year.

**[704 REPORT, PART II contains:]{.underline}**

\(A\) [Subpart IIA - Self Evaluation]{.underline}: a measure of the
extent to which a CIL is in compliance with the standards in section
725(b) of the Act and the indicators of minimum compliance with the
standards in 34 CFR Part 366, Subpart G;

\(B\) [Subpart IIB - Narrative]{.underline}: a comparison of the
activities of the CIL within the reporting year with the proposed
activities of the CIL in the work plan. This shall include:

> \(1\) A comparison of activities and accomplishments during the
> reporting year with the goals and activities included in the reporting
> years work plan;
>
> \(2\) A comparison between the reporting year with the previous years
> work plan;
>
> \(3\) Descriptions of significant activities or practices not reported
> in previous years, which could be replicated and used by other States
> and CILs;
>
> \(4\) A report of which counties are served by the CIL and how many
> consumers received services in each county; and
>
> \(5\) Descriptions of substantial problems or difficulties,
> particularly problems that may affect compliance, alternative
> resolutions explored, and which ones worked (why did they work?).

\(C\) [Subpart IIC - Program Planning objectives]{.underline}: a report
on compliance with the assurance that a CIL will establish annual and
3-year work plans and a copy of the CILs work plan for the next fiscal
year;

\(D\) [Subpart IID - Sources and Amounts of Funding for the Operation of
the CIL]{.underline}: a report on resources received and expended by a
CIL during the reporting year;

\(E\) [Subpart IIE - Next Fiscal Year Budget Information]{.underline}:
submittal of budgets for the remaining years of the grant where the
budgets have not been previously negotiated, or a

> revised budget where appropriate;

\(F\) [Subpart IIF - Consumer Demographics]{.underline}: provides
information from CSRs controlled by the CIL on the numbers and types of
consumers receiving IL services, regardless of the source of funding for
a particular service; and

\(G\) [Subpart IIG - Types and Amounts of Services
Provided]{.underline}: a report of how much, the type, and overall
community work and the results of such work. This should reflect the
community and individual (Subpart IIGII) IL services provided by the
CIL. Information on individual services is reported only from CSRs
controlled by the CIL, regardless of the source of funding for a
particular service.

**WHO MUST COMPLETE THE REPORT AND WHERE MUST IT BE SUBMITTED?**

**[Section 722 State]{.underline}:**

> \(A\) The part C funded CILs will submit two copies of the Part II
> report to the RSA regional office and one copy to the SILC. If the CIL
> is receiving both part B and part C funds, a copy of the report should
> also be submitted to the DSU.
>
> \(B\) CILs funded solely with part B or State funds will submit their
> Part II reports to the DSU and the SILC by the date established by the
> DSU. The DSU will then transmit the CIL reports to RSA with their Part
> I report.

**[Section 723 State]{.underline}:**

> CILs will file their Part II reports with the DSU and the SILC. The
> State will aggregate the data and summarize other information in the
> Part II reports with their Part I report and attach the incoming
> reports from the CILs for reference, including the States Technical
> Assistance and Training Needs Survey. The aggregate Part I report will
> be forwarded to RSA (one copy to the regional office, and one copy to
> RSA central office).
>
> \*\*\*\*\*A list of RSA regional and central office contacts,
> addresses, telephone numbers and electronic contact user IDs, is
> included at the end of these instructions.

**WHEN MUST THE REPORT BE SUBMITTED TO RSA?**

**[Section 722 States]{.underline}:**

> Part II reports from part C funded CILs are due to RSA regional
> offices Feb. 12, 1999.

**[Section 723 States]{.underline}:**

> The information from the Part II reports is included in the aggregate
> Part I report, which is due to RSA February 26, 1999.

**RECORD RETENTION**

The information provided in this report by Federal grantees is subject
to confirmation at an on-site compliance review; therefore, financial
records, statistical records, and all supporting documents and other
records pertinent to the grant award, adequate to document the accuracy
of the information and statements in the 704 Annual Performance Report,
must be kept for five years.

**INSTRUCTIONS for COMPLETING the 704 ANNUAL PERFORMANCE REPORT**

**[SELF-EVALUATION]{.underline} (Part II, Subpart IIA & IIB)**

The purpose of the self evaluation is to assist the CIL to assess the
CILs compliance with the standards in Section 725 (b) and the
indicators of minimum compliance with the standards in 34 CFR Part 366,
Subpart G; and the assurances in Section 725 (c) and 34 CFR Part 366,
Subpart F.

The standards, indicators, and assurances are requirements reflecting
essential elements that a CIL must meet to comply with the statutory
definition of a CIL and to be eligible for continuation funding.

This subpart and the instructions for the narrative section (Subpart
IIB) provide guidance against which a CIL should review its activities
to determine whether or not it may have a problem complying with the
standards in the event of an on-site compliance review under Section
706(c) or 723(g) and (h) of the Act. If the CIL does identify particular
compliance problems, it should address them in the manner suggested
below.

> *If a CIL determines through its self evaluation that it may have a
> problem meeting one of the standards or an assurance, it should note
> in the Part II report either:*
>
> *(A) What action has been taken since the end of the reporting year to
> correct the deficiency (Attachment II-B); or*
>
> *(B) Include in next years work plan, a description of the corrective
> action the CIL proposes to take to correct the deficiency (Attachment
> II-C(a)).*

[Staffing]{.underline} Part II, Subpart IIAI(a)(1)

> \(1\) FTE means one person working full-time equivalent of one year
> (approx. 2,080 hours). Part-time employees and employees who worked
> for any fraction of the year are counted as a fraction of an FTE to
> the nearest tenth.
>
> \(2\) To compute FTE for purposes of the 704 report, determine the
> number of hours (excluding overtime) for which employees were actually
> paid during the last six months of the reporting year. Multiply the
> hours worked by two and then divide the result by 2080 = FTE.
>
> \(3\) Categories of positions are:
>
> \(i\) Decision making - e.g., executive director, supervisors, and any
> other policy position;
>
> \(ii\) Staff - e.g., counselors, teachers, trainers, and other staff
> not included in the definition above (3)(i).

