1 **PROTECTION AND ADVOCACY OF INDIVIDUAL RIGHTS (PAIR)**  **PROGRAM PERFORMANCE REPORT**

**INSTRUCTIONS**
**FISCAL YEAR:** Enter the fiscal y ear covered by this report. **DESIGNATED AGENCY IDENTIFICATION:** Enter the name, address, telephone, TTY and fax numbers (includi ng area codes), and e

- mail and website addresses (if applicable) of the agency designated to administer the PAI R program. Also, enter the names of the Executive Director of the Protection and Advocacy

(P&A) agency, the PAI R director/coordinator (if applic able), and the person to contact (including telephone number) in the event questions arise regarding the report. **DEFINITIONAL GUIDELINES FOR THIS REPORT I&R SERVICES:**  I&R services are those services that include responses to individuals at meetings, one

- time telephone discussions, and follow

- up mailings of letters, brochures and/or pamphlets per an individual's request. These services generally take less than one hour of service time. PAI R generally

would not have personal identify ing information about the individuals who request and/or receive I&R services, except possibly for the name, address and telephone number. For purposes of this section of the report, individuals who receive I&R services are those who do not meet the definition of "individual served" (see definition below). **INDIVIDUAL SERVED:** To be considered an "individual served" (a.k.a. a "client" of PAI R), the individual must meet three criteria: 1. The individual is eligible for PAI R services according to section 509(a) of the Rehabilitati on Act of 1973, as amended (the act); 2. PAI R has opened a case file/service record, which includes at least the individual's name, address, age, race, disability , signed release of information form (if appropriate), the individual's concern or complaint, an d the action taken by PAI R; and;
3. PAI R provided at least one "significant service," such as: a. at least one hour of case service time; b. a supervised referral that allows follow

- up to assure that the referral was appropriate and completed; c. the completion of a second telephone call to the client when the time between telephone calls was used to obtain additional information about appropriate programs; or d. the provision of any allowable service bey

ond I&R services, as defined above.2

To s atisfy the first criterion above, an individual is eligible for PAI R services if he/she: 1. is ineligible for the Protection and Advocacy for Developmental Disabilities (PADD) program because the individual does not meet the definition of having a "developme ntal disability" as defined in the Developmental Disabilities Assistance and Bill of Rights Act; 2. is ineligible for the Protection and Advocacy for I ndividuals with Mental I llness (PAI MI ) program because the individual is not an "individual with a mental i llness" as defined in the Protection and Advocacy for Mentally

I ll I ndividuals Act; and; 3. needs services that are beyond the scope of services authorized to be provided by the Client Assistance Program (CAP) under section 112 of the act. **CASE FILE/SER**

**VICE RECORD:** This is the compilation of personal identify ing information about the individual, documents, letters, complaints/issues raised, advocate's notes, etc., used in working with an "individual served" (as defined above). I t may contain many

issue s at any

one time. I n fact, many

individuals served will present several issues to PAI R during the course of the PAI R/client relationship. The case file/service record is opened at the time PAIR determines that it will provide at least one "significant se rvice" (as defined above) for the individual. New issues may arise while still working with the individuals. These new issues, if appropriate for PAI R intervention, should be added to the existing case file/service record. **PART I. NON -**  **CASE SERVICES :**  **A. Individual Information and Referral (I&R) Services:**  In clude in this category the number of times that PAI R provided I&R services to individuals during the fiscal y ear. Be sure to include only numbers that reflect I &R services provided by only the PAI R p rogram - not the P&A agency as a whole. Estimated counts are not acceptable for this section. All PAI Rs should maintain logs to respond accurately

to this section. Such routine requests should not require maintenance of client confidential information, e xtensive research by PAIR staff, or extended contact with the individual. For purposes of this section of the report, do not include any data regarding I&R services provided to individuals who meet the definition of "individual served" (as defined above). Services provided to those individuals are recorded in another section of this report. When counting follow

- up mailings of letters, brochures or pamphlets, be sure to count only the number of individuals who actually requested the information, not the nu mber of letters, brochures or pamphlets sent. Do not include the number of brochures, pamphlets or newsletters that are routinely distributed en masse or the number of individuals who attend workshops or trainings presented by

PAI R staff. This data will be collected in another section of this report. **Line A1:** Enter the number of individuals who received I&R services from PAI R for issues that were **within** the priorities set by PAI R for the fiscal year covered by this report. I n other words, PAI R was able to meet these individuals' needs by providing I&R services only and did not open a case file/service record for these individuals.3

**Line A2:** Enter the number of individuals who received I&R services from PAI R on issues that were **not** within PAI R's priorit ies for the fiscal y ear covered by this report. **Line A3:** Add lines A1 and A2. This is the total number of individuals who received I&R services from PAI R during the fiscal y ear covered by this report. **B. Training Activities:** Include in this category information about the trainings offered by the PAI R program. PAI R staff frequently offers trainings for individuals with disabilities, their families, and various community groups. The purpose of these trainings is generally to educate individuals with disabilities, their families, and members of the community about the laws protecting individuals with disabilities. These trainings are also often used to teach self

