# Instructions

OMB Control Number:  1820-0606

Expiration Date: xxxx xx, xxxx

**UniTed States Department of Education**

###### Office of Special Education and Rehabilitative Services

**Rehabilitation Services Administration**

**Section 704**

**annual performance report**

###### For

###### STATE INDEPENDENT LIVING SERVICES PROGRAM

**(Title VII, Chapter 1, Part B of the Rehabilitation Act of 1973, as amended)**

**Part I**

**INSTRUCTIONS**

**(To be completed by Designated State Units**

###### And Statewide Independent Living Councils)

**According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number.  Public reporting burden for this collection of information is estimated to average 35 hours per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  The obligation to respond to this collection is required to obtain or retain benefit (P.L. 105-220 Section 410 Workforce Investment Act).  Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Education, 400 Maryland Ave., SW, Washington, DC 20202-4536, Attention Timothy Beatty, Rehabilitation Services Administration, PCP Room 5057 or email ICDocketMgr@ed.gov and reference the OMB Control Number 1820-0606.  Note: Please do not return the completed 704 Report to this address.**

# TABLE OF CONTENTS

**FREQUENTLY ASKED QUESTIONS**

**Question:** What is the Purpose of the Annual Performance Report, or 704 Report?

**Answer:**  The purpose of Part I of the 704 Report is to:

A) Serve as a performance activity measuring instrument of independent living (IL) programs, including both quantitative and qualitative information.

B) Determine the training and technical assistance needs of Statewide Independent Living Councils (SILCs) as required by Section 721(b)(3) of the Rehabilitation Act of 1973, as amended (Act).

C) Collect information on the administration of the Part C program by states who administer that program under section 723 of the Act. 

D) Collect information necessary for issuance of continuation awards for the State Independent Living Services (SILS) program.

E) Collect the data required by Section 13, 706, and 721 of the Act for the SILS program.

F) Serve as the basis for on-site reviews of the SILS program. 

G) Obtain a report on SILC and designated state units (DSU) activities.

H) Establish a uniform reporting system to compile an accurate national report on independent living.

I) Serve as the state’s official request for continued funding under Part B or Part C of Chapter 1 of Title VII of the Act.

J) Collect information on the distribution of title VII, chapter 1, Part B funds within the state and the monitoring of the use of those funds by grantees and contractors of the state.

K) Enable each state to access information on all funds expended for independent living in the state, including individuals served, services provided and outcomes achieved, and to enable RSA to compare the performance among states. (Authority:  Section 13, 704(m)(4)(D); 705 (c)(5); 706(d); 721; 723; of the Act; 34 CFR Parts 364, 365, and 366).

**Question:**  What is the Structure of the 704 Report?

**Answer:**  The 704 Report is composed of Part I and Part II

Part I reports on the SILC and DSU’s activities for the reporting year.  It also contains data from consumer service records from the DSUs, DSU contractors and grantees and any center for independent living (CIL) receiving Part B funds from the DSU (not including CILs that also receive Part C funds and that file the 704 Report, Part II).

Part II contains a CIL’s evidence of compliance with the requirements of Section 725 of the Act, a comparison of the CIL’s activities during the reporting year with its work plan for that year, work plans for the next year, and data from consumer service records maintained by the CIL.

The structure of the 704 Report Part I is as follows:

Subpart I – Administrative Data:  This subpart contains information reflecting the duties of the DSU (including section 723 states) outlined in section 704(c) of the Act, including the sources and expenditures of funds during the reporting year as well as the DSU’s administrative support services, staffing and monitoring activities involving grantees and contractors.

Subpart II – Numbers and Types of Individuals with Significant Disabilities Receiving Services: This subpart asks for information from CSRs on the numbers and types of consumers receiving IL services.

Subpart III – Individual Services and Achievements: This subpart asks for information on the individual IL services provided and received, goals set and met, and outcomes achieved.

Subpart IV – Community Activities and Coordination: This subpart asks for a report on the community activities involving the DSU, SILC and DSU contractors and grantees and the outcomes of such activities.

Subpart V – Statewide Independent Living Council: This subpart asks for a report on the composition, qualifications and activities of the Statewide Independent Living Council (including technical assistance and training needs for next fiscal year).

Subpart VI – SPIL Comparison and Updates, Other Accomplishments and Challenges:  This subpart asks for program accomplishments and goal achievements, updates to the SPIL, substantial problems or difficulties and any additional information.

Subpart VII – Signatures:  Signatures, printed names, titles and phone numbers of DSU director(s) and SILC chair.

**Question:**  Who Must Complete Part I of the 704 Report?

**Answer:**

Each DSU and SILC will jointly complete Part I.  The SILC and the DSU must be given the freedom to independently prepare the portions of the report for which they are responsible.  Subpart VI is designed to be a cooperative venture of both the DSU and SILC.  In this manner, a complete report of activities that is jointly developed and shared within the state is assured.

Only a single Part I report, with data aggregated from the state’s reporting entities, will be accepted by RSA.

Subparts II and III report information obtained from CSRs maintained by the DSU and grantees/contractors receiving Part B funds (other than CILs who receive Part C funds and who complete Part II of the 704 Report).  This is also true for section 723 states.

**Question:**  Where must the 704 Report bE Submitted?

**Answer:**

Section 722 states**:**

The DSU and SILC will jointly submit the 704 Report both electronically and in an original, signed hard copy.  For the FY 2008 reporting year, states may submit the 704 Report via email to RSA and the Independent Living Research Utilization Project (ILRU) or they may choose to complete and submit the 704 Report directly through the RSA Management Information System (MIS).  The signed hard copy of the 704 Report is to be mailed to RSA only. 