**[ATTACHMENT II -B CIL NARRATIVE (REPORTING YEAR FY
1998)]{.underline}**

**\***Please do not report information in this section that is included
elsewhere in the report.

In the following order, please describe or discuss:

\(A\) [Activities and accomplishments during the reporting
year]{.underline}. Compare the reporting year goals and activities to
intended activities and accomplishments. Briefly discuss how the
activities compare and refer to the section(s) of the self-evaluation
(Part II, Section IIA Indicators) with which the activities and
accomplishments demonstrate compliance. Address:

> \(1\) [Advocacy efforts]{.underline}, including but not limited to:
>
> . Community and systems efforts;
>
> . Technical assistance plans;
>
> . Communication, coordination, and cooperation plans; and

Affirmative action plans.

> \(2\) [Outreach efforts]{.underline}. Describe the CILs outreach
> activities to consumers who are members of populations of individuals
> with significant disabilities, including minorities, who are unserved
> or under served. As part of your identification of unserved and
> underserved areas and populations for outreach discuss: 1. the CILs
> percentage of minorities receiving services when considered with their
> population percentage in the service area and 2. which counties were
> served by the CIL and how many individuals with significant
> disabilities received services in each county.
>
> \(3\) [Community and individual IL service needs]{.underline}. In
> addition to your report on work plan activities in this area, provide
> a brief summary of the type of opportunities provided consumers to
> express satisfaction including the number of individuals assessed and
> the number of respondents. Also, indicate any planned needs assessment
> of individuals with significant disabilities living in the service
> area. Please describe the type of assessment approach, e.g., focus
> group, written survey, telephone survey, public meeting, etc.
>
> \(4\) [Resource development.]{.underline} If the information is
> available, please report the percentage and dollar amount of the CILs
> total funding represented by resources received from sources other
> than Title VII of the Act. Please note any exemplary replicable
> methods of resource development.
>
> \(5\) [Training]{.underline}. Please provide a brief report on staff
> and governing board training activities during the reporting year.

\(B\) [Significant activities not accounted for elsewhere in the
report]{.underline}. This may include things such as brief summaries of
innovative activities or practices not reported in previous years, which
could be replicated and used by other States and CILs.

\(C\) [Descriptions of substantial problems or
difficulties]{.underline}. This section should describe challenges faced
by the center, the types of resolutions attempted, and information about
which resolution methods worked. If a corrective action plan is included
in next years work plan, please just cross-reference it here. There is
no need to restate such information.

**[ATTACHMENT II - C(a) - NEXT YEARS WORK PLAN]{.underline}**

This attachment contains information about the CILs work plan for the
next Federal fiscal year (FY 2000). The plan should be specific and
measurable so that, at the end of the reporting year, the CIL can
compare its achievements against its projected goals and the indicators
in Part II, Subpart IIA. This work plan should be arranged around
particular goals and the related activities that will lead to the
accomplishment of those goals. In addition, if a corrective action plan
is included to correct a self-identified compliance problem, it should
be specifically cross-referenced to the related standard or indicator in
Part II Section IIA.

The work plan should include goals and activities in the following
areas:

\(A\) [Advocacy Efforts]{.underline} This section describes how the CIL
will achieve individual and systems advocacy. This may include:

> \(1\) Community advocacy plan and related activities;
>
> \(2\) Technical assistance plan and related activities;
>
> \(3\) Collaboration plan that indicates efforts for communication,
> coordination, and cooperation with other agencies and groups; and
>
> \(4\) Affirmative action plan or policy statement.

\(B\) [Outreach Efforts]{.underline} This section describes the CILs
plans for outreach to consumers who are members of populations of
individuals with significant disabilities, including minorities, who are
unserved or under served. If the CIL conducted a needs assessment or
used information from a needs assessment completed by another entity,
RSA recommends that this information be included in Part II, Attachment
II-B(4). In addition, needs assessment information may be beneficial to
the SILC and CIL governing board, and as such, RSA further recommends
that this information be shared with both entities.

\(C\) [Community and Individual IL Services]{.underline} This section
identifies the community and IL services the CIL anticipates providing
during the next Federal fiscal year.

\(D\) [Consumer Satisfaction Assurances]{.underline} This section
ensures that CILs provide opportunities for consumers to express their
satisfaction with the CILs services and policies in facilitating their
achievement of IL goals. In addressing this requirement CILs:

> \(1\) Should afford consumers an opportunity to anonymously express
> satisfaction or dissatisfaction with the effectiveness of the CILs
> services and policies in facilitating consumers achievement of IL
> goals;
>
> \(2\) May use various approaches such as town meetings, focus groups,
> written and telephone surveys;
>
> \(3\) Must report the results to the CILs governing board, SILC, and
> include a brief summary of such results in Part II, Attachment II-B.

\(E\) [Response to Needs]{.underline} This section is included if there
are needs identified in the work plan to respond to consumer
satisfaction assurances and other community needs assessment
information. Such needs may include:

> \(1\) Making adjustments in the CILs resource allocations to meet
> consumer needs;
>
> \(2\) Advocacy efforts intended to expand the options available to
> consumers through the creation of new programs;
>
> \(3\) A corrective action plan addressing specific deficiencies in the
> CILs activities or operation.

\(F\) [Resource Development Plans]{.underline} This section describes
the CILs goals and activities for obtaining and increasing funding
(including in-kind) from sources other than Title VII of the Act. RSA
encourages CILs to set goals to increase funding received by the center
from sources other than Title VII of the Act by setting a percentage
target increase related to the CILs anticipated funding from all
sources for the next year.