- advocacy skills to individuals with disabilities and their families. **Line B1:** Enter the number of trainings and workshops presented by PAI R staff during the fiscal ye ar covered by this report. **Line B2:** Enter the number of individuals who attended these trainings. I f PAI R did not maintain registration logs of these trainings and workshops, it is acceptable to provide an estimate of the number of individuals who attended the trainings and workshops. **Descriptive Information:** Describe the trainings and workshops presented by PAI R staff as completely

as possible. For each of the trainings an d workshops presented, be sure to include information about: 1) the topics and issues covered by the trainings; 2) the training methods used (i.e., lecture, hands

- on learning, etc.); and 3) the purpose of the training. Please use additional sheets as nec essary

to provide this information. **C. Information Disseminated to the Public:** In clude in this category information that PAI R disseminated to the public at large. I n many of these circumstances, PAI R will be unable to provide the number of individuals w ho received the information. Therefore, this data will not be requested for many of the following items. **Line C1:** Enter the number of radio and/or TV appearances that PAI R staff made during the fiscal ye ar covered by this report. **Line C2:** Enter the nu

mber of articles that PAI R staff wrote and had published in the newspaper, magazines, journals or other periodicals. Also include on this line the number of articles, written by others, but that highlighted the work done by PAI R during the fiscal y ear cov ered by this report. **Line C3:** Enter the number of videos or public service announcements (PSAs) that were aired pursuant to efforts by

PAIR. Do not include the number of times the videos or PSAs were aired. Instead, count only

the actual number of PSAs or videos that were aired during the fiscal y ear covered by

this report. For example, the local radio station aired two of PAI R's PSAs about architectural barriers thirty times each. For purposes of this line entry , there were 2 PSAs aired. **Line C4:** E nter the number of hits that were made on PAI R's (or the P&A's) website (if applicable) during the fiscal y ear covered by this report.4

**Line C5:** Enter the number of publications, booklets or brochures that PAI R disseminated during the fiscal y ear covered b y this report. I nclude on this line, those brochures, booklets and publications that were disseminated en masse at trainings or via regular mailings to PAI R' s mailing list. Do not include on this line those brochures, booklets or publications that were d isseminated to individuals at the individual's request. This information was collected in category “A” above. **Line C6:** Enter the number of other information, not otherwise collected in this section of the report, which was disseminated to the public at large during the fiscal y ear covered by this report. Be sure to specify

the ty pes of information and the method used to disseminate this information on a separate sheet. **PART II. INDIVIDUALS SERVED :**  **A. Individuals Served:** Include in this category , the number of individuals to whom PAI R provided advocacy

services during this fiscal y ear. As stated in the definitional guidelines section above, an "individual served" is someone who is eligible for PAI R services; who has a case file/service record with PAI R; and who received one or more significant services from PAI R. All concerns noted in the case file/service record should have required some ty pe of intervention (even if it is only

brief) that goes bey

ond the definition of "I&R" services. An "individual served" is counted only once during a fiscal year, regardless of how many case files/service records were opened/closed for that individual during the y ear. Estimated counts are not acceptable. All PAI Rs should maintain logs to respond accurately to thi s item. Do not include in this section any

"I&R services" provided to individuals who do not meet the definition of "individuals served." I&R services provided to those individuals are recorded in an earlier section of this report. **Line A1:** Enter the n

umber of individuals who had open case files/service records on hand at the beginning of the fiscal y

ear, which were carried over from the prior fiscal y ear. **Line A2:** Enter the number of individuals who had new case files/service records opened during th is fiscal y ear. **Line A3:** Add lines A1 + A2 and enter the total number here. This is the total number of individuals served during this fiscal y ear. Remember, no individual may be counted more than once in a fiscal y ear. **Line A4:** Of the number of indi viduals accounted for on Line A3 above, enter here the number of those individuals who had more than one case file/service record opened/closed during the fiscal ye ar. **Example:** An individual may have received legal advice for one issue early in the fisca l ye ar. However, a new and unrelated issue arose several months later (in the same fiscal ye ar) for this individual and PAI R agreed to represent him/her. Depending on the PAI R program's case management program, this individual may have had two cases open ed/closed during the fiscal y ear. Thus, this individual would be counted on Line A4 as having5

multiple case files/service records during the fiscal year. I f this were the only such individual for PAI R this fiscal y ear, PAI R should enter a "1" on Line A4. **B. Individuals Still Served as of September 30:** Enter here the number of individuals served who still had open case files/service records with PAI R as of September 30. These are the individuals who need PAI R intervention to continue into the next fisca l y ear (carr yover) in order to resolve the problems/issues raised this fiscal y ear. This number may not exceed the total number of "individuals served" listed on Line II.A3 above. This number will equal the "number of individuals who were still being ser

ved as of October 1" (Line II.A1) on next fiscal y ear's annual report. **C. Problem Areas/Complaints of Individuals Served:** In clude in this category the ty pes of problems/complaints that "individuals served" presented to PAI R during this fiscal y ear. Be s ure to include only

those problems/complaints that were directly related to the individual's disability

