FORM RSA-509 OMB NO. 1820- 0627 

 EXPIRES XXX XXX XXX

ANNUAL PROTECTION & ADVOCACY OF INDIVIDUAL RIGHTS (PAIR)

PROGRAM PERFORMANCE REPORT

Fiscal Year 

DESIGNATED AGENCY IDENTIFICATION

Name:

Address:

E-mail Address (if applicable):

Website Address (if applicable):

Phone: ( ) TTY: ( )

Toll-free Phone: ( ) Toll-free TTY: ( )

Fax: ( )

Name of P&A Executive Director:

Name of PAIR Director/Coordinator:

Person to contact regarding report:

Contact Person's phone: ( )

PART I. NON-CASE SERVICES:

A. Individual Information and Referral Services (I&R):

(Multiple responses are not permitted.)

1. Individuals receiving I&R within PAIR's priority areas

2. Individuals receiving I&R outside of PAIR's priority areas

3. Total individuals receiving I&R (lines A1+A2)

B. Training Activities:

1. Number of trainings presented by PAIR staff

2. Number of individuals who attended these trainings (approximate)

Describe the trainings presented by PAIR staff. Be sure to include information about 

the topics covered, the training methods used, and the purpose for the training. Use 

separate sheets if necessary.

C. Information Disseminated to the Public:

1. Radio and TV appearances by PAIR staff

2. Newspaper/magazine/journal articles

3. PSAs/videos aired

4. Hits on the PAIR/P&A website

5. Publications/booklets/brochures disseminated

6. Other (specify on separate sheet)
PART II. INDIVIDUALS SERVED:

A. Individuals Served: (An individual is counted only once per fiscal year. Multiple 

counts are not permitted for lines A1 through A3.)

1. Individuals who were still being served as of October 1 (carryover 

from prior fiscal year)

2. Additional individuals who were served during the year

3. Total individuals served (lines A1+A2)

4. Individuals who had more than one case file opened/closed during 

the fiscal year. (This number is not added to the total on line A3 

above.)

B. Individuals still served as of September 30 (carryover to next year) (May not 

exceed total on line II.A.3 above.)

C. Problem Areas/Complaints of Individuals Served:

1. Architectural accessibility

2. Employment

3. Program access

4. Housing

5. Government benefits/services

6. Transportation

7. Education

8. Assistive technology

9. Voting

10. Health care

11. Insurance

12. Non-government services

13. Privacy rights

14. Access to records

15. Abuse

16. Neglect

17. Other

D. Reasons for Closing Individual's Case Files:

1. Issues resolved partially or completely in the individual's favor

2. Other representation found

3. Individual withdrew complaint

4. Appeals were unsuccessful

5. PAIR services not needed due to individual's death, relocation, 

etc.

6. PAIR withdrew from case

7. PAIR unable to take case because of lack of resources

8. Individual's case lacks legal merit

9. Other (Please explain on separate sheet.)

E. Intervention Strategies Used in Serving Individuals: (List the highest level of 

intervention used by PAIR prior to closing each case file.)

1. Technical assistance in self-advocacy

2. Short-term assistance
3. Investigation/monitoring

4. Negotiation

5. Mediation/alternative dispute resolution

6. Administrative hearings

7. Litigation (including class actions)

8. Systemic/policy activities

PART III. STATISTICAL INFORMATION ON INDIVIDUALS SERVED:

A. Age of Individuals Served: (as of October 1)

(Multiple responses not permitted.)

1. 0 - 4

2. 5 - 22

3. 23 - 59

4. 60 - 64

5. 65 and over

B. Gender of Individuals Served: (Multiple responses not permitted)

1. Females

2. Males

C. Race/Ethnicity of Individuals Served:

1. Hispanic /Latino of any race

For individuals who are non-Hispanic/Latino only:

2. American Indian or Alaska Native

3. Asian 

4. Black or African American

5. Native Hawaiian or other Pacific Islander

6. White

7. Two or more races

8. Race/ethnicity unknown

D. Living Arrangements of Individuals Served: (Multiple responses not permitted)

1. Independent

2. Parental or other family home

3. Community residential home

4. Foster care

5. Nursing home

6. Public institutional living arrangement

7. Private institutional living arrangement

8. Jail/prison/detention center

9. Homeless

10. Other living arrangements

11. Living arrangements not known

E. Primary Disability of Individuals Served: (Identify the individual's primary 

disability, namely the one directly related to the issues/complaints raised by the 

individual.)