\(G\) [Training Efforts]{.underline} This section describes plans for
training the CIL governing board, employees, volunteers, and consumers.
Training areas may include staff development, IL philosophy, ADA,
self-advocacy and personal power; and, moving people out of nursing
homes.

**[ATTACHMENT II - C(b) - CIL TRAINING AND TECHNICAL ASSISTANCE
NEEDS]{.underline}**

This attachment describes in priority order center training and
technical assistance needs for the next fiscal year. The needs
identified will be used to design CIL training opportunities offered
through the training and technical assistance cooperative agreement.

**[ATTACHMENT II - D - SOURCES AND AMOUNTS OF RESOURCES]{.underline}**

This section describes the amount and sources of funds obligated during
the reporting year by the CIL.

**[ATTACHMENT II - E - ED FORM NO. 524 - BUDGET PROPOSAL]{.underline}**

A CIL that has negotiated a budget for each year of its grant award is
not required to submit this form unless certain changes are anticipated
in the budget for the upcoming year. These changes, which require RSA
approval, are specified in 34 CFR 74.25 and 80.30 of EDGAR. The
following is a list of instructions for completing ED Form No. 524:

**General Instructions**

> This form is used to apply to individual U. S. Department of Education
> discretionary grant programs. Unless directed otherwise, provide the
> same budget information for each year of the multi-year funding
> request. Pay attention to applicable specific instructions, if
> attached.

**Section A - Budget Summary**

> **U. S. Department of Education Funds**
>
> All applicants must complete Section A and provide a breakdown by the
> applicable budget categories shown in lines 1-11.
>
> Lines 1-11, columns (a)-(e):
>
> For each project year for which funding is requested, show the total
>
> amount requested for each applicable budget category.
>
> Lines 1-11, column (f):
>
> Show the multi-year total for each budget category. If funding is
> requested for only one project year, leave this column blank.
>
> Line 12, column (a)-(e):
>
> Show the total budget request for each project year for which funding
> is requested.
>
> Line 12, column (f):
>
> Show the total amount requested for all project years. If funding is
> requested for only one year, leave this space blank.
>
> **Section B - Budget Summary**
>
> **Non-Federal Funds**
>
> If you are required to provide or volunteer to provide matching funds
> or other non-Federal resources to the project, these should be shown
> for each applicable budget category on lines 1-11 of Section B.
>
> Lines 1-11, columns (a)-(e):
>
> For each budget year for which matching funds or other contributions
> are provided, show the total contribution for each applicable budget
> category.
>
> Lines 1-11, column (f):
>
> Show the multi-year total for each budget category. If non-Federal
> contributions are provided for only one year, leave this column blank.
>
> Line 12, columns (a)-(e):
>
> Show the total matching contribution for each project year.
>
> Line 12, column (f):
>
> Show the total amount to be contributed for all years of the
> multi-year project. If non-Federal contributions are provided for only
> one year, leave this space blank.
>
> **Section C - Other Budget Information**
>
> **Pay attention to applicable program specific instructions, if
> attached**
>
> 1\. Provide an itemized budget breakdown, by project year, for each
> budget category listed in Sections A and B.
>
> 2\. If applicable to this program, enter the type of indirect rate
> (provisional, predetermined, final, or fixed) that will be in effect
> during the funding period. In addition, enter the estimated amount of
> the base to which the rate is applied, and the total indirect expense.
>
> 3\. If applicable to this program, provide the rate and base on which
> fringe benefits are calculated.
>
> 4\. Provide other explanations or comments you deem necessary.

**[NUMBERS AND TYPES OF INDIVIDUALS WITH SIGNIFICANT DISABILITIES
RECEIVING SERVICES]{.underline} (Subpart IIF)**

**I** [Active Consumer Service Records]{.underline} This is a count of
individuals who were determined eligible for IL services during any part
of the year, and for whom a CSR was initiated.

> \(A\) Enter the number of active CSRs carried over from September 30
> of the preceding year;
>
> \(B\) Enter the number of new CSRs initiated during the year; and
>
> \(C\) Enter the total number of consumers served during the year.

**II** [Inactive Consumers at Year End]{.underline} This is a count of
consumer records that have been purged from the active CSR file because
the individual has moved, stated that he or she had no further interest
in the program, died, or achieved all goals set, or for any other reason
is no longer an active consumer of the CIL.

**III** [Active Consumers at Year End]{.underline} This is a count of
the total number of consumers remaining active on September 30 of the
reporting year.

**For the remaining sections of this subpart, RSA intends that the
demographic information include [all]{.underline} consumers served
during the year.**

**IV** [Consumer Plans and Waivers]{.underline} Please indicate the
number of individuals who signed a waiver and the number of individuals
who developed an independent living plan.

**V** [Consumer Achievements]{.underline} Report the total number of
goals set by consumers and the number of goals achieved by consumers
during the reporting year. Please classify goals in the following
categories:

> \(A\) Self-Care - Goals to improve/maintain a consumers autonomy with
> respect to activities of daily living such as personal grooming and
> cleaning, toileting, meal preparation, shopping, eating, etc\...
>
> \(B\) Communication - Goals involving either improvement in the
> consumers ability to understand and acknowledge communication by
> others (receptive skills), or improvement in ones ability to
> communicate with others (receptive skills).
>
> \(C\) Mobility - Goals to improve a consumers access to their life
> space, environment, and community. This may occur by improving the
> individuals own ability to move or transport themselves, or by
> others.
>
> \(D\) Residential - Goals that provide for a change in living
> situations with increased autonomy for the consumer. This may include
> movement from a nursing home to another more independent residential
> situation.
>
> \(E\) Educational - Goals of an academic or training nature that are
> expected to improve the consumers basic knowledge or increase their
> ability to perform certain skills deemed to increase their
> independence consistent with IL philosophy.
>
> \(F\) Vocational - IL goals related to obtaining, maintaining, or
> advancing in employment.
>
> \(G\) Other - IL goals not included in the above categories.