. **Example:** An individual with a disability may have a housing problem that is not related in any way to the individual's disability . Although that in dividual with a disability might otherwise be eligible for PAI R services, PAI R cannot represent that individual on the housing problem if that housing problem is not related to the individual's disability . PAI R could, however, represent that same individu al on a different issue, such as employ ment, that is related to the individual's disability

. The following list contains broad categories of the common ty pes of complaints/problems individuals served present to PAI R. Please account for each problem/compl aint in the most appropriate category . Multiple counts are permitted in case one individual presents more than one problem/complaint for PAI R intervention. **Line C1:** Enter on this line the number of individuals who sought PAI R assistance for complaints r elated to architectural barriers or other building accessibility problems. These complaints could relate to any

aspect of accessibility

to the building or structure, including the adjoining parking lot or garage, building entrance, interior rooms, signage , etc. I nclude on this line complaints for both public and private buildings/structures. **Line C2:** Enter on this line the number of individuals who sought PAI R assistance for complaints related to employ

ment. These employ

ment complaints may

involve such issues as hiring or termination, reasonable accommodations, supported employ ment, or employment benefits. **Line C3:** Enter on this line the number of individuals who sought PAI R assistance for complaints related to program access. I nclude on this line the number of individuals who were denied equal access to a program due to their disabilities. Examples might an include an individual who is not allowed to participate in a YMCA program due to a particular disability or a child who is not allowed to attend camp due to a disability . Do not enter on this line those complaints that relate to the accessibility

of the building in which the program is housed. **Line C4:** Enter on this line the number of individuals who sought PAI R assistance for complaints related to housing. These housing complaints may involve such issues as contracts/property ownership, zoning or restrictive covenants, reasonable accommodations, landlord/tenant, and subsidized or section 8 housing.6

**Line C5:** Enter on this line the number of i ndividuals who sought PAI R assistance for complaints related to government benefits or services. I nclude on this line those individuals who had difficulty securing equal access to a government service or who have problems with government financial benefit s programs, welfare

- to
- work programs, and other government programs. **Line C6:** Enter on this line the number of individuals who sought PAI R assistance for complaints related to transportation. These complaints may involve such issues as the accessibility or availability

of accessible public transportation. **Line C7:** Enter on this line the number of individuals who sought PAI R assistance for complaints related to education. These education complaints may involve such issues as I EP planning, development o r implementation; inclusive settings in the schools; availability of assistive technology and interpreter services and devices in the schools; discipline, suspension or expulsion; and other education

- related issues. Do not include on this line those compl aints that relate to building accessibility

or program access of the school program. These issues should be counted on lines C1 or C3 above. **Line C8:** Enter on this line the number of individuals who sought PAI R assistance for complaints related to assis tive technology. These complaints generally will involve the individual's access to needed assistive technology , such as augmentative communication devices, durable medical equipment, vehicle modifications, etc. **Line C9:** Enter on this line the number of individuals who sought PAI R assistance for complaints related to voting, such as the accessibility of the voting process for individuals with disabilities. **Line C10:** Enter on this line the number of individuals who sought PAI R assistance for complaints related to health care. These complaints may involve such issues as Medicaid problems; access to or denial of coverage for medical insurance; access to medical or treatment services or managed care, etc. **Line C11:** Enter on this line the number of indivi duals who sought PAI R assistance for complaints related to insurance. These issues may include denial of private disability or life insurance coverage due to the individual's disability . Do not include on this line issues related to medical insurance bec ause those complaints are accounted for on Line C10 above. **Line C12:** Enter on this line the number of individuals who sought PAI R assistance for complaints related to an inability

to receive non

- government services. These complaints may involve such i ssues as problems with obtaining interpreter services for medical visits; access to menus in an alternative format; obtaining needed personal assistance services; etc. This line is distinguished from L ine C5 above which captures all complaints regarding s ervices paid for with government (Federal, State or local) funds. **Line C13:** Enter on this line the number of individuals who sought PAI R assistance for complaints related to privacy

rights. These issues involve some invasion of the individual's right of privacy , such as the release of medical information without the individual's consent.7