Detailed instructions for the electronic and hard copy submittals will be provided when RSA officially transmits the 704 Report.

Section 723 states:

The 723 states forward their Part I 704 Report, along with the Part II reports of the Part C funded CILs, to RSA both electronically and in an original, signed hard copy.  For the FY 2008 reporting year, states may submit the 704 Report via email to RSA and the Independent Living Research Utilization Project (ILRU) or they may choose to complete and submit the 704 Report directly through the RSA Management Information System (MIS).  The signed hard copy of the 704 Report is to be mailed to RSA only.  The 723 states are no longer responsible for aggregating Part II report data into their Part I report.  (They still may want to summarize applicable Part II information in their Part I report, as appropriate).  

Detailed instructions for the electronic and hard copy submittals will be provided to DSUs and SILCs when RSA officially transmits the 704 Report.  

**Question:**  When Must the DSU and SILC Submit the 704 Part I Report to RSA?

**Answer:** The date will vary depending on whether the state is a section 722 or section 723 state.

Section 722 states must submit the 704 Report, Part I to RSA postmarked by December 31, 2006, for the preceding federal fiscal year (10/1/2005 – 9/30/2006). 

Section 723 states must submit the 704 Report, Part I to RSA postmarked by January 31, 2007, for the preceding federal fiscal year (10/1/2005 – 9/30/2006).

**Question:**  How long must records be retained?

**Answer:**

Three Years. Information provided in this report by federal grantees is subject to confirmation at an on-site review; therefore, financial records, statistical records, and all supporting documents and other records pertinent to the grant award, adequate to document the accuracy of the information and statements in the 704 Annual Performance Report, must be kept for three years.  (Authority: 34 CFR 74.53)

## GLOSSARY OF TERMS

ActThe Rehabilitation Act of 1973, as amended.

CILA Center for Independent Living meeting the definition in Section 702 of the Act, the standards in Section 725 of the Act, and included in the state’s network of centers.

CIL ProgramThe Centers for Independent Living Program funded under Part C, Chapter 1 of title VII of the Act. 

Community-basedThese living arrangements include apartments,

Livingprivately owned housing, self-directed assisted living, or self-directed living with family or friends.

ConsumerAny individual with a significant disability who is eligible for IL services under 34 CFR 364.40(a) and is currently receiving or has been provided with any IL service(s) under the program, other than information and referral.

Core ServicesIL services defined in Section 7(17) of the Act means: information and referral services; IL skills training; peer counseling (including cross-disability peer counseling); and, individual and systems advocacy.

CSRA Consumer Service Record maintained for an eligible consumer receiving IL services and meeting the requirements of 34 CFR 364.53.  In cases where IL services are provided to the parent or guardian of a consumer, the CSR is established for the consumer and the services provided are reflected in that CSR.

DSU The designated state unit, or units, identified under section 101(a)(2)(B) of the Act, authorized to jointly develop and sign, with the Statewide Independent Living Council (SILC), the State Plan for Independent Living (SPIL) under section 704 of the Act.  The term includes a state agency solely designated under state law to provide IL services to individuals who are blind.  In such states, the state agency for the blind may administer the provisions in the state plan related to services for individuals who are blind.  In a 723 state, the DSU receiving, accounting for, and disbursing the funds for the CIL program is always the general agency. 

Earmarked FundsFunds appropriated by the state and expressly or clearly identified as state expenditures in the relevant fiscal year for the sole purpose of funding the general operation of CILs meeting the requirements of Sections 702 and 725 of the Act.

FTEThe equivalent of one person working full-time for one year.

ILIndependent Living

ILPAn Independent Living Plan for the provision of IL services mutually agreed upon by an appropriate staff member of a service provider and an individual with significant disabilities.

MinorityAlaskan Natives, American Indians, Asian Americans, Blacks (African Americans), Hispanic  Americans, Native Hawaiians, and Pacific Islanders.

Pass ThroughFunds that a provider receives on behalf of a consumer that are subsequently issued by the provider directly to the consumer (e.g., representative payee funds, Medicaid or state PAS funds).

Reporting YearThe most recently completed federal fiscal project year starting October 1 and ending September 30.

RSAThe Rehabilitation Services Administration at the United States Department of Education, Office of Special Education and Rehabilitative Services.

Section 722 StateA state in which RSA issues grants under Part C directly to eligible agencies for the planning, establishment, and operation of CILs.

Section 723 StateA state where the DSU issues grants or assistance contracts under Part C to eligible entities for the planning, establishment, and operation of CILs.

Service ProviderCan mean: 1) A DSU that directly provides IL services to consumers; 2) A CIL; or 3) An entity that provides IL services under a grant or contract from the DSU.

SILCThe Statewide Independent Living Council established in each state as required by Section 705 of the Act.

SILSA State Independent Living Services program funded under Part B, Chapter 1 of Title VII of the Act.

SPILA State Plan of Independent Living jointly developed and signed by the director of the designated state unit(s) and the chairperson of the Statewide Independent Living Council, acting on behalf of and at the direction of the Council.  The plan addresses the provision of state IL services, the development and support of a statewide network of centers for independent living and the working relationships among programs providing IL services, CILs, the state VR program, and other programs providing services for individuals with disabilities.

StateThe term state includes, in addition to each of the several states of the United States, the District of Columbia, the Commonwealth of Puerto Rico, the United States Virgin Islands, Guam, American Samoa, and the Commonwealth of the Northern Mariana Islands, except where otherwise noted. 