**VI** [Age]{.underline} - Enter the number of consumers in each age
category at the end of the reporting years. For CSRs put in inactive
status during the year, use the consumers age reached during the
reporting year.

**VII** [Gender]{.underline} - Enter the number of males and females
served during the fiscal year.

**VIII** [Race/Ethnicity]{.underline} - Enter a count of individuals by
race or ethnicity. Information should be solicited on a voluntary basis.
If unavailable, consumers should be included in the group to which they
appear to belong. If unknown, do not enter a count. For persons who are
of mixed racial origin, use the category which reflects the individuals
choice. The racial categories are:

> \(A\) White - (non-Hispanic) - A person having origins in any of the
> original peoples of Europe, North Africa, or the Middle East.
>
> \(B\) Black (non-Hispanic) - A person having origins in any of the
> black racial groups of Africa.
>
> \(C\) American Indian or Alaskan Native (including Native Hawaiians) -
> A person having origins in any of the original peoples of North
> America or Hawaii, and who maintains cultural identification through
> affiliation or community identification.
>
> \(D\) Asian or Pacific Islander - A person having origins in any of
> the original peoples of the Far East, Southeast Asia, the Indian
> subcontinent, or the Pacific Islands, and Samoa.
>
> \(E\) Hispanic - A person of Mexican, Puerto Rican, Cuban, Central or
> South American, or other Spanish culture or origin.

**IX** [Disability]{.underline} - Enter a count of individuals with a
significant cognitive, mental, physical, hearing, vision, or multiple
disability.

**X** [Community-Based Living]{.underline} -

> \(A\) Indicate the number of consumers who have received IL services
> in the reporting year who successfully relocated from nursing homes or
> other institutions to community-based living arrangements.
> Community-based living arrangements include privately owned housing,
> apartments, self-directed assisted living, or self-directed with
> family/friends.
>
> \(B\) Indicate the number of consumers for whom IL services prevented
> the necessity of entering nursing homes or other institutions. These
> individuals were therefore continued living in a community-based
> living arrangements.

**[TYPES OF SERVICES PROVIDED AND NUMBER OF INDIVIDUALS RECEIVING
SERVICES]{.underline} (Subpart IIG)**

**I** [Community Services]{.underline} - A yes or no response is
required. Centers are encouraged but not required to report the number
of hours of community service provided. The intent is to obtain a count
of the types and hours of all services being provided. Please round to
the nearest whole hour.

> \(A\) Information and Referral \-- this is a service that does not
> entail the creation of a CSR and may include such things as group
> presentations or telephone referrals.
>
> \(B\) Community and Systems Advocacy \-- this includes efforts to
> implement local policy and legislation changes to make facilities,
> services, and opportunities available and accessible to individuals
> with disabilities.
>
> \(C\) Outreach Efforts \-- this entails the location of and provision
> of services to individuals with significant disabilities in the
> community.
>
> \(D\) Publications \-- these may include accessibility guides,
> disability awareness brochures, ADA information, etc..
>
> \(E\) Community Education \-- activities and information programs to
> enhance the communitys awareness of disabilities and disability
> issues, e.g. local TV, radio, or newspaper campaigns.
>
> \(F\) Maintaining Registries \-- includes activities related to
> creating and maintaining directories for personal assistants,
> recreation opportunities, accessible transportation, accessible
> housing, and other support services.
>
> \(G\) Other \-- activities that do not fit in any of the above.

**II** [Individual Services]{.underline} - The number of consumers
receiving each of the following services offered during the reporting
year. This number is not expected to equal the number of consumers
served, as a single individual may receive a number of different
services during the reporting year. Individual IL services include, but
are not limited to the following areas:

> \(A\) Advocacy/Legal Services \-- assistance and/or representation in
> obtaining access to those benefits, services and programs to which a
> consumer may be entitled.
>
> \(B\) Assistive Devices/Equipment \-- provision of specialized devices
> and equipment such as TDDs, wheelchairs and lifts, or the provision of
> assistance to obtain these devices and equipment from other sources.
>
> \(C\) Childrens Services \-- the provision of IL services to
> individuals with significant disabilities under the age of six.
>
> \(D\) Communication Services \-- services directed to enable consumers
> to better communicate such as: interpreter services; training in
> communication equipment use; Braille instruction; and reading
> services.
>
> \(E\) Counseling Services \-- these include psychological,
> psychotherapeutic, and related services.
>
> \(F\) Family Services \-- these are provided to the family members of
> an individual with significant disabilities when necessary for
> improving the individuals ability to live and function more
> independently, or their ability to engage or continue in employment.
> Such services may include respite care. CILs should record the service
> in the consumers CSR on behalf of whom services were provided to the
> family.
>
> \(G\) Housing or Shelter Services \-- these are related to securing
> housing or shelter, adaptive housing services (including appropriate
> accommodations to and modifications of any space used to serve, or
> occupied by individuals with significant disabilities). A CIL shall
> not provide housing or shelter as an IL service on either a temporary
> or long term basis unless the housing or shelter is incidental to the
> overall operation of the CIL and is provided to any one individual for
> a period not to exceed eight weeks during any six-month period.
>
> \(H\) IL Skills Training and Life Skills Services and Training
> \--these may include instruction to develop independent living skills
> in areas such as personal care, coping, financial management, social
> skills, and household management. This may also include education and
> training necessary for living in the community and participating in
> community activities.
>
> \(I\) Information and Referral Services \-- individual services
> provided to a consumer. Some CILs record this service using strokes on
> an answering pad, others create a CSR or other such files for future
> contact and outreach.
>
> \(J\) Mental Restoration \-- psychiatric restoration services
> including maintenance on psychotropic medication, psychological
> services, and treatment management for substance abuse.
>
> \(K\) Mobility Training \-- a variety of services involving assisting
> consumers to get around their homes and communities.
>
> \(L\) Peer Counseling \-- counseling, teaching, information sharing,
> and similar kinds of contact provided to consumers by peers (other
> people with disabilities).
>
> \(M\) Personal Assistance Services \-- these include attendant care
> and the training of such personnel providing these services.
>
> \(N\) Physical Restoration \-- restoration services including medical
> services; therapeutic treatments, such as physical therapy,
> occupational therapy, speech, language, and hearing therapy; health
> maintenance; eyeglasses and visual services; and prosthetic, orthotic
> and other assistive appliances and devices.
>
> \(O\) Preventative Services \-- these are intended to prevent
> additional disabilities, or to prevent an increase in the severity of
> an existing disability.
>
> \(P\) Prosthesis and other Appliances (See Rehab technology)
>
> \(Q\) Recreational Services \-- provision or identification of
> opportunities for the involvement of consumers in meaningful leisure
> time activities. These may include such things as participation in
> community affairs and other recreation activities that may be
> competitive, active or quiet.
>
> \(R\) Rehabilitation Technology \-- provision of, or assistance to
> obtain through other sources, adaptive modifications which address the
> barriers confronted by individuals with significant disabilities with
> respect to education, rehabilitation, employment, transportation, IL
> and/or recreation.
>
> \(S\) Therapeutic Treatment \-- services provided by registered
> occupational, physical, recreational, or speech therapists.
>
> \(T\) Transportation \-- provision of or arrangements for
> transportation.
>
> \(U\) Youth Services \-- these are provided to youth with significant
> disabilities, ages 6-17, and may include training to develop skills
> specifically designed for youths to promote self-awareness and esteem,
> develop advocacy and personal power skills, and the exploration of
> career options.
>
> \(V\) Vocational Services \-- any of the services defined in Section
> 103 of the Act.
>
> \(W\) Other \-- any IL service not listed above.

**[RSA REGIONAL OFFICE DIRECTORY]{.underline}**

> REGION I REGION II

Regional Commissioner: Mr. John Szufnarowski Regional Commissioner: Mr.
John Szufnarowski

Dept. Of Education, OSERS Dept. Of Education, OSERS

J.W. McCormack Post Office and Court House Rm 232 75 Park Place, Rm 1208

Boston, MA 02109 New York, NY 10007

(617)223-4086 VOICE (212)264-4016 VOICE

(617)223-4573 TDD (212)264-4028 TDD

(617)223-4573 FAX (212)264-3029 FAX

IL Program: Richard Anderson IL Program: Richard Anderson

> Illeana Prancan Janice Plumer

\*CT, ME, NH, RI, VT, MA \*NJ, PR, VI, NY

> REGION III REGION IV

Regional Commissioner: Dr. Ralph Pacinelli Regional Commissioner: Dr.
Ralph Pacinelli

Dept. Of Education, OSERS Dept. Of Education, OSERS

The Wanamaker Building Suite 512

100 Penn Square East 61 Forsyth St. SW Suite 18T91

Philadelphia, PA 19107 Atlanta, GA 30303-3104

(215)656-8531 VOICE (404)562-6330 VOICE

(215)656-6186 TDD (404)562-6347 TDD

(215)656-6188 FAX (404)562-6346 FAX

IL Program: Keith Beichner IL Program: Sue Rankin-White

> Margurite Pinkney Dan Hunsberger

\*DC, DE, MD, VA, WVA, PA \*AL, FL, KY, NC, SC, TN, GA, MS

> REGION V REGION VI

Regional Commissioner: Dr. Douglas Buleigh Regional Commissioner: Mr.
Loerance Deaver

Dept. Of Education, OSERS Dept. Of Education, OSERS

111 N. Canal Rm. 1048 1999 Bryan St. Rm. 2740

Chicago, IL 60606 Dallas, TX 75201-6817

(312)886-8630 VOICE (214)880-4927 VOICE

(312)353-9694 TDD (214)880-4833 TDD

(312)353-8623 FAX (214)880-4931 FAX

IL Program: Zilpha Hibner IL Program: Mike McGill

> Kathy Neimi Loretta Thomas

\*IN, MI, MN, OH, WI, IL \*AK, LA, NM, OK

> REGION VII REGION VIII

Regional Commissioner: Dr. Douglas Burleigh Regional Commissioner: Mr.
Loerance Deaver

Dept. Of Education, OSERS Dept. Of Education, OSERS

10220 N. Executive Hills Blvd FOB Suite 310- 1244 Speer Blvd

Kansas City, MO 64153-1367 Denver, CO 80204-3582

(816)880-4107 VOICE (303)844-2135 VOICE

(816)891-0985 TDD (303)844-2890 TDD

(816)891-0807 FAX (303)844-6269 FAX

IL Program: Rodney King IL Program: Mike McGill

> Mari Kierstein Patty Burrows

\*IA, KS, NB, MO \*MT, ND, SD, UT, WY, CO

> REGION IX REGION X

Regional Commissioner: Mr. Gilbert Williams Regional Commissioner: Mr.
Gilbert Williams