**Line C14:** Enter on this line the number of individuals who sought PAI R assistance for complaints related to access to records. I nclude on this line the number of indiv iduals who were denied access to their records for some reason related to their disabilities. **Line C15:** Enter on this line the number of individuals who sought PAI R assistance for complaints related to abuse. These complaints may involve such issues as inappropriate or excessive phy sical restraint, isolation or seclusion; inappropriate or excessive medication; involuntary sterilization; failure to provide appropriate medical treatment; physical or sexual assault; threats of retaliation by facility staff; coercion; suspicious death; etc. **Line C16:** Enter on this line the number of individuals who sought PAI R assistance for complaints related to neglect. These complaints may involve such issues as the failure to provide appropriate diagnostic evaluations, personal care, written habilitation plan, adequate discharge planning, etc. **Line C17:** Enter on this line the number of individuals who sought PAI R assistance for complaints not otherwise covered by

the above list. Examples of complaints that PAI R might address, but are not included in the above listing, are issues related to criminal actions, commitment to institutions, guardianship/conservator

- ship, wills, etc. You do not need to itemize these "other" complaints/problem areas for purposes of this repo rt. **D. Reasons for Closing Individual's Case Files:** Following is a list of the various reasons PAI R might give for closing the case file/service record of an "individual served." Please choose **one** primary (most appropriate) reason for closing each case file/service record (defined in the definitional guidelines section of these instructions). Do not itemize a reason for resolving each issue raised. This item asks y ou to choose one overall reason for closing the entire case file/service record after PAI R has done all it can for the individual in terms of resolving the issues/problems/complaints raised by the individual. The number of case files/service records may , in some situations, be greater than the total number of individuals served (Line II.A3) i n order to account for those situations, referred to in Line II.A4, when an individual had multiple case files/service records closed during the fiscal y ear. Estimated counts are not acceptable. PAI Rs should maintain records to respond accurately to this item. **Line D1:** Enter the number of case files/service records that were closed by PAI R in which all or some of the issues were resolved in the individual's favor. **Line D2:** Enter the number of case files/service records that were closed by PAI R because the individual obtained other representation. I nclude on this line those times when PAI R referred the individual to another advocate/attorney , as well as those times when the individual decided to seek representation by

someone other than a PAI R advocate /attorney

. **Line D3:** Enter the number of case files/service records that were closed by PAI R because the individual withdrew the complaint because he/she did not want to pursue resolution of the problem at this time. I

n these situations, the individual s imply wanted to "forget it." **Line D4:** Enter the number of case files/service records that were closed by PAI R because the individual had exhausted all available or appropriate formal appeal procedures and did not prevail.8

The appeal procedures relevant to this item include formal administrative hearings and legal remedies. For example, PAI R may choose to close a case file/service record for this reason if the individual served did not prevail at the formal administrative hearing and the case lacks merit for judicial review. PAI R also may choose to close a case file/service record for this reason if the individual served did not prevail at the formal administrative hearing and judicial review is not allowed under the State's Administrative Procedures Act (APA). **Line D5:** Enter the number of case files/service records that were closed by PAI R because the individual no longer needed PAI R services due to the individual's death, relocation, etc. I n other words, the individual is no longer available for rep resentation by PAI R. **Line D6:** Enter the number of case files/service records that were closed by PAI R because PAI R withdrew from the case. Generally , a withdrawal occurs when the consumer

- advocate relationship has deteriorated to the point that PAI R can not continue effective representation. Some of the reasons might have been that the individual refused to: a) give PAI R access to all necessary information; b) follow or accept PAI R's advice; or c) follow through on the individual's obligations in some w ay . **Line D7:** Enter the number of case files/service records that were closed by PAI R because the PAI R lacks sufficient staff or resources to represent the individual. **Line D8:** Enter the number of case files/service records that were closed by PAI R beca

use PAI R has determined, after exploring the facts and the law further, that the individual's complaint lacked legal merit. **Line D9:** Enter the number of case files/service records that were closed by PAI R for a reason that is not listed above. RSA has a ttempted to list all of the possible reasons PAIR could cite for closing a case file/service record. However, we realize there may be some circumstances not encompassed in this listing. This response should be reserved for rare instances when a reason fo r closure clearly does not fit into any

of the above categories. Be sure to attach a separate explanation of the circumstances for the case closure if y ou use this response. **E. Intervention Strategies Used in Serving Individuals:** PAI Rs engage in a varie ty of intervention strategies to resolve complaints raised by the individuals served. Following is a listing of the categories of services that PAI R can provide to an individual served in attempting to resolve a complaint. Although PAIRs generally provid e more than one ty

pe of service during the PAI R/client relationship, this report form asks y ou to choose **one** primary

service that PAIR provided to the individual before closing the case file/service record. Choose the **highest** level of intervention strateg y used by

PAI R on behalf of the individual served to resolve the complaint. As stated in earlier sections of these instructions, the number of case files/service records may be greater than the total number of individuals served (Line II.A3) in order to a ccount for those situations, referred to in Line II.A4, when an individual had multiple case files/service records closed during the fiscal y ear. Estimate counts are not acceptable. PAI Rs should maintain records to respond to this item accurately