Unserved and Include, but are not limited to, groups or 

Underservedpopulations of individuals with significant 

Populationsdisabilities who:

(1) have cognitive and sensory impairments;

(2) are members of racial and ethnic minority groups;

(3) live in rural areas; or

(4) have been identified by the eligible agency as   

unserved or underserved with a center’s project area.

Instructions:  704 Report, Part I

**General Instructions:** Please respond to each subpart of this preprint.

1) When a question/section requests a description, list or other non-data information but does not apply to your state, a “NOT APPLICABLE” response is appropriate.

2) When a subpart requests data or a numerical response but does not apply to your state, enter zero, “0”.

**Specific Instructions:**  Please carefully read the instructions below and provide the requested details and/or data.

# SubPart I – Administrative Data

## Section A – Sources and Amounts of Funds and Resources

Sections 704(m)(3) and (4) of the Act; 34 CFR 364.35 and 364.36

List the amounts of all resources received by the state from items 1 through 3 during the federal fiscal reporting year. In item 2 include “pass through” funds received from state or local governments.  “Pass through” funds are funds, received by the DSU on behalf of consumers, that are subsequently passed on to consumers, e.g., personal assistance services, representative payee funds, or Medicaid funds.  In item 3(H), “other resources” may include, for example, foundations, corporations or trust grants, donations from individuals or investment or endowment income.  

Note: If the State receives funding dedicated or restricted to a particular purpose, that funding should be included in the appropriate source category.  For example, if the DSU receives funding from another Federal agency for specified transportation services for people with significant disabilities under the IL program, that funding should be included in the “Other Federal Funds” category.

Round off to the nearest dollar amount any funds ending with cents.  Example: $4,240,010.87 ($4,240,011)

(1) Add lines 1(A) through 3(H) to get the amount of Total Income received by the state.  Record this amount in Item 4. 

(2) Enter the total amount of “pass through” funds received in Item 5.  

(3) Subtract the amount in Item 5 from the amount in Item 4 to get the total of Net Operating Resources for the state.  Enter this amount in Item 6.

**Section B – Distribution of Title VII, Chapter 1, Part B Funds**

Section 713 of the Act; 34 CFR 364.22, 365.1, 365.20, and 365.21

Complete the table by providing in items (1) through (8) the amount of Part B funds expended by the state directly or through grant or contract in each category in the appropriate column.  If funds were not used for a purpose listed, please indicate by placing $0 in the appropriate column.

## Section C – Grants or Contracts Used to Distribute Title VII, Chapter 1, Part B Funds  

Sections 704(f) and 713 of the Act; 34 CFR 364.43, and 34 CFR 365 Subpart C 

Review your answers to Section B and enter the requested information for all grants or contracts funded at least in part by Part B funds, in the table.  Include Part C funded centers if they also received Part B funds.  Add more rows as necessary.  A contractor or grantee that receives Part B funds for more than one activity (e.g., to provide IL services, as well as to conduct IL philosophy training), must be listed for as many different activities it performs.  If a column is not applicable to a particular grant or contract, such as the consumer eligibility or CSR columns intended only for service providers, enter “N/A.”   If there were no non-Part B funds (e.g. title VII, Chapter 2 funds, other federal funds or state funds) provided to this grantee or contractor for the purpose listed, enter “$0” in that column.

## Section D – Grants or Contracts for Purposes Other Than Providing IL Services or For the General Operation of Centers

Section 713 of the Act; 34 CFR 365.1 and 34 CFR 365.20

For Part B funds awarded as grants or contracts ***for purposes other than to provide IL services or for the general operation of centers***, provide a brief narrative description of the objectives for each agreement, what activities were conducted during the year, and what results were achieved (e.g. funding for data collection, outreach programs to minorities, surveys).

### Section E – Monitoring Part B Funds

34 CFR 80.40(a)

Provide a summary of the program or fiscal review, evaluation, and monitoring activities conducted by the state during the reporting year for any of the grantees/contractors receiving Part B funds.  Examples of review, evaluation and monitoring activities include review of 704 Reports or other program reports, on-site reviews by DSU and/or SILC, fiscal audits of expenditures of Part B funds, summaries of corrective action plans, etc.

**Section F – Administrative Support Services and Staffing**

Section 704(m)(2) and (4) of the Act; 34 CFR 364.31

**Item 1 – Administrative Support Services**

Section 704(c)(2); 34 CFR 364.22(a)(2)

Describe any administrative support services, including staffing, provided by the DSU to the Part B program.

**Item 2 – Staffing**

Report the total number Full Time Equivalents (FTEs) employed in the SILS program administered by the DSU(s) and by service providers other than CILs reporting in 704 Report, Part II.  Report the total decision making and other staff and the number of FTEs filled by individuals with disabilities.

· To compute FTEs, determine the number of hours (excluding overtime) for which all employees were actually paid during the last six months of the reporting year.  Multiply the hours worked by 2 (two), divide by 2080 (approximate number of hours worked by an FTE), the subsequent total is the equivalent fraction of the FTEs. 

## Section G – For Section 723 States ONLY

Section 723 of the Act, 34 CFR Part 366, Subpart D

### Item 1 – Distribution of Part C Funds to Centers

In the table provided, please respond with the following information: 

A) the name of each center within your state that received Part C funding during the reporting year; 

B) the amount of Part C funding each center received; 

C) whether the Part C funding included a cost-of-living increase, with a yes or no response; 

D) whether the Part C funding included any excess funds remaining after cost-of-living increases were provided, with a yes or no response; 

E) whether any of the centers received its Part C funding pursuant to a competition for a new center in the state, with a yes or no response; and 

F) whether the center was the subject of an on-site compliance review conducted by the DSU during the reporting year, with a yes or no response.  