Dept. Of Education, OSERS Dept. Of Education, OSERS

FOB, Rm 215 - 50 United Nations Plaza 915 Second Ave Rm 2848

San Francisco, CA 94102 Seattle, WA 98174-1099

(415)437-7840 VOICE (206)220-7840 VOICE

(415)556-3323 TDD (206)220-7849 TDD

(415)437-7848 FAX (206)220-7842 FAX

IL Program: Gilbert Williams IL Program: Chris Smith

> Gayle Palumbo Diana Koreski

\*AZ, HI, NV, GU, AS, CA, CNMI \*AK, ID, OR, WA

**[CENTRAL OFFICE DIRECTORY]{.underline}**

IL Team Leader: Mr. John Nelson CIL Program Officer: Ms. Merri Pearson

Office of Development Programs Office of Developmental Programs

Rehabilitation Services Administration Rehabilitation Services
Administration

330 C St. SW Rm. 3326 330 C St. SW Rm. 3316

Washington, DC 20202-2741 Washington, DC 20202-2741

(202)205-9362 VOICE (202)205-8484 VOICE

(202)260-9424 FAX (202)260-9424 FAX

(202)205-8243 TDD (202)205-8243 TDD

E-mail: john_nelson@ed.gov E-mail: merri_pearson@ed.gov

**UNITED STATES DEPARTMENT OF EDUCATION**

**OFFICE OF SPECIAL EDUCATION AND REHABILITATIVE SERVICES**

**REHABILITATION SERVICES ADMINISTRATION**

Washington, DC 20202-2741

ANNUAL PERFORMANCE REPORT

CENTERS FOR INDEPENDENT LIVING PROGRAMS

FISCAL YEAR 1998

Non-Cited Version

**CENTER\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_STATE\_\_\_\_\_\_\_\_\_\_\_\_**

**COUNTIES
SERVED\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**NAME OF
GRANTEE\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**GRANT NUMBER
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

November, 30, 1998 THE REHABILITATION ACT OF 1973, AS AMENDED (ACT)

\*INSERT STANDARD FORM 524 (FACE SHEET OF GRANTS)

\*INSERT INSTRUCTIONS FOR FILLING OUT FORM 524

**CENTER\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_STATE\_\_\_\_\_\_\_\_Report
YR\_\_\_\_\_\_\_\_\_**

**SUBPART II A - APPLICANT SELF EVALUATION**

**I - [COMPLIANCE INDICATOR 1 PHILOSOPHY]{.underline}**

> \(A\) Consumer Control
>
> \(1\) Over 50 percent of the CILs \--
>
> . Governing board is composed of individuals with significant
> disabilities
>
> Y N

  ----------------------- ------------- --------------- -----------------
  b\. CIL Employees       Total         Number of       Number of persons
                          Positions     persons with    who are
                                        disabilities    minorities

  Decision making                                       
  Positions                                             

  Staff Positions                                       
  ----------------------- ------------- --------------- -----------------

> \(B\) Self-help and Self-advocacy
>
> \(1\) During the reporting year the CIL has conducted activities that
> promote self-help and self-advocacy among individuals with significant
> disabilities.

Y N

> \(C\) Development of Peer Relationships and Peer Role Models
>
> \(1\) During the reporting year the CIL has conducted activities that
> promote the development of peer relationships and peer role models
> among individuals with significant disabilities as instructors and
> counselors in its programs.

Y N

\(D\) Equal Access

> \(1\) Ensures equal access to the CILs services, programs,
> activities, resources, and facilities, whether publicly or privately
> funded. Equal access means that the same access is provided to the
> individual with a disability regardless of the individuals type of
> disability.

Y N

> \(2\) Advocates for and conducts activities that promote the equal
> access to all services, programs, activities, resources, and
> facilities in society, whether public or private, and regardless of
> funding sources for individuals with significant disabilities. Equal
> access means that the same access is provided to the individual with a
> disability regardless of the individuals type of disability.

Y N

> \(3\) Makes available, as appropriate, all written policies,
> materials, and IL services in alternative formats.

Y N

**II - [COMPLIANCE INDICATOR 2 - PROVISION OF SERVICES ON A
CROSS-]{.underline} [DISABILITY BASIS]{.underline}**

The Center provides the following:

> \(A\) IL services to eligible individuals or groups of individuals
> without restrictions based on the particular types of disabilities
> that the individuals or groups of individuals may have.

Y N

> \(B\) IL services to individuals with a diversity of significant
> disabilities, and individuals who are members of populations that are
> unserved or underserved

by programs under Title VII of the Act.

Y N

> \(C\) IL core services to individuals with significant disabilities in
> a manner that is neither targeted nor limited to a particular type of
> disability.

Y N

**III - [COMPLIANCE INDICATOR 3 - INDEPENDENT LIVING
GOALS]{.underline}**

\(A\) The CIL maintains a CSR for each consumer that contains:

> \(1\) documentation concerning eligibility or ineligibility of
> services; Y N
>
> \(2\) either an ILP or a waiver of the ILP; and Y N
>
> \(3\) the IL goals or objectives established with the consumer. Y N

\(B\) The CIL maintains documentation that includes evidence of:

> \(1\) that the CIL notifies all consumers of their right to develop or

waive the development of the ILP;

Y N

> \(2\) the number of ILPs developed by consumers receiving services

from the CIL;

Y N

> \(3\) the CIL facilitates the development and achievement of IL

goals selected by individuals with significant disabilities

who request assistance from the CIL;

Y N

> \(4\) that the CIL provides opportunities for consumers to express

satisfaction with the CILs services and policies in facilitating

their achievement of IL goals and provides any results to its

governing board and SILC; and

Y N

> \(5\) the number of waivers signed by consumers receiving services

from the CIL stating that an ILP is unnecessary.