.9

**Examp le 1:**  PAI R may

have engaged in investigation, negotiation, and ADR activities on behalf of an individual served in order to resolve the complaint. PAI R provided all three of these services during the course of one case file/service record. PAI R should ac count for this individual on Line E5 (Mediation/ADR) since this was the highest level of service provided to this particular individual. **Example 2:** PAI R may

have opened and closed two different case files/service records on behalf of an individual served during the fiscal y ear. During the course of working with the individual in the first case file/service record, PAI R provided only short

- term assistance and advice. However, in the second case file/service record, PAI R represented the individual at a fo rmal administrative hearing. PAI R should account for this individual on Line E2 (short

term assistance) for the first case file/service record **and** Li ne E6 (administrative hearings) for the second case file/service record. **Line E1:** Enter the number of ca se files/service records closed in which the highest level of service (intervention strategy) provided by PAI R was technical assistance to the individual to enable him/her to engage in self

- advocacy

. **Line E2:** Enter the number of case files/service record s closed in which the highest level of service (intervention strategy) provided by PAI R was short

- term assistance. I n these cases, PAI R was able to assist the individual simply by providing legal advice or extended I&R services. The individual did not ne ed other PAI R services. **Line E3:** Enter the number of case files/service records closed in which the highest level of service (intervention strategy) provided by PAI R was investigating or monitoring a particular situation. I n these cases, PAI R was able t o assist the individual by merel y investigating the complaint or monitoring a situation or facility . No other services were needed by PAI R. **Line E4:** Enter the number of case files/service records closed in which the highest level of service (interventio n strategy) provided by PAI R was negotiation. I

n these cases, PAIR was able to affect a resolution for the individual by engaging in negotiation with the adverse party in an informal environment. No other PAI R services were needed. **Line E5:** Enter the n

umber of case files/service records closed in which the highest level of service (intervention strategy) provided by PAI R was mediation or another form of alternative dispute resolution (ADR) procedure. I n these cases, PAI R assisted the individual by enga ging in mediation or another form of ADR to resolve the dispute between the individual and another party

. **Line E6:** Enter the number of case files/service records closed in which the highest level of service (intervention strategy) provided by PAI R was re presentation at a formal administrative hearing. I n these cases, PAI R may

have assisted the individual in requesting, preparing for, or participating in a formal administrative hearing. Do not include any legal services provided (i.e., in a judicial sett ing). **Line E7:** Enter the number of case files/service records closed in which the highest level of service (intervention strategy) provided by PAI R was representation in litigation. I n these cases, PAI R10

assisted the individual in pursuing legal recourse in the judicial sy stem to resolve the individual's complaint. I

nclude on this line any

case files/service records that were part of a class action. **Line E8:** Enter the number of case files/service records closed in which the highest level of service (in tervention strategy) provided by PAI R was to engage in sy stemic or other policy

- making activities to resolve the individual's complaint. For example, PAI R may have been successful in changing an agency

policy on a particular issue, raised by many individu als, without resorting to formal administrative or legal remedies. Case files/service records that were closed because PAI R was able to resolve the matter through these sy stemic efforts should be counted on this line. **PART III. STATISTICAL INFORMATION ON INDIVIDUALS SERVED**  **:** The items in this section are based on statistical information learned about the "individuals served" (as defined earlier in these instructions). Each individual may be counted only once during a fiscal ye ar, for statistical purposes , regardless of how many case files/service records were opened/closed. Estimated counts are not acceptable for the items in these sections. All PAI Rs should maintain records to respond to these items accurately

. **A. Age of Individuals Served:** Enter the number of individuals served in each of the age categories listed on the form. Record the individual's age as of the beginning of the fiscal y ear (as of October 1). No individual may be counted more than once for purposes of reporting the age of individ uals served in this section. **B. Gender of Individuals Served:** Enter the number of individuals served according to their gender. Do not count an individual more than once in this section, regardless of the number of case files/service records that were o pened/closed on the individual's behalf. **C. Race/Ethnicity of Individuals Served:** Enter the number of individuals served according to their stated racial or ethnic origin. All Hispanic self identifiers are reported as “Hispanic” whether the individual c hooses or does not choose a race. Non

- Hispanics are identified as their single race or as “two or more races.” If they do not identify

themselves as “Hispanic” and do not identify

a race, the non

- identifier is recorded as “race/ethnicity unknown.” Only individuals who are non

- Hispanic/Latino should enter a race in lines C2 through C8. **Line C1:** Enter the number of individuals served who consider themselves to be Latino or Hispanic, regardless of the individual’s race. **Line C2:** Enter the number of ind ividuals served who consider themselves to be an American Indian or Alaskan Native. **Line C3:** Enter the number of individuals served who consider themselves to be Asian. These individuals have origins in the Far East, Southeast Asia, or the Indian subcon tinent. **Line C4:** Enter the number of individuals served who consider themselves to be Black or African American. These individuals may be African