Add additional rows as necessary.

**Item 2 – Administrative Support Services**

Section 704(c)(2); 34 CFR 364.22(a)(2)

Describe the administrative support services used by the DSU to administer the Part C program.

### Item 3 – Monitoring and On-site Compliance Reviews

Section 723(g), (h), and (i); 34 CFR 366.38, 366.40-46

Provide a summary of the monitoring activities involving Part C centers conducted by the state during the current reporting year, including the on-site reviews of at least 15% of centers receiving Part C funds under section 723.  The summary should include, at least, the following:

A) the center’s level of compliance with the standards and assurances in section 725 of the Act; 

B) any adverse actions taken against centers;

C) any corrective action plans entered into with centers; and

D) exemplary, replicable or model practices of centers.

### Item 4 – Updates or Issues

Provide any updates to the administration of the Part C program by the DSU, including any significant changes in the amount of earmarked funds or any changes in the order of priorities in the distribution of Part C funds.  Provide a description of any issues of concern addressed by the DSU in its administration of the Part C program.

**SUBPART II – NUMBER AND TYPES OF INDIVIDUALS WITH SIGNIFICANT DISABILITIES RECEIVING SERVICES**

Section 704(m)(4) of the Act; 34 CFR 364.53

In this section, provide data from all service providers (DSU, grantees, contractors) who received Part B funds and who were listed in subpart I, section C of this report, except centers for independent living that receive Part C funds.  (Part C centers will provide this data themselves on their annual 704 Reports, Part II.)

## Section A – Number of Consumers Served During the Reporting Year

Include Consumer Service Records (CSRs) for ALL consumers served during the reporting year.

(1) Enter the number of active CSRs carried over from September 30 of the year preceding the reporting year.  Active CSRs are those corresponding to consumers who were actually served during the reporting year.

(2) Enter the number of new CSRs opened since October 1 of the reporting year.

(3) To get the number of consumers served during the reporting year, add the number of active CSRs carried over from the preceding year to the number of new CSRs opened for the reporting year.  Enter this number in line A(3).  A(1) + A(2) = A(3).

## Section B – Number of CSRs Closed by September 30 of the Reporting Year

In the appropriate category, enter the number of CSRs that have been closed out of the active CSR files during the reporting year because the consumer has:

(1) Moved - The consumer has moved out of the service provider’s service area and/or has moved and left no forwarding address (e.g. unable to locate consumer).

(2) Withdrawn - The consumer has stated he or she is no longer interested in receiving services at this time.

(3) Died.

(4) Completed all goals set - The consumer has completed all goals and objectives, whether or not listed in the Independent Living Plan (ILP), and does not need/is not interested in receiving additional services at this time. 

(5) Other - The CSR has been closed for any other reason than those listed above.

Total the number of CSRs for each category to get the number of CRSs closed for the reporting year.  Example:  line B(1) + B(2) + B(3) + B(4) + B(5) = B(6).

## Section C – Number of CSRs Active on September 30 of the Reporting Year

To get the number of CSRs active on September 30 of the Reporting Year subtract the total number of CSRs closed by September 30 (line B(6)) from the total number of consumers served during the reporting year (line A(3)).  Enter this number in the table in Section C.

## Section D – IL Plans and Waivers

(1) Enter the total number of consumers with active CSRs during the reporting year who have knowingly and voluntarily signed a waiver stating an IL plan was unnecessary.  

(2) Enter the total number consumers with active CSRs during the reporting year with whom an ILP was developed.  

(3) Add the total number of consumers who signed a waiver to the total number of consumers who developed ILPs.  Enter this figure in line D(3).  D(1) + D(2) = D(3).  This is the total number of consumers served during the reporting year and **MUST** equal the “number of consumers served” in Section A, line 3 above.

## Section E – Age

(1) through (6) - Enter the number of consumers served during the reporting year in each age category as self reported by each consumer.

## Section F – Sex

(1) and (2) – Enter the number of male and female consumers served during the reporting year as self reported by each consumer.

**Section G – Race and Ethnicity**

(1) through (8) - Enter the number of consumers served during the reporting year in each category, as self-reported by each consumer.  **Each consumer may be counted under ONLY ONE of the following categories in the 704 Report, even if the consumer reported more than one race and/or Hispanic/Latino ethnicity.**

(1) American Indian or Alaska Native.  American Indian or Alaska Native means a person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.

(2) Asian means a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

(3)  Black or African American means a person having origins in any of the black racial groups of Africa.  Terms such as “Haitian” may be used.

(4) Native Hawaiian or Other Pacific Islander means a person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

(5) White means a person having origins in any of the original peoples of Europe, the Middle East or North Africa.

(6) Hispanic/Latino of any race or Hispanic/ Latino only.  Hispanic or Latino means a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.  **Any consumer who reports Hispanic/Latino ethnicity can only be counted as “Hispanic/Latino,” even if the consumer also reported one or more race categories.**

(7) Two or more races.  If a consumer self-reports more than one race, that consumer must counted once in the 704 Report, that is, as “Two or More Races.”

(8) “Race and ethnicity unknown” – A consumer is counted as Race/Ethnicity Unknown if the consumer does not reports any race or ethnicity. 

Note: The total of G1 through G8 must agree with subpart II, A3.

**Section H – Disability**

(1) through (7) – Enter the total number of consumers served in each category during the current reporting year as self reported by each consumer.  These categories are meant to describe the functional limitations involved with a consumer’s disability rather than a grouping of specific diagnoses of disabilities.