Y N

**IV - [COMPLIANCE INDICATOR 4 - COMMUNITY OPTIONS AND COMMUNITY
CAPACITY]{.underline}**

During the reporting year, the CIL promoted the increased availability
and improved quality of community-based programs that serve individuals
with significant disabilities and promoted the removal of any existing
architectural, attitudinal, communication, environmental, or other type
of barrier that prevents the full integration of these individuals into
society. The CIL advocated and performed at least one activity in each
of the following categories:

> \(A\) Community advocacy; Y N
>
> \(B\) Technical assistance to the community on making services,
> programs,
>
> activities, resources, and facilities in society accessible to
> individuals

with significant disabilities; Y N

> \(C\) Public information and education; Y N
>
> \(D\) Aggressive outreach to consumers who are members of populations
> of

individuals with significant disabilities that are unserved or
underserved

by programs under Title VII of the Act in the CILs service area; and

Y N

> \(E\) Collaboration with service providers, other agencies and
> organizations

that could assist in improving the options available for individuals
with

> significant disabilities to participate in the services, programs,
> activities,

resources, and facilities in the service area.

Y N

**V - [COMPLIANCE INDICATOR 5 - IL CORE SERVICES AND OTHER IL
SERVICES]{.underline}**

> \(A\) The CIL provides information and referral to all individuals who
> request

these types of assistance or services from the center; and

Y N

> \(B\) As appropriate in response to their requests, provides to
> individuals with significant disabilities who are eligible for IL
> services from the CIL the

following services: IL skills training; Peer counseling (including

cross-disability peer counseling; individual and systems advocacy; and,

a combination, as appropriate, of any two or more other IL services.

Y N

**VI - [COMPLIANCE INDICATOR 6 - RESOURCE DEVELOPMENT
ACTIVITIES]{.underline}**

> \(A\) The CIL conducted resource development activities during the
> reporting

year to obtain funding from sources other than Chapter 1 of Title VII

of the Act.

Y N

**SUBPART IIB: NARRATIVE - COMPARISON OF THE ACTIVITIES OF THE CIL WITH
THE REPORTING YEAR WORK PLAN AND WITH THE PLANNED ACTIVITIES AND THE
ACTIVITIES IN THE YEAR IMMEDIATELY PRECEDING THE REPORTING YEAR**

This section compares the accomplishments of fiscal year 1998 with the
work plan for fiscal year 1998. Fiscal year 1999 (the current year) is
not addressed in this report. *Fiscal year 2000 work plans are to be
included in **Subpart C.***

**[ATTACHMENT II - B]{.underline}**

In the following order please provide:

> \(A\) A comparison of fiscal year 1998 activities and accomplishments
> with the plan goals and activities. Where appropriate, provide a brief
> comparison of program accomplishments and goal achievements during
> fiscal year 1998 to fiscal year 1997.
>
> \(B\) If appropriate, descriptions of significant activities not
> accounted for elsewhere in this report.
>
> \(C\) As appropriate, descriptions of substantial problems or
> difficulties, alternative solutions explored, and what worked and why.

**SUBPART IIC: PROGRAM PLANNING OBJECTIVES**

**[ATTACHMENT II - C(a)]{.underline}**

This is a copy of Federal fiscal year 2000\'s work plan.

**[ATTACHMENT II - C(b)]{.underline}**

This is a list of training and technical assistance needs listed in
priority area for the CIL.

**SUBPART IID: SOURCES AND AMOUNTS OF RESOURCES FOR THE OPERATION OF THE
CIL DURING THE REPORTING YEAR**

I - RESOURCES

> \(A\) Federal Funds
>
> . Ch. 1, part B, Title VII
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> . Ch. 1, part C, Title VII
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> . Ch. 2, Title VII \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> . Other Federal Funds \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \(B\) Other Government Funds
>
> . State Government Funds
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> . Local Government Funds
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \(C\) Private Funds
>
> . Foundations, Corporations, or Trust Grants
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> . Donations from Individuals
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> . Memberships \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> . Investment Income, Endowments
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> . Fee for Service (program income)
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> . Other Resources (in-kind, etc.)
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \(D\) TOTAL RESOURCES \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \(E\) Amount of Total Resources that pass through to

consumers, e.g. personal assistance service funds
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> \(F\) Net Resources (line d minus line e)
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**SUBPART IIE: NEXT YEAR BUDGET INFORMATION**

If a CIL has negotiated a budget for each year of its grant award, and
there are no changes needing RSA approval, the completion of this
section is not required. This section is Education Form 524, and found
on the following page.

**SUBPART IIF: NUMBERS AND TYPES OF INDIVIDUALS WITH SIGNIFICANT
DISABILITIES RECEIVING SERVICES THROUGH THE CIL**

I - Consumers served during the reporting year:

> \(A\) CSRs carried from previous year \_\_\_\_\_\_\_\_\_\_
>
> \(B\) CSRs started since Oct. 1 of the reporting year
> \_\_\_\_\_\_\_\_\_\_
>
> \(C\) Total consumers served \_\_\_\_\_\_\_\_\_\_

II - Consumers inactive on September 30^th^ of the reporting year

> \(A\) Moved \_\_\_\_\_\_\_\_\_\_
>
> \(B\) Withdrew \_\_\_\_\_\_\_\_\_\_
>
> \(C\) Died \_\_\_\_\_\_\_\_\_\_
>
> \(D\) Inactive because goals were met \_\_\_\_\_\_\_\_\_\_
>
> \(E\) Other \_\_\_\_\_\_\_\_\_\_
>
> \(F\) Total \_\_\_\_\_\_\_\_\_\_

III - Consumers (CSRs) active on September 30^th^ of the reporting year

> \[line I-c minus line I-f\] \_\_\_\_\_\_\_\_\_\_

IV - Consumer Plans and Waivers

> \(A\) Number of individuals declining offer to develop ILP
> \_\_\_\_\_\_\_\_\_\_
>
> \(B\) Number of individuals with whom an ILP was developed
> \_\_\_\_\_\_\_\_\_\_

V - Consumer Achievements

> **Goals Set Goals Met**
>
> \(A\) Self-care \_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_
>
> \(B\) Communication \_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_
>
> \(C\) Mobility \_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_
>
> \(D\) Residential \_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_
>
> \(E\) Educational \_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_
>
> \(F\) Vocational \_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_
>
> \(G\) Other \_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_