- American, African, Jamaican, etc.11

**Line C5:** Enter the number of individuals served who consider themselves to be a Native Hawaiian or other Pacific Islander. **Line C6:** Enter the number of individuals served who consider themselves to be White or Caucasian. **Line C7:** Enter the number of individuals served who consider themselves to be of two or more races. **L ine C8:**  Enter the number of individuals served whose race or ethnicity is unknown. This line should rarel y be used. **D. Living Arrangements of Individuals Served:** Include in this category information about the living arrangements for all individuals s erved by PAI R during this fiscal year. An individual served may be counted only

once, for purposes of reporting information about his/her living arrangements. **Line D1:** Enter the number of individuals served who live independently . These individuals may live alone or may

share housing with a roommate, spouse or significant other. The key here is that the individual is responsible for his/her own housing. **Line D2:** Enter the numbers of individuals served who live with their parents or with another relat ive. **Line D3:** Enter the number of individuals served who live in a community residential home, such as a group home of some kind. **Line D4:** Enter the number of individuals served who live in a foster care setting and are part of the State's foster care sy stem. **Line D5:** Enter the number of individuals served who live in a public or private nursing home. **Line D6:** Enter the number of individuals served who live in some public institution (i.e., hospital). Do not include those individuals who live in a public nursing home because these individuals are counted on Line D5. **Line D7:** Enter the number of individuals served who live in a private institution (i.e., hospital). Do not include those individuals who live in a private nursing home because these i ndividuals are counted on Line D5. **Line D8:** Enter the number of individuals served who live in a jail, prison, or some other detention center, **Line D9:** Enter the number of individuals served who are homeless. These individuals may spend an occasional night with friends or relatives or in a shelter; however, they have no real address.12

**Line D10:** Enter the number of individuals served who have some other living arrangement that is not listed in this section. **Line D11:** Enter the number of individuals served for whom PAI R has no information about their living arrangements. **E. Primary Disability of Individuals Served:** In clude in this category information about the primary disabilities of the individuals served by PAIR. The primary

disability , for purpo ses of this report, is the individual's disability that is directly

related to the issues or complaints raised by the individual served. **Example 1:** An individual is deaf and also has an orthopedic impairment that requires the use of a wheelchair. The i ndividual has come to PAI R because the local pizzeria is inaccessible for wheelchair

- users. PAI R should account for this individual on Line E4 (orthopedic impairment) because the issue raised focuses on building accessibility problems. The fact that the individual also is deaf has no bearing on this particular complaint. **Example 2:** Let's say the same individual as described above came to PAI R for a different problem, namely

a complaint that the county hospital refused to provide an interpreter to expla in the diagnostic testing she was to undergo. In this case, PAI R should count this individual on Line E2 (deaf/hearing impairment) because the issue dealt with interpreter services. The fact that the individual also has an orthopedic impairment has no be aring on this particular complaint. **Line E1:** Enter the number of individuals served who are blind or have some visual impairment. **Line E2:** Enter the number of individuals served who are deaf or are hard

- of

- hearing. **Line E3:** Enter the number of indivi duals served who are deaf

- blind. These individuals meet the criteria for both deafness and blindness. **Line E4:** Enter the number of individuals served who have an orthopedic impairment. These individuals may

be missing a limb, may

be paraly zed, or may

h ave some other functional impairment involving the limbs, digits, trunk, back or spine. **Line E5:** Enter the number of individuals served who have a mental illness. **Line E6:** Enter the number of individuals served who have alcohol and/or drug addictions

. **Line E7:** Enter the number of individuals served with any degree of mental retardation (i.e., mild, moderate, severe/profound). **Line E8:** Enter the number of individuals served with any form of learning disability

. **Line E9:** Enter the number of indivi duals served with any form of a neurological impairment.13

**Line E10:** Enter the number of individuals served who are disabled from any respiratory sy stem impairment/condition. **Line E11:** Enter the number of individuals served who are disabled from any card iac or other circulatory

s ys tem impairment or condition. **Line E12:** Enter the number of individuals served with any form of a muscular/skeletal impairment. **Line E13:** Enter the number of individuals served with speech impairments, such as cleft palate and harelip with speech imperfections, lary ngectomies, stuttering, etc. **Line E14:** Enter the number of individuals served who are infected with the human immunodeficiency

virus (HI V), regardless of whether the individual is sy mptomatic or asy mptomatic. **Line E15:**  Enter the number of individuals served whose disabling condition or functional limitation is caused by

traumatic brain injuries (TBI). **Line E16:** Enter the number of individuals served who have other impairments or disabling diseases or conditions that are not covered by the above categories. **PART IV. SYSTEMIC ACTIVITIES AND LITIGATION :**  **A. Systemic Activities:** The information collected in this category of the report focuses on PAI R's sy stemic activities in general. This category goes beyond any sy stemic efforts made on behalf of "individuals served" (as defined earlier in these instructions). Estimated counts are appropriate for this category . However, PAI R must be able to demonstrate a reasonable basis for the estimate. **Line A1:** Enter the nu