SubPart III – Individual Services and Achievements Funded Through Title VII, Chapter 1, part B funds 

Sections 13, 704(m)(4) of the Act; 34 CFR 364.53; Government Performance Results Act (GPRA) Performance Measures

Subpart III features three related tables designed to measure how IL core services and other IL services help maximize the leadership, empowerment, independence, and productivity of individuals with disabilities, and the integration and full inclusion of individuals with disabilities into the mainstream of American society.  Each table is described below.

## Section A – Individual Services - Quantifies the IL services requested by, and provided to, consumers during the reporting year. These services can be considered as the independent living program’s outputs contributing to the consumers’ expected outcomes, that is, greater independence and community integration. 

Section B- Independence And Community Integration  - Quantifies the independent living program’s outcomes, expressed in terms of the diverse goals that consumers have achieved through the provision of IL services (outputs), including the four core services.  Section B consists of two related tables:

Item 1 (Goals Related to Increased Independence in a Significant Life Area).  This table tracks the number of consumers who achieved independence in at least one significant life area.  The term *significant life area* (SLA) is a way to classify the multiplicity of possible consumer goals into a few categories representing the range of life achievements made possible through IL services.  SLAs represent the varying ways in which diverse consumers with disabilities can realize their particular potential – ranging from competence in self-care to relocation from a nursing home/institution to fulfillment of educational and vocational aspirations.

Item 2 (Improved Access to Transportation, Health Care and Assistive Technology).  The lack of access to essential opportunities such as transportation, appropriate health care services, or assistive technology may prevent an individual from achieving independence in one or more significant life areas. This table measures how the independent living program enables consumers to overcome barriers to their independence by helping them to access previously unavailable transportation, health care services, and assistive technology.  These are certainly not the only barriers faced by individuals with disabilities.  However, data provided in these areas will enhance RSA’s ability to document the impact of the independent living program on individuals in these areas.

Individuals with disabilities can overcome barriers to accessing transportation, health care services, or assistive technology through a combination of the IL services listed in the table under section A, including the four core services -- information and referral services, independent living skills training, peer counseling, and individual advocacy. [Systems advocacy is addressed in subpart IV.]  For example, a service provider may facilitate a consumer’s access to previously unavailable transportation through mobility training, assistive devices, prosthesis or personal attendant care assistance; or independent living skills training to help consumers avail themselves of existing community transportation services.  Access to appropriate health care services may be enhanced through information and referral services, such as the provision of directories of local medical facilities with available interpreters or TDD phone numbers; individual advocacy efforts resulting in accessible ramps or examining tables at doctors’ offices; peer counseling services to improve consumers’ self-advocacy abilities; or the arrangement of assistive technology services for consumers to better communicate with their doctors.  Access to assistive technology may be expanded through information and referral to public and private sector sources of funding or equipment, independent living skills training on the use of assistive technology, and peer counseling and individual advocacy to help consumers advocate for the services and equipment for which they are eligible.

Note: The term “assistive technology” (as defined in subpart III, section A) encompasses a broad range of independent living resources such as daily living, mobility, cognitive and communications aids as well as information technology.  

The subpart III tables (section A, section B, item 1 and section B, item 2) are closely related.  Transportation and assistive technology, for example, appear in each table.  There are important differences, however, as the following examples illustrate:

· A consumer whose goal is *Mobility/Transportation* (section B, item 1) may receive *Transportation Services* such as information and referral to the community’s para-transit system (section A).  Yet it may be that the consumer cannot achieve the *Mobility/Transportation*goal until he or she gains the necessary confidence to utilize the para-transit system through IL skills training and peer counseling services.  In this example, the *Mobility/Transportation* goal (section B, item 1) involves more than just *Transportation Services (*section A)*.*

· A consumer whose goal is *Community-Based Living*(section B, item 1)**may be impeded from reaching that goal because he/she lacks *Access To Transportation* (section B, item 2).  Access to transportation is not the consumer’s goal, but simply the means to the consumer’s goal, community-based living.

Consumers may appear in more than one of the subpart III tables:

· In the first example, the successful consumer would appear in section A (under *Transportation Services*, *Peer Counseling*and*IL Skills Training*); in section B, item 1 (under the *Mobility/Transportation*goal); and in section B, item 2 (under *Access to Transportation*).  

· In the second example, the consumer would also appear in the three tables, except that he/she would appear under the *Community-Based Living*goal instead of the *Mobility/Transportation* goal in section B, item 1. 

*Detailed instructions for completing subpart III follow below:*

## Section A – Individual Services

List the number of consumers requesting and the number of consumers receiving each of the following services during the reporting year, including the IL core services.  Include all consumers who were provided services during the reporting year through Part B funds, either directly by DSU staff or via grants or contracts with other providers.  Do not include consumers who were served by any centers that received Part C funds during the reporting year.  

Note: The total number of individual services provided is not expected to equal the number of active CSRs during the reporting year, because one consumer may receive multiple services during the reporting year.  Also, individuals who receive information and referral (I&R) services would not necessarily have an CSRs.  

A) Advocacy/Legal Services – Assistance and /or representation in obtaining access to benefits, services, and programs to which a consumer may be entitled.

B) Assistive Technology – Any assistive technology device, that is, any item, piece of equipment or product system that is used to increase, maintain or improve functional capabilities of individuals with disabilities and any assistive technology service that assists an individual with a disability in the selection, acquisition or use of an assistive technology device.

C) Children’s Services – The provision of specific IL services designed to serve individuals with significant disabilities under the age of 14.  

D) Communication Services – Services directed to enable consumers to better communicate, such as interpreter services, training in communication equipment use, Braille instruction, and reading services.

E) Counseling and Related Services – These include information sharing, psychological services of a non-psychiatric, non-therapeutic nature, parent-to-parent services, and related services.

F) Family Services – Services provided to the family members of an individual with a significant disability when necessary for improving the individual’s ability to live and function more independently, or ability to engage or continue in employment.  Such services may include respite care.  Record the service in the consumer’s CSR on behalf of whom services were provided to the family.

G) Housing, Home Modifications, and Shelter Services – These services are related to securing housing or shelter, adaptive housing services (including appropriate accommodations to and modifications of any space used to serve, or occupied by individuals with significant disabilities).   

· Note: A CIL may not provide housing or shelter as an IL service on either a temporary or long term basis unless the housing or shelter is incidental to the overall operation of the CIL and is provided to any individual for a period not to exceed eight weeks during any six-month period.

H) IL Skills Training and Life Skill Training Services – These may include instruction to develop independent living skills in areas such as personal care, coping, financial management, social skills, and household management.  This may also include education and training necessary for living in the community and participating in community activities.  

I) Information and Referral Services – Identify all individuals who requested this type of assistance.  This is the only service (other then services to family members) that may be provided to all individuals, whether or not the individual has a disability.  Some entities record this service using strokes on an answering pad without opening a CSR, others create a CSR or other such file for future contact and outreach.  

J) Mental Restoration Services – Psychiatric restoration services including maintenance on psychotropic medication, psychological services, and treatment management for substance abuse.

K) Mobility Training Services – A variety of services involving assisting consumers to get around their homes and communities.

L) Peer Counseling Services – Counseling, teaching, information sharing, and similar kinds of contact provided to consumers by other people with disabilities.

M) Personal Assistance Services – These include, but are not limited to, assistance with personal bodily functions; communicative, household, mobility, work, emotional, cognitive, personal, and financial affairs; community participation; parenting; leisure; and other related needs.

N) Physical Restoration Services – Restoration services including medical services, health maintenance, eyeglasses, and visual services.

O) Preventive Services – Services intended to prevent additional disabilities, or to prevent an increase in the severity of an existing disability.

P) Prostheses, Orthotics, and Other Appliances – Provision of, or assistance in obtaining through other sources, an adaptive device or appliance to substitute for one or more parts of the human body.

Q) Recreational Services – Provision or identification of opportunities for the involvement of consumers in meaningful leisure time activities.  These may include such things as participation in community affairs and other recreation activities that may be competitive, active, or quiet.

R) Rehabilitation Technology Services – Any service that assists an individual with a disability in the selection, acquisition or use of applied technologies, engineering methodologies or scientific principles to meet the needs of the individual and address the barriers confronted by individuals with significant disabilities with respect to education, rehabilitation, employment, transportation, IL and/or recreation.  

Note: Rehabilitation technology services may include assistive technology devices and services.  However, for the purpose of this report, include the provision of assistive technology devices and services under item B, above. 

S) Therapeutic Treatment – Services provided by registered occupational, physical, recreational, hearing, language, or speech therapists.

T) Transportation Services – Provision of, or arrangements for, transportation.

U) Youth/Transition Services – Any service that develops skills specifically designed for youth with significant disabilities between the ages 14 and 24 to promote self-awareness and esteem, develop advocacy and self-empowerment skills and career exploration, including the transition from school to post school activities such as postsecondary education, vocational training, employment, continuing and adult education, adult services, independent living or community participation.

V) Vocational Services – Any services designed to achieve or maintain employment.

W) Other Services – Any IL services not listed above in A-V.

**Section B – Increased Independence And Community Integration**

**Item 1****– Goals Related to Increased Independence in a Significant Life Area**

For each of the significant life areas below, indicate the number of consumers who set goals, the number who achieved their goals, and the number whose goals were in progress at the end of the reporting year.  Goal achievement is to be determined through self-reporting by the consumer and recorded in the individual’s CSR.

(A) Self-Advocacy/Self-Empowerment – Goals involving improvement in a consumer’s ability to represent himself/herself with public and/or private entities, the ability to make key decisions involving himself/herself, or the ability to organize and manage his/her own activities to achieve desired objectives.

(B) Communication – Goals involving either improvement in a consumer’s ability to understand communication by others (receptive skills), and/or improvement in a consumer’s ability to share communication with others (expressive skills).

(C) Mobility/Transportation – Goals to improve a consumer’s access to her/his life space, environment, and community.  This may occur by improving the consumer’s ability to move, travel, transport himself/herself, or use public transportation.

(D) Community-Based Living – Goals that provide for a change in living situations with increased autonomy for the consumer.  This may involve a consumer’s goals related to obtaining/modifying an apartment or house.  Community-based living arrangements may include apartments, privately owned housing, self-directed assisted living, or self-directed living with family/friends.

(E) Educational – Academic or training goals that are expected to improve the consumer’s knowledge or ability to perform certain skills that would expand his/her independence, productivity or income-generating potential.

(F) Vocational – Goals related to obtaining, maintaining, or advancing in employment. 

(G) Self-Care – Goals to improve/maintain a consumer’s autonomy with respect to activities of daily living such as personal grooming and hygiene, meal preparation and nutrition, shopping, eating, and other aspects of personal health and safety.

(H) Information Access/Technology – Goals related to a consumer obtaining and/or using information necessary for the consumer’s independence and community integration.  These may include use of a computer or other assistive technology, devices, or equipment, as well as developing information technology skills, such as using computer screen-reading software.