1. Blind/visual impairment

2. Deaf/hard of hearing

3. Deaf-blind
4. Orthopedic impairment

5. Mental illness

6. Substance abuse

7. Mental retardation

8. Learning disability

9. Neurological impairment

10. Respiratory impairment

11. Heart/other circulatory impairment

12. Muscular/skeletal impairment

13. Speech impairment

14. AIDS/HIV

15. Traumatic brain injury

16. Other disability

PART IV. SYSTEMIC ACTIVITIES AND LITIGATION:

A. Systemic Activities:

1. Number of policies/practices changed as a result of non-litigation 

systemic activities

2. Number of individuals potentially impacted by policy changes

Describe your systemic activities. Be sure to include information about the policies 

that were changed and how these changes benefit individuals with disabilities. 

Include case examples of how your systemic activities impacted individuals served. 

(Attach separate sheets if necessary.)

B. Litigation/Class Actions:

1. Number of individuals potentially impacted by changes as a result 

of PAIR's litigation/class action efforts

2. Number of individuals named in class actions

Describe your litigation/class action activities. Explain how individuals with disabilities 

benefited from your litigation activities. Be sure to include case examples that 

demonstrate the impact of your litigation. (Attach separate sheets if necessary.)
PART V. PAIR'S PRIORITIES AND OBJECTIVES:

A. Priorities and Objectives for the Fiscal Year Covered by this Report:

For each of your PAIR program priorities for the fiscal year covered by this report, 

please:

1. Identify and describe the priority.

2. Identify the need, issue or barrier addressed by this priority.

3. Identify and describe indicators PAIR used to determine successful outcome of 

activities pursued under this priority.

4. Explain whether pursuing this priority involved collaborative efforts by other 

entities. If so, describe this collaboration.

5. Provide the number of cases handled under the priority. Indicate how many of 

these, if any, were class actions.

6. Provide at least one case summary that demonstrates the impact of the priority.

B. Priorities and Objectives for the Current Fiscal Year:

Please include a statement of priorities and objectives for the current fiscal year 

(the fiscal year succeeding that covered by this report), which should contain the 

following information:

1. a statement of each priority;

2. the need addressed by each priority; and;

3. a description of the activities to be carried out under each priority.
PART VI. NARRATIVE:

At a minimum, you must include all of the information requested. You may include 

any other information, not otherwise collected on this reporting form that would be 

helpful in describing the extent of PAIR activities during the prior fiscal year. Please 

limit the narrative portion of this report, including attachments, to 20 pages or less.

The narrative should contain the following information. The instructions for this form 

outline the information that should be contained in each section.

A. Sources of funds received and expended

B. Budget for the fiscal year covered by this report

C. Description of PAIR staff (duties and person-years)

D. Involvement with advisory boards (if any)

E. Grievances filed under the grievance procedure 

F. Coordination with the Client Assistance Program (CAP) and the State long-term 

care program, if these programs are not part of the P&A agency

Reports are to be submitted to RSA within 90 days after the end of the fiscal year 

covered by this report. Please be reminded that you can enter data directly into 

RSA’s Management Information System (MIS) via the Internet. Information on 

transmittal of the form, including electronic transmission, is found on pages 18 

and 19 of the reporting instructions. 

Signature of agency official Date 

Paperwork Burden Statement: 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 1820-0627. The 

time required to complete this information collection is estimated to average 16 hours per response, 

including the time to review instructions, search existing data resources, gather the data needed, 

and complete and review the information collection. The obligation to respond to this collection is 

required to obtain or retain benefit pursuant to Section 509 of the Rehabilitation Act of 1973, as 

amended, and its implementing federal regulations at 34 CFR Part 381. If you have any comments 

concerning the accuracy of the time estimate or suggestions for improving this form, please write 

to: U.S. Department of Education, Washington, DC 20202-2703. If you have comments or concerns 

regarding the status of your individual submission of this form, write directly to: OSERS/RSA, U.S. 

Department of Education, 400 Maryland Avenue S.W, Washington, DC 20202-2800.