mber of policies or practices that were changed as a result of sy stemic activities. Do not include those policies or practices that were changed as a result of litigation because those will be collected in category IV.B. **Example:** PAI R focused much of its sy stemic efforts this y ear on discriminatory questions contained in State professional licensure applications. PAI R successfully negotiated with the State Supreme Court and with the State Nursing Board to change a question regarding mental illness on their applications. For purposes of this example, PAI R would enter "2" on Li ne A1. **Line A2:** Enter the approximate number of individuals who will benefit by the changes made in policy or practice, as reported in Line A1 above. **Example:** Let's say tha

t 25 percent of the applicants for the State bar and nursing licenses have historically

been individuals with mental illness. There are generally 600 total attorney applicants and 300 nurse applicants in any given y ear. This means that 150 attorney appli cants and 75 nurse applicants could potentially benefit from the changes made that14

were reported in Line A1. The PAI R would report "225" on Line A2, for purposes of this example. **Narrative regarding Systemic Activities:** Describe the sy stemic activity un dertaken. I dentify

the policies and practices that were problematic and explain why they were problematic. Describe the sy stemic activities PAI R engaged in to change these policies or practices. Be sure to include information about how these changes wil l benefit individuals with disabilities in the State. I nclude case examples of how y

our sy stemic activities impacted the individuals served by PAI R. As appropriate, provide PAIR's plans for continuing to address these issues during the next fiscal y ear. Use additional sheets as needed. **B. Litigation/Class Actions:** This category focuses on the changes that PAI R effected by engaging in litigation on behalf of an individual or in a class action on behalf of many individuals. **Line B1:** Enter the number of individuals who potentially will benefit from a change brought about as a result of PAI R's litigation efforts. **Example:** Let's say that PAIR sued the State Board of Medicine, via a class action in which 12 plaintiffs were named, for its discriminatory questions regarding mental illness on its phy sician license applications. The plaintiffs won. The Court ruled that the Board must modify its application to delete the offending question. Historically , 20 percent of the State's 200 phy sician applicants have been individuals with mental illness. This means that potentially

40 individuals could benefit from this court

- ordered change this y ear. For purposes of this example, PAI R would report 40 on line B1. **Line B2:** Enter the number of individuals named in any class actions handled by

PAI R during the fiscal y ear. **Example:** Using the above example here, PAI R would report "12" on this line because there were 12 named plaintiffs in that class action. **Narrative regarding Litigation/Class Actions:** Descri be y our litigation/class action activities. Be sure to identify

the issue that prompted the litigation and explain how individuals with disabilities were impacted negatively . Explain how individuals with disabilities benefited from y our litigation activi ties. Be sure to include case examples that demonstrate the impact of your litigation. Use additional sheets as necessary

. **PART V. PAIR'S PRIORITIES AND OBJECTIVES :**  **A. Priorities and Objectives for the Fiscal Year Covered by this Report:**  Be sure to provi de the information requested for **each** of the priorities and objectives set by PAI R for the fiscal year covered by this report. The information requested is as follows: 1. Identify

and describe the priority . Be sure to include enough information so that the issue is clear.15

2. Identify

the need, issue, or barrier addressed by this priority . I t is not enough to identify an issue as a priority . You must explain why this issue is a priority

and the desired effect it will have on individuals with disabilities. **Example:** Let's say that PAIR identified discriminatory questions on State professional licensure applications as a priority . The barrier that will be addressed by this priority

is that a significant percentage of the applicants are routinely denied a license because of a particular disability . Thus, a significant population is denied access to certain professional fields in the State. 3. Identify

the indicators PAIR used to determine whether it was successful in terms of an outcome with this priority . I n the above example, one indicator could be that PAI R was successful in getting the discriminatory questions removed from the applications. 4. Explain whether pursuing this priority involved collaborative efforts by other entities or programs. For ex ample, PAI R may work with PAIM I or PADD or CAP to bring about sy stemic change for one of its priorities. Be sure to describe these joint efforts, if appropriate. Explain the role each program play ed and the activities pursued by each. 5. Provide the num

ber of cases handled under the priority . This number can be derived from determining the number of "individuals served" (from Line II.A3) whose problem/complaint involved this priority . Specify if any of these "individuals served" were part of a class ac tion handled by

the PAIR. 6. Provide at least one case summary that demonstrates the impact of the priority. Identify the facts and issue of the case, the resolution of that case, and how the individual served benefited. **B. Priorities and Objectives for the C**  **urrent Fiscal Year:** Be sure to provide the information requested for **each** of the priorities and objectives set by PAI R for the fiscal year succeeding that covered by this report. The information requested is as follows:

a. a statement of each priority deve loped for the current fiscal y ear; b. the need addressed by each priority ; and

c. a description of the activities proposed to be carried out under each priority