VI - Age Information **Numbers of Individuals**

> \(A\) Under 6 \_\_\_\_\_\_\_\_\_\_
>
> \(B\) 6 - 17 \_\_\_\_\_\_\_\_\_\_
>
> \(C\) 18 - 22 \_\_\_\_\_\_\_\_\_\_
>
> \(D\) 23 - 54 \_\_\_\_\_\_\_\_\_\_
>
> \(E\) 55 & Over \_\_\_\_\_\_\_\_\_\_

VII - Gender

> \(A\) Female \_\_\_\_\_\_\_\_\_\_
>
> \(B\) Male \_\_\_\_\_\_\_\_\_\_

VIII - Race/ethnicity

> \(A\) White (non-Hispanic) \_\_\_\_\_\_\_\_\_\_
>
> \(B\) Black (non-Hispanic) \_\_\_\_\_\_\_\_\_\_
>
> \(C\) American Indian or Alaskan Native (including Native Hawaiian)
> \_\_\_\_\_\_\_\_\_\_
>
> \(D\) Asian or Pacific Islander \_\_\_\_\_\_\_\_\_\_
>
> \(E\) Hispanic \_\_\_\_\_\_\_\_\_\_

IX - Disability

> \(A\) Cognitive \_\_\_\_\_\_\_\_\_\_
>
> \(B\) Mental/Emotional \_\_\_\_\_\_\_\_\_\_
>
> \(C\) Physical \_\_\_\_\_\_\_\_\_\_
>
> \(E\) Hearing \_\_\_\_\_\_\_\_\_\_
>
> \(F\) Vision \_\_\_\_\_\_\_\_\_\_
>
> \(G\) Multiple Disability \_\_\_\_\_\_\_\_\_\_

X - Community-Based Living

> \(A\) Individuals successfully relocated from nursing homes or other
> institutions to community-based living arrangements
> \_\_\_\_\_\_\_\_\_\_
>
> \(B\) Individuals for whom IL services prevented the necessity of
> entering nursing homes or other institutions and therefore continued
> living in a community-based living arrangements \_\_\_\_\_\_\_\_\_\_

**SUBPART IIG: TYPES OF SERVICES PROVIDED AND THE NUMBER OF INDIVIDUALS
WITH SIGNIFICANT DISABILITIES RECEIVING EACH TYPE OF SERVICE**

I - Community Services (***this section is optional***) **Total Hrs**

> \(A\) Information and Referral \_\_\_\_\_\_\_\_\_\_

I - Community Services (***this section is optional***)(continued)
**Total Hrs**

> \(B\) Community and Systems Advocacy \_\_\_\_\_\_\_\_\_\_
>
> \(C\) Outreach \_\_\_\_\_\_\_\_\_\_
>
> \(D\) Publications \_\_\_\_\_\_\_\_\_\_
>
> \(E\) Community Education \_\_\_\_\_\_\_\_\_\_
>
> \(F\) Maintaining Registries \_\_\_\_\_\_\_\_\_\_
>
> \(G\) Other \_\_\_\_\_\_\_\_\_\_
>
> \(H\) Total \_\_\_\_\_\_\_\_\_\_

II - Individual Services **Numbers of Individuals**

> \(A\) Advocacy \_\_\_\_\_\_\_\_\_\_
>
> \(B\) Legal \_\_\_\_\_\_\_\_\_\_
>
> \(C\) Childrens \_\_\_\_\_\_\_\_\_\_
>
> \(D\) Communication \_\_\_\_\_\_\_\_\_\_
>
> \(E\) Counseling and Related \_\_\_\_\_\_\_\_\_\_
>
> \(F\) Family \_\_\_\_\_\_\_\_\_\_
>
> \(G\) Housing, Home Modifications, and Shelter \_\_\_\_\_\_\_\_\_\_
>
> \(H\) Information and Referral \_\_\_\_\_\_\_\_\_\_
>
> \(I\) IL Skills Training and Life Skills Training \_\_\_\_\_\_\_\_\_\_
>
> \(J\) Mental Restoration \_\_\_\_\_\_\_\_\_\_
>
> \(K\) Mobility Training \_\_\_\_\_\_\_\_\_\_
>
> \(L\) Peer Counseling (incl: Cross-disability Peer Counseling)
> \_\_\_\_\_\_\_\_\_\_
>
> \(M\) Personal Assistance Services \_\_\_\_\_\_\_\_\_\_
>
> \(N\) Physical Rehabilitation \_\_\_\_\_\_\_\_\_\_
>
> \(O\) Preventative Services \_\_\_\_\_\_\_\_\_\_
>
> \(P\) Prostheses and other \_\_\_\_\_\_\_\_\_\_
>
> \(Q\) Recreational \_\_\_\_\_\_\_\_\_\_
>
> \(R\) Rehabilitation Technology \_\_\_\_\_\_\_\_\_\_
>
> \(S\) Therapeutic Treatment \_\_\_\_\_\_\_\_\_\_
>
> \(T\) Transportation \_\_\_\_\_\_\_\_\_\_
>
> \(U\) Youth \_\_\_\_\_\_\_\_\_\_
>
> \(V\) Vocational \_\_\_\_\_\_\_\_\_\_
>
> \(W\) Other \_\_\_\_\_\_\_\_\_\_

**I hereby affirm that the information contained in this Section 704
Annual Performance Report, Part II is true and correct to the best of my
knowledge:**

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_

SIGNATURE OF THE CENTER FOR INDEPENDENT LIVING DIRECTOR DATE

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

SIGNATURE OF THE GRANT OFFICIAL (IF DIFFERENT FROM THE DIRECTOR) DATE

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

NAME AND TITLE OF GRANT OFFICIAL PHONE NUMBER