FORM RSA

- 509 OMB NO. 1820

- 0627 EXPIRES XXX XXX XXX

**AN NUA**  **L PROTECTION & A DVOCA**  **CY OF INDIVIDUA L RIGHTS (PA**  **I R)** 

**PROGRA M PERFORMA**  **NCE REPORT**

**Fiscal Year**

**DESIGNA TED**  **AG ENCY IDENTIFICA** **TION** Name: Address:

E

- mail Address (if applicable): We bsite 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: ( ) **PA RT I. NON** 

**- CA** **SE SERVICES: A.**  **Individual Information and Referral Services (I&R):** (Multiple r esponses 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 A ctiv**  **ities:** 1. Number of trainings pr esented 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 train ing. 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/boo klets/brochures disseminated 6. Other (specify on separate sheet)**PA RT II. INDIVIDUA**  **LS 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 w ho 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 A reas/Complaints of Individuals Served:**  1. Architect ural 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 rig hts 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 expla in 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 assistance3. Investigation /monitoring

4. Negotiation 5. Mediation/alternative dispute resolution 6. Administrative hearings 7. Litigation (including class actions) 8. Systemic/policy activities **PA RT III. STA** **TISTICA L INFORMA** **TION ON INDIVIDUA LS SERVED:**  **A. Ag**  **e 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 Individual s Served:**  1. Hispanic /Latino of any race **For individuals w ho 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

. Wh ite 7

. Tw o or more races 8 . Race/ethnicity unknown **D. Living Ar**  **rangements 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 liv ing 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 pri mary 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

- blind4. Orthopedic impairment

5. Mental illness 6. Substance abuse 7. Mental retar dation 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 **PA RT IV. SYSTEMIC A**  **CTIVITIES A ND LITIGA** **TION: A.**  **Sy stemic A**  **ctiv ities:**  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 a ctivities. 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 nec essary.)

**B. Litigation/Class A ctions:**  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 activ ities. 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.)**PA RT V. PA**  **IR'S PRIORITIES A ND**  **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, desc ribe 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 fo**  **r 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 ne ed addressed by each priority; and;

3. a description of the activities to be carried out under each priority.**PA RT VI. NA**  **RRA TIVE:** 

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 t he 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 (duti es 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 tran smittal 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 display** **s a valid OMB control number. The valid OMB control number for this information collection is 1820** 

**- 0627. The**  **time required to complete this information collecti on 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 requir** **ed 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 y ou have an**  **y comments**  **concerning the accuracy of**  **the time estimate or suggestions for imp roving this form, please write**  **to: U.S. Department of Education, Washington, DC 20202**

**- 2703. If**  **yo u have comments or concerns**  **regarding the status of y our individual submission of this form, write directly**  **to: OSERS/RSA, U.S. Department of Education, 40**  **0 Mary land Avenue S.W, Washington, DC 20202** 

**- 2800.**