. See the instructions above under Part V.A for additional explanation.16

**PART VI. NARRATIVE :**  A t a minimum, y

ou must provide the information requested for the narrative portion of this report. You may include any

other information, not otherwise collected on this reporting form that would be helpful in describing the extent of activities performed by the PAI R program during the fiscal ye ar. Please limit the narrative portion of this report, including attachments, to 20 pages or less. The information requested is as follows: **A. Sources of funds received and expended:** Provide the amount of funds the PAI R program received from each of the sources indicated during the fiscal y ear covered by

this report. I

n addition, specify

the total amount expended, from each of the sources of funds, in providing services to PAI R

- eligible individuals. Provide thi s information even if the PAIR's only source of funding is the Federal formula grant under section 509 of the act. The following chart is recommended when providing this information: Source of Funding Amount Received Amount Spent Federal (section 509) State Program income Private All other funds Total (from all sources) The "all other" category above is broad. I t includes funds from local governments, earned income (i.e., legal fees), charitable contributions, and other grants or cont racts. This category does not include in

- kind donations. However, it is hoped that PAI Rs will collect this information separately if appropriate. **B. Budget for the fiscal year covered by the report:** Outline the budget for the fiscal y ear covered by

the report (prior fiscal y ear), as well as a projection for the current fiscal y ear. Be sure to include a breakdown of dollars expended/allotted for: administrative costs (i.e., personnel salaries, equipment, etc.); services to individuals; and other expens es (i.e., staff training, travel, etc.). The following chart is recommended:17

Category Prior Fiscal Year Current Fiscal Year Wages/salaries Fringe benefits (FICA, unemploy ment, etc.) Materials/supplies Postage Telephone Rent Travel C opy ing Bonding/insurance Equipment (rental/purchase) Legal services Indirect costs Miscellaneous Total Budget **C. Description of PAIR staff:** Provide a description of the PAI R staff in terms of "person

- ye ars" and duties. "Person

- ye ars " refer to the actual time that positions (both professional and clerical) were filled during the period covered by this annual report. I f a position was filled throughout the ye ar, it counts as one person

- ye ar. For those positions that were filled for o nly a fraction of the y ear, you will have to calculate the "person

- ye ar" for that position by first calculating the "full

- time equivalents (FTEs)" for that position. Person

- ye ars should be reported for all PAI R personnel whose salaries are paid fully or p artially

by section 509 funds. Be sure to include an explanation of the number of full

- time part

- time, and vacant positions. **Example 1 on how to calculate person -**  **years:** PAIR has two full

- time attorney s. Both positions were filled all year. The person

- ye ar calculation for full

- time professional staff is two. **Example 2:** PAI R has two full

- time attorney s. One position was filled all y ear; the second was filled only

for 6 months. The person

- ye ar calculation for full

- time professional staff is 1 + .5 ( 1 FTE times 50% of the year) = 1.5. The vacant position category would be reported as follows: 1 FTE times 50% of the y ear = .5 person

- years. The following chart is recommended:18 Ty pe of Position FTE % of year filled Person

- years Professional Full

- time Part

- time Vacant Clerical Full

- time Part

- time Vacant **D. Involvement with advisory boards:** Id entify in what way s, if any , is PAIR involved with advisory boards. I nclude here any

information regarding PAI R's involvem ent with the P&A's advisory board (if applicable). **E. Grievances filed:** The act requires that PAI R establish a grievance procedure to handle any complaints by

clients regarding the services received/not received from PAI R. Provide a description of the i ssues involved in any grievances filed against PAI R during the fiscal y ear covered by

this report. Explain why

the individual filed the grievance and describe the outcome of the grievance process for each complaint. You should not include personally iden tify ing information regarding the individual served. **F. Coordination with the CAP and the State long -**  **term care program:** In some States, the CAP and the State's long

- term care programs are not part of the designated P&A agency , which administers the PAI R program. However, the act mandates that PAI R coordinate its activities with the CAP and the long

- term care programs. I f the CAP and/or the long

- term care program is not a part of y our P&A, describe how PAI R coordinates its activities with those entities. **END OF FORM :**  **Signature:** The form should be signed by a P&A official who has responsibility for the completion of the form and who can verify its accuracy. **Date:** Enter the month, day and year in which y ou send the form to RSA. **Transmittal:** The PAI R annual report should be sent within 90 day s after the fiscal y ear covered by this report. Reports may be sent by mail or electronically

using one of the options listed below. If yo u have questions regarding the completion of this form, contact Jessica Sp ataro at (202) 245

- 6493.19

**A. Electronic Mail addresses via Internet:** Specific instructions for key entry /on

- line editing of data directly into the RSA MI S can be obtained by

contacting RSA, or by

going to t he following URL for information and the forms needed to access the RSA MI S: http://rsa.ed.gov

. The RSA E

- mail address for the RSA

- 509 is: jessica. spataro @ed.gov. For information about completion of the RSA

- 509, please use the same Internet E

- mail address.

**B. US Mail and Facsimile --**  The RSA fa x # is (202) 245

- 7590 ; and the US postal address is: Rehabilitation Services Administration 400 Mary land Avenue, SW Washington, D.C. 20202

- 2800