*Response Required *Program Type: £ £ £ £ £ UCEDD LEND LEAH PPC DBP *Fiscal Year: 2016 *Core Function: Performing Research or Evaluation *Title of Activity: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Activity Description (This field may be used to provide brief explanatory information (up to 50 words) on the activity being reported in this record) \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Involvement \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ the first and last name of all staff members who were involved in conducting this activity.) *Type of Activity (Select one)    Advocacy Capacity Building Systemic Change *Area of Emphasis (Check one) Areas listed in the DD Act:   Quality Assurance Activities Education & Early Intervention   Child Care-Related Activities Health-Related Activities   Employment-Related Activities Housing-Related Activities   Transportation-Related Activities Recreation-Related Activities Areas not listed in the DD Act:   Quality of Life Activities Other-Assistive Technology   Other-Cultural Diversity Other-Leadership  Other, Please Specify: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Types and Numbers of Participants (Supply number for all that apply) Trainees Total \_\_\_\_\_\_\_\_ Adults with Disabilities Other Classroom Students \_\_\_\_\_\_\_\_ Children/Adolescents with Disabilities/SHCN Professionals & Para-Professionals \_\_\_\_\_\_\_\_ Legislators/Policymakers Family Members/Caregivers \_\_\_\_\_\_\_\_ General Public/Community Members *Primary Agency Collaborating on the Work of the Activity (Select one) £ Not Applicable/No Collaborating Agency   State Title V Agency Post Secondary Education (Community

  State Health Dept. Employment/Voc Rehab   Clinical Programs/Hospitals State/Local MR/DD Agency or Provider   State Adolescent Health State/Local Social Services   Other Health-Related Program Aging Organization   Health Insurance/Managed Care Organization Health Agency - Public/Private   Medicaid Mental Health/Substance Abuse Agency   Development Disabilities Council H o u s i n g Agency/Provider   Protection & Advocacy Agency (P&A) R e c r e a tion Agency   Another UCEDD Transportation Agency   Childcare/Early Childhood/Part C Infants and Provider Organization  Toddlers Consumer/Advocacy Organization   Head Start/Early Head Start State/Local Coalition   State/Local Special Education (3-21) Legislative Body   State/Local General Education Justice/Legal Organization NIRS FY 16 Activity form Page