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PROTECTION AND ADVOCACY OF INDIVIDUAL RIGHTS

(PAIR) 

PROGRAM PERFORMANCE REPORT

INSTRUCTIONS

FISCAL YEAR: Enter the fiscal year covered by this report.

DESIGNATED AGENCY IDENTIFICATION: Enter the name, address, telephone, TTY and 

fax numbers (including area codes), and e-mail and website addresses (if applicable) of the agency

designated to administer the PAIR program. Also, enter the names of the Executive Director of the 

Protection and Advocacy (P&A) agency, the PAIR director/coordinator (if applicable), 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. PAIR generally would not have personal identifying 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 PAIR), the 

individual must meet three criteria:

1. The individual is eligible for PAIR services according to section 509(a) of the 

Rehabilitation Act of 1973, as amended (the act);

2. PAIR 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, and the action taken by PAIR; and;

3. PAIR 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 beyond I&R services, as defined 

above.
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To satisfy the first criterion above, an individual is eligible for PAIR 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 

"developmental disability" as defined in the Developmental Disabilities Assistance 

and Bill of Rights Act;

2. is ineligible for the Protection and Advocacy for Individuals with Mental Illness 

(PAIMI) program because the individual is not an "individual with a mental illness" 

as defined in the Protection and Advocacy for Mentally Ill Individuals 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/SERVICE RECORD: This is the compilation of personal identifying information 

about the individual, documents, letters, complaints/issues raised, advocate's notes, etc., used in 

working with an "individual served" (as defined above). It may contain many issues at any one 

time. In fact, many individuals served will present several issues to PAIR during the course of the 

PAIR/client relationship. The case file/service record is opened at the time PAIR determines that it 

will provide at least one "significant service" (as defined above) for the individual. New issues may

arise while still working with the individuals. These new issues, if appropriate for PAIR 

intervention, should be added to the existing case file/service record.

PART I. NON-CASE SERVICES:

A. Individual Information and Referral (I&R) Services: Include in this category the number of 

times that PAIR provided I&R services to individuals during the fiscal year. Be sure to include only

numbers that reflect I&R services provided by only the PAIR program- not the P&A agency as a 

whole. Estimated counts are not acceptable for this section. All PAIRs should maintain logs to 

respond accurately to this section. Such routine requests should not require maintenance of client 

confidential information, extensive 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 number 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 PAIR 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 PAIR for issues that 

were within the priorities set by PAIR for the fiscal year covered by this report. In other words, 

PAIR 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.
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Line A2: Enter the number of individuals who received I&R services from PAIR on issues that 

were not within PAIR's priorities for the fiscal year covered by this report. 

Line A3: Add lines A1 and A2. This is the total number of individuals who received I&R services 

from PAIR during the fiscal year covered by this report.

B. Training Activities: Include in this category information about the trainings offered by the 

PAIR program. PAIR 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 PAIR staff during the fiscal 

year covered by this report.

Line B2: Enter the number of individuals who attended these trainings. If PAIR 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 PAIR staff as 

completely as possible. For each of the trainings and 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 necessary to provide this information.

C. Information Disseminated to the Public: Include in this category information that PAIR 

disseminated to the public at large. In many of these circumstances, PAIR will be unable to provide 

the number of individuals who 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 PAIR staff made during the fiscal 

year covered by this report.

Line C2: Enter the number of articles that PAIR 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 PAIR during the fiscal year covered 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 year 

covered by this report. For example, the local radio station aired two of PAIR's PSAs about 

architectural barriers thirty times each. For purposes of this line entry, there were 2 PSAs aired.

Line C4: Enter the number of hits that were made on PAIR's (or the P&A's) website (if applicable) 

during the fiscal year covered by this report.
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Line C5: Enter the number of publications, booklets or brochures that PAIR disseminated during 

the fiscal year covered by this report. Include on this line, those brochures, booklets and 

publications that were disseminated en masse at trainings or via regular mailings to PAIR's mailing 

list. Do not include on this line those brochures, booklets or publications that were disseminated 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 year covered by this report. 

Be sure to specify the types 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 PAIR 

provided advocacy services during this fiscal year. As stated in the definitional guidelines section 

above, an "individual served" is someone who is eligible for PAIR services; who has a case 

file/service record with PAIR; and who received one or more significant services from PAIR. All 

concerns noted in the case file/service record should have required some type of intervention (even 

if it is only brief) that goes beyond 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 year. Estimated counts are 

not acceptable. All PAIRs should maintain logs to respond accurately to this 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 number of individuals who had open case files/service records on hand at the 

beginning of the fiscal year, which were carried over from the prior fiscal year.

Line A2: Enter the number of individuals who had new case files/service records opened during 

this fiscal year.

Line A3: Add lines A1 + A2 and enter the total number here. This is the total number of 

individuals served during this fiscal year. Remember, no individual may be counted more than once 

in a fiscal year.

Line A4: Of the number of individuals 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 

year.

Example: An individual may have received legal advice for one issue early in the fiscal 

year. However, a new and unrelated issue arose several months later (in the same fiscal 

year) for this individual and PAIR agreed to represent him/her. Depending on the PAIR 

program's case management program, this individual may have had two cases opened/closed 

during the fiscal year. Thus, this individual would be counted on Line A4 as having 
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multiple case files/service records during the fiscal year. If this were the only such 

individual for PAIR this fiscal year, PAIR 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 PAIR as of September 30. These are the individuals 

who need PAIR intervention to continue into the next fiscal year (carryover) in order to resolve the 

problems/issues raised this fiscal year. 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 served as of October 1" (Line II.A1) on next fiscal year's annual report.

C. Problem Areas/Complaints of Individuals Served: Include in this category the types of 

problems/complaints that "individuals served" presented to PAIR during this fiscal year. Be sure 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 individual with a disability might 

otherwise be eligible for PAIR services, PAIR cannot represent that individual on the 

housing problem if that housing problem is not related to the individual's disability. PAIR 

could, however, represent that same individual on a different issue, such as employment, 

that is related to the individual's disability.

The following list contains broad categories of the common types of complaints/problems 

individuals served present to PAIR. Please account for each problem/complaint in the most 

appropriate category. Multiple counts are permitted in case one individual presents more than one 

problem/complaint for PAIR intervention.

Line C1: Enter on this line the number of individuals who sought PAIR assistance for complaints 

related 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. Include on this line complaints for both 

public and private buildings/structures.

Line C2: Enter on this line the number of individuals who sought PAIR assistance for complaints 

related to employment. These employment complaints may involve such issues as hiring or 

termination, reasonable accommodations, supported employment, or employment benefits.

Line C3: Enter on this line the number of individuals who sought PAIR assistance for complaints 

related to program access. Include 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 PAIR 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. 
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Line C5: Enter on this line the number of individuals who sought PAIR assistance for complaints 

related to government benefits or services. Include on this line those individuals who had difficulty

securing equal access to a government service or who have problems with government financial 

benefits programs, welfare-to-work programs, and other government programs.

Line C6: Enter on this line the number of individuals who sought PAIR 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 PAIR assistance for complaints 

related to education. These education complaints may involve such issues as IEP planning, 

development or 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 complaints 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 PAIR assistance for complaints 

related to assistive 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 PAIR 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 PAIR 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 individuals who sought PAIR 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 

because those complaints are accounted for on Line C10 above. 

Line C12: Enter on this line the number of individuals who sought PAIR assistance for complaints 

related to an inability to receive non-government services. These complaints may involve such 

issues 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 Line C5 above which captures all complaints regarding services paid for with government 

(Federal, State or local) funds.

Line C13: Enter on this line the number of individuals who sought PAIR 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.
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Line C14: Enter on this line the number of individuals who sought PAIR assistance for complaints 

related to access to records. Include on this line the number of individuals 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 PAIR assistance for complaints 

related to abuse. These complaints may involve such issues as inappropriate or excessive physical 

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 PAIR 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 PAIR assistance for complaints 

not otherwise covered by the above list. Examples of complaints that PAIR 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 report.

D. Reasons for Closing Individual's Case Files: Following is a list of the various reasons PAIR 

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 you to choose one overall reason for closing the entire case file/service 

record after PAIR 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) in 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 year. Estimated counts are not acceptable. PAIRs 

should maintain records to respond accurately to this item.

Line D1: Enter the number of case files/service records that were closed by PAIR 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 PAIR because the 

individual obtained other representation. Include on this line those times when PAIR referred the 

individual to another advocate/attorney, as well as those times when the individual decided to seek 

representation by someone other than a PAIR advocate/attorney.

Line D3: Enter the number of case files/service records that were closed by PAIR because the 

individual withdrew the complaint because he/she did not want to pursue resolution of the problem 

at this time. In these situations, the individual simply wanted to "forget it."

Line D4: Enter the number of case files/service records that were closed by PAIR because the 

individual had exhausted all available or appropriate formal appeal procedures and did not prevail. 
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The appeal procedures relevant to this item include formal administrative hearings and legal 

remedies. For example, PAIR 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. PAIR 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 PAIR because the 

individual no longer needed PAIR services due to the individual's death, relocation, etc. In other 

words, the individual is no longer available for representation by PAIR.

Line D6: Enter the number of case files/service records that were closed by PAIR because PAIR 

withdrew from the case. Generally, a withdrawal occurs when the consumer-advocate relationship 

has deteriorated to the point that PAIR cannot continue effective representation. Some of the 

reasons might have been that the individual refused to: a) give PAIR access to all necessary

information; b) follow or accept PAIR's advice; or c) follow through on the individual's obligations 

in some way.

Line D7: Enter the number of case files/service records that were closed by PAIR because the 

PAIR lacks sufficient staff or resources to represent the individual.

Line D8: Enter the number of case files/service records that were closed by PAIR because PAIR 

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 PAIR for a reason that 

is not listed above. RSA has attempted 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 for 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 you use this response.

E. Intervention Strategies Used in Serving Individuals: PAIRs engage in a variety of 

intervention strategies to resolve complaints raised by the individuals served. Following is a listing 

of the categories of services that PAIR can provide to an individual served in attempting to resolve a 

complaint. Although PAIRs generally provide more than one type of service during the PAIR/client 

relationship, this report form asks you to choose one primary service that PAIR provided to the 

individual before closing the case file/service record. Choose the highest level of intervention 

strategy used by PAIR 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 account for those 

situations, referred to in Line II.A4, when an individual had multiple case files/service records 

closed during the fiscal year. Estimate counts are not acceptable. PAIRs should maintain records to 

respond to this item accurately.
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Example 1: PAIR may have engaged in investigation, negotiation, and ADR activities on 

behalf of an individual served in order to resolve the complaint. PAIR provided all three of 

these services during the course of one case file/service record. PAIR should account for this 

individual on Line E5 (Mediation/ADR) since this was the highest level of service provided 

to this particular individual.

Example 2: PAIR may have opened and closed two different case files/service records on 

behalf of an individual served during the fiscal year. During the course of working with the 

individual in the first case file/service record, PAIR provided only short-term assistance and 

advice. However, in the second case file/service record, PAIR represented the individual at 

a formal administrative hearing. PAIR should account for this individual on Line E2 (shortterm assistance) for the first case file/service record and Line E6 (administrative hearings) 

for the second case file/service record.

Line E1: Enter the number of case files/service records closed in which the highest level of service 

(intervention strategy) provided by PAIR was technical assistance to the individual to enable 

him/her to engage in self-advocacy.

Line E2: Enter the number of case files/service records closed in which the highest level of service 

(intervention strategy) provided by PAIR was short-term assistance. In these cases, PAIR was able 

to assist the individual simply by providing legal advice or extended I&R services. The individual 

did not need other PAIR services.

Line E3: Enter the number of case files/service records closed in which the highest level of service 

(intervention strategy) provided by PAIR was investigating or monitoring a particular situation. In 

these cases, PAIR was able to assist the individual by merely investigating the complaint or 

monitoring a situation or facility. No other services were needed by PAIR.

Line E4: Enter the number of case files/service records closed in which the highest level of service 

(intervention strategy) provided by PAIR was negotiation. In 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 PAIR services were needed.

Line E5: Enter the number of case files/service records closed in which the highest level of service 

(intervention strategy) provided by PAIR was mediation or another form of alternative dispute 

resolution (ADR) procedure. In these cases, PAIR assisted the individual by engaging 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 PAIR was representation at a formal administrative hearing. In 

these cases, PAIR 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 setting).

Line E7: Enter the number of case files/service records closed in which the highest level of service 

(intervention strategy) provided by PAIR was representation in litigation. In these cases, PAIR 
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assisted the individual in pursuing legal recourse in the judicial system to resolve the individual's 

complaint. Include 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 

(intervention strategy) provided by PAIR was to engage in systemic or other policy-making 

activities to resolve the individual's complaint. For example, PAIR may have been successful in 

changing an agency policy on a particular issue, raised by many individuals, without resorting to 

formal administrative or legal remedies. Case files/service records that were closed because PAIR 

was able to resolve the matter through these systemic 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 

year, 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 PAIRs 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 year (as 

of October 1). No individual may be counted more than once for purposes of reporting the age of 

individuals 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 opened/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 chooses 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 individuals 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 subcontinent.

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.
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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.

Line C8: Enter the number of individuals served whose race or ethnicity is unknown. This line

should rarely be used. 

D. Living Arrangements of Individuals Served: Include in this category information about the 

living arrangements for all individuals served by PAIR 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 

relative.

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 system.

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 individuals 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.
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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 PAIR has no information about their 

living arrangements.

E. Primary Disability of Individuals Served: Include in this category information about the 

primary disabilities of the individuals served by PAIR. The primary disability, for purposes 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 individual has come to PAIR because the local pizzeria is 

inaccessible for wheelchair-users. PAIR 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 PAIR for a different 

problem, namely a complaint that the county hospital refused to provide an interpreter to 

explain the diagnostic testing she was to undergo. In this case, PAIR 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 bearing 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 individuals 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 paralyzed, or may have 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 individuals served with any form of a neurological impairment.
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Line E10: Enter the number of individuals served who are disabled from any respiratory system 

impairment/condition.

Line E11: Enter the number of individuals served who are disabled from any cardiac or other 

circulatory system 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, laryngectomies, stuttering, etc.

Line E14: Enter the number of individuals served who are infected with the human 

immunodeficiency virus (HIV), regardless of whether the individual is symptomatic or 

asymptomatic.

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 PAIR's 

systemic activities in general. This category goes beyond any systemic efforts made on behalf of 

"individuals served" (as defined earlier in these instructions). Estimated counts are appropriate for 

this category. However, PAIR must be able to demonstrate a reasonable basis for the estimate.

Line A1: Enter the number of policies or practices that were changed as a result of systemic 

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: PAIR focused much of its systemic efforts this year on discriminatory questions 

contained in State professional licensure applications. PAIR 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, PAIR would enter "2" on 

Line 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 that 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 year. This means that 150 attorney

applicants and 75 nurse applicants could potentially benefit from the changes made that 
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were reported in Line A1. The PAIR would report "225" on Line A2, for purposes of this 

example.

Narrative regarding Systemic Activities: Describe the systemic activity undertaken. Identify the 

policies and practices that were problematic and explain why they were problematic. Describe the 

systemic activities PAIR engaged in to change these policies or practices. Be sure to include 

information about how these changes will benefit individuals with disabilities in the State. Include 

case examples of how your systemic activities impacted the individuals served by PAIR. As 

appropriate, provide PAIR's plans for continuing to address these issues during the next fiscal year. 

Use additional sheets as needed.

B. Litigation/Class Actions: This category focuses on the changes that PAIR 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 PAIR'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 

physician 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 physician applicants have been individuals with mental illness. This means that 

potentially 40 individuals could benefit from this court-ordered change this year. For 

purposes of this example, PAIR would report 40 on line B1.

Line B2: Enter the number of individuals named in any class actions handled by PAIR during the 

fiscal year. 

Example: Using the above example here, PAIR would report "12" on this line because 

there were 12 named plaintiffs in that class action.

Narrative regarding Litigation/Class Actions: Describe your 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 your litigation 

activities. 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 provide the information requested for each of the priorities and objectives set by PAIR 

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.
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2. Identify the need, issue, or barrier addressed by this priority. It 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. In the above example, one indicator could be that PAIR 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 example, PAIR may work with PAIMI or PADD or CAP to bring about 

systemic change for one of its priorities. Be sure to describe these joint efforts, if 

appropriate. Explain the role each program played and the activities pursued by each.

5. Provide the number 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 

action 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 Current Fiscal Year:

Be sure to provide the information requested for each of the priorities and objectives set by PAIR 

for the fiscal year succeeding that covered by this report. The information requested is as follows:

a. a statement of each priority developed for the current fiscal year;

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.
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PART VI. NARRATIVE:

At a minimum, you 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 PAIR program during the fiscal 

year. 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 PAIR program 

received from each of the sources indicated during the fiscal year covered by this report. In 

addition, specify the total amount expended, from each of the sources of funds, in providing 

services to PAIR-eligible individuals. Provide this 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. It includes funds from local governments, earned income 

(i.e., legal fees), charitable contributions, and other grants or contracts. This category does not 

include in-kind donations. However, it is hoped that PAIRs will collect this information separately

if appropriate.

B. Budget for the fiscal year covered by the report: Outline the budget for the fiscal year 

covered by the report (prior fiscal year), as well as a projection for the current fiscal year. Be sure to 

include a breakdown of dollars expended/allotted for: administrative costs (i.e., personnel salaries, 

equipment, etc.); services to individuals; and other expenses (i.e., staff training, travel, etc.). The 

following chart is recommended:
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Category Prior Fiscal Year Current Fiscal Year

Wages/salaries

Fringe benefits (FICA, 

unemployment, etc.)

Materials/supplies

Postage

Telephone

Rent

Travel

Copying

Bonding/insurance

Equipment (rental/purchase)

Legal services

Indirect costs

Miscellaneous

Total Budget

C. Description of PAIR staff: Provide a description of the PAIR staff in terms of "person-years" 

and duties. "Person-years" refer to the actual time that positions (both professional and clerical) 

were filled during the period covered by this annual report. If a position was filled throughout the 

year, it counts as one person-year. For those positions that were filled for only a fraction of the year, 

you will have to calculate the "person-year" for that position by first calculating the "full-time 

equivalents (FTEs)" for that position. Person-years should be reported for all PAIR personnel 

whose salaries are paid fully or partially 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 attorneys. Both 

positions were filled all year. The person-year calculation for full-time professional staff is 

two.

Example 2: PAIR has two full-time attorneys. One position was filled all year; the second 

was filled only for 6 months. The person-year 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 year = .5 person-years. The following chart is 

recommended:
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Type 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: Identify in what ways, if any, is PAIR involved with 

advisory boards. Include here any information regarding PAIR's involvement with the P&A's 

advisory board (if applicable).

E. Grievances filed: The act requires that PAIR establish a grievance procedure to handle any

complaints by clients regarding the services received/not received from PAIR. Provide a 

description of the issues involved in any grievances filed against PAIR during the fiscal year 

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 identifying 

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 PAIR program. However, the act mandates that PAIR coordinate its activities with 

the CAP and the long-term care programs. If the CAP and/or the long-term care program is not a 

part of your P&A, describe how PAIR 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 you send the form to RSA.

Transmittal: The PAIR annual report should be sent within 90 days after the fiscal year covered 

by this report. Reports may be sent by mail or electronically using one of the options listed below. 

If you have questions regarding the completion of this form, contact Jessica Spataro at (202) 245-

6493.
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A. Electronic Mail addresses via Internet:

Specific instructions for key entry/on-line editing of data directly into the RSA MIS can be 

obtained by contacting RSA, or by going to the following URL for information and the forms 

needed to access the RSA MIS: 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 fax # is (202) 245-7590; and the US postal address is:

Rehabilitation Services Administration

400 Maryland Avenue, SW

 Washington, D.C. 20202-2800