(I) Personal Resource Management – Goals related to a consumer learning to establish and maintain a personal/family budget, managing a checkbook, and/or obtaining knowledge of available direct and indirect resources related to income, housing, food, medical, and/or other benefits.

(J) Relocation from a Nursing Home or Institution– Goals related to relocation from nursing homes or other institutions to community-based living arrangements.  This significant life area specifically pertains to consumers who live in a nursing home or institution, unlike the *Community-Based Living* life area, above, which includes any consumer regardless of his/her living situation prior to receiving IL services.

(K) Community/Social Participation – Goals related to full participation in the mainstream of American society, including the ability to participate in community events such as community fairs and government functions, attend worship services and access recreational activities and facilities.

(L) Other – IL goals not included in the above categories.

**Item 2 –****Improved Access To Transportation, Health Care Services and Assistive Technology**

**(A) Table:**

Please complete the columns in the Access Table found at (A) as follows:

Column 1 (Consumers Requiring Access) – Indicate the number of consumers – whether or not they originally requested the assistance – who required access to previously unavailable transportation, assistive technology or health care services in order to reach one or more of their IL goals listed in Item 1.

· The lack of transportation, health care services or assistive technology as barriers to independence may be identified by the consumer and/or by the service provider’s staff (as the consumer’s advisor).

Column 2 (Consumers Achieving Access) – Of the consumers counted in column 1, indicate the number who gained access to previously unavailable transportation, assistive technology or health care services as a result of the provision of IL services.  Include all consumers whose access in these areas was facilitated through the IL services provided – whether or not such access had been the consumers’ originally stated goal.

Column 3 (Consumers Whose Access Is In Progress) – Indicate the number of consumers who, at the end of the reporting year, were in the process of attaining access to previously unavailable transportation, assistive technology or health care services through the provision of IL services.

· Any consumer counted in column 2 or 3 must also be counted in column 1.  In the case of a consumer who achieves access as a result of I & R services, for example, that consumer should be counted under “Consumers Requiring Access” (column 1) as well as under “Consumers Achieving Access” (column 2).

Note: For most IL services, a consumer’s access to previously unavailable transportation, health care and assistive technology is documented through his or her CSR. In some instances, consumers may achieve an outcome solely through information and referral services.  In order to report these instances as successful outcomes, providers are not required to create CSRs for these consumers but must be able to document that follow-up contacts with these consumers showed access to previously unavailable transportation, health care and assistive technology.

**(B) Information and Referral Information:**

To inform RSA how many service providers engaged in I&R follow-up contacts regarding access to transportation, health care services or assistive technology, please respond to the corresponding question in the instrument.

**Section C – Additional Information Concerning Individual Services or Achievements**

Please provide any additional description or explanation concerning individual services or achievements reported in subpart III, including outstanding success stories and/or major obstacles encountered. 

Subpart IV – Community Activities AND coordination 

Section 704(i), (l), and (m)(4) of the Act; 34 CFR 364.26, 364.27, 364.32

## Section A – Community Activities 

### Item 1 – Community Activities Table

In the table provided, give a summary of the community activities involving the DSU staff, SILC members/staff and CIL board members or staff during the reporting year.  **Include in this count only CILs in the statewide network of centers that do not receive Part C funds.**Add more rows as needed.  

#### · Including information about the community activities of non-Part C centers in the statewide network, in addition to DSU and SILC community activities, will help provide a more complete picture of the independent living program’s impact on the lives of individuals with disabilities.  

#### For each activity, complete the following columns:

Column 1 (Issue Area) – Indicate which of the following disability issue areas is most closely related to the purpose of the activity by placing it in column 1: 

· Increasing accessibility to transportation

· Increasing access to appropriate health care

· Increasing the availability /access to assistive technology

· Increasing opportunities for affordable, accessible housing units

RSA has chosen to highlight the four issue areas listed above.  However, respondents are expected to include all community activities in which they participated during the reporting year.  Therefore, respondents should identify any other disability issue areas and include them in column 1.  **A sample table is provided below.**

Column 2 (Activity Type) – Indicate which of the following activity types best describes the activity by placing it in column 2:

· Community/Systems Advocacy – Includes efforts to implement local and state policy changes to make facilities, services, and opportunities available and accessible to individuals with disabilities.

· Technical Assistance – Assistance to the community on making services, programs, activities, resources, and facilities in society accessible to individuals with significant disabilities.

· Community Education and Public Information – Activities and information programs to enhance the community’s awareness of disabilities and disability issues, e.g., local TV, radio, or newspaper campaigns. This type of services may include the creation and distribution of publications (such as accessibility guides, disability awareness brochures, ADA information) and databases/directories for personal assistants, recreation opportunities, accessible transportation, accessible housing, and other available services.  

· Outreach Efforts – Entails the location of, and encouragement to use services for unserved/underserved populations, including minority groups and urban and rural populations.  

· Collaboration/Networking – Activities related to building coalitions or collaborative partnerships designed to expand the participation of individuals with significant disabilities in services, programs, activities, resources and facilities. 

RSA has chosen to highlight the five activity types listed above.  However, respondents are expected to include all community activities in which they participated during the reporting year.  Therefore, respondents should identify any additional types of activities related to the disability issue areas identified in column 1.  **A sample table is provided below.**

Column 3 (Entity) – Specify whether the DSU, the SILC and/or a center was the primary entity involved in the activity.  More than one primary entity may be specified, if appropriate.  (Entities with a secondary or supportive role may be included in Subpart IV, Section A, item 2)  **A sample table is provided below.**

Column 4 (Number of Hours) – Report the number of hours spent by DSU staff, SILC members/staff or CIL board members or staff on each activity.  Please round to nearest whole hour.  **A sample table is provided below.**

· The number of hours of community activities must be reported, not the number of hours times the number of participants.  For example:  If one CIL staff member gives a one-hour presentation to an audience of 50 people, one hour of community service would be counted, not 50 hours.  Conversely, if three CIL staff persons each gave a one-hour presentation at the same event, three hours of community service would be counted.

Column 5 (Objectives) – Provide a brief narrative describing the primary objective(s) of the activity.  Include, wherever possible, quantifiable data such as the number of people the activity is expected to benefit.  **A sample table is provided below.**

Column 6 (Outcomes) – Provide a brief narrative describing the primary outcome(s) of the DSU, SILC or CIL activity including, wherever possible, the number of people who actually benefited from the activity.  **A sample table is provided below.**

###### SAMPLE TABLE

# Item 2 – Description of Community Activities

For the community activities mentioned above, provide any additional details such as the role of the DSU, SILC, CIL, and/or consumers, names of any partner organizations and further descriptions of the specific activities and services performed and benefits conferred.

### Section B – Working Relationships Among Various Entities

Describe DSU and SILC activities to maximize the cooperation, coordination, and working relationships among the independent living program, the SILC, and CILs; and the DSU, other state agencies represented on the SILC, other councils that address the needs of specific disability populations and issues, and other public and private entities.  Describe the expected or actual outcomes of these activities.

**Part V – Statewide Independent Living Council (SILC)**

Section 705 of the Act; 34 CFR 364.21

## Section A - Composition and Appointment

### Item 1 – Current SILC Composition

Provide the requested information for each SILC member in the table.  Employment data is requested in order to ascertain whether the SILC member is employed by a center, a state agency, or neither.  The category in which the member was appointed can be described, for example, as ex-officio state agency representative, other state agency representative, center representative, person with a disability not employed by a center or state agency, section 121 funded project director, parent of person with a disability, community advocate, other service provider, etc.).  Include current vacancies, along with the corresponding appointment category for each.  Add more rows as necessary.

### Item 2 – SILC Composition Requirements

Provide the number of SILC members requested in each category.  Include any current vacancies in a particular appointment category.

## Section B – SILC Membership Qualifications

Section 705(b)(4) of the Act; 34 CFR 364.21(c)

### Item 1 – Statewide Representation

Describe how the SILC is composed of members who provide statewide representation.  For example, you may list the service areas currently represented in the SILC by center representatives or section 121 representatives.  You may also describe the policies and practices adopted by the SILC to ensure continued statewide representation on the SILC.

Item 2 – Broad Range of Individuals with Disabilities from Diverse Backgrounds

Describe how the SILC members represent a board range of individuals with disabilities from diverse backgrounds.  For example, you may list the different disability groups and minority, urban and rural populations represented.  You may also describe the policies and practices adopted by the SILC to ensure continued diversity on the SILC.

###### Item 3 – Knowledgeable about IL

Describe how SILC members are knowledgeable about centers for independent living and independent living services.  For example, you may describe in general terms the SILC members’ IL background or expertise or efforts made to train members on IL philosophy, laws, or best practices.  You may also describe the policies and practices adopted by the SILC to ensure continued IL knowledge possessed by members of the SILC.

**Section C – SILC Staffing and Support**

**Item 1 – SILC Staff**

Please provide the name and contact information for the SILC executive director.  Indicate the number and titles of any other SILC staff, if applicable.  Also indicate whether any SILC staff is also a state agency employee.

**Item 2 – SILC Support**

Describe the administrative support services for the SILC provided by the DSU, if any.

## Section D – SILC Duties

Section 705(c); 34 CFR 364.21(g)

### Item 1 – SILC Duties

Provide a summary of SILC activities conducted during the reporting year related to the SILC’s duties outlined in section 705(c) of the Act:

**(A) State Plan Development**

Describe any activities related to the joint development of the state plan.  Include any activities in preparation for developing the state plan, such as needs assessments, evaluations of consumer satisfaction, or hearings and forums.  

**(B) Monitor, Review and Evaluate the Implementation of the State Plan**

Describe any activities related to the monitoring, review and evaluation of the implementation of the state plan.  Examples of discussion issues may include review of 704 Reports, SILC participation on site reviews conducted by RSA, the DSU, and/or other relevant federal or state agencies, comments from persons with disabilities, surveys conducted, etc. 

**(C) Coordination With Other Disability Councils**

Describe the SILC’s coordination of activities with the State Rehabilitation Council (SRC) established under section 105, if the state has such a Council, or the commission described in section 101(a)(21)(A), if the state has such a commission, and councils that address the needs of specific disability populations and issues under other federal law.  Please state whether the SILC has at least one representative serving as a member of the SRC and whether the SILC has any members serving on other councils, boards or commissions in the state. 

**(D) Public Meeting Requirements**

Describe how the SILC has ensured that all regularly scheduled meetings and other public hearings and forums hosted by the SILC are open to the public and sufficient advance notice is provided.  This summary may include, for example, how meetings were publicized, methods used to ensure that individuals across the state had access to meetings, outreach to special populations, state notification requirements, etc.

**Item 2 – Other Activities**

Describe any other SILC activities funded by non-Part B funds.  Please note that the SILC may use Part B funds only to conduct the activities outlined in section 705 of the Act.  Any activities that do not fall into the SILC’s federal duties may only be conducted with non-federal funds.

## Section E – Training and Technical Assistance Needs 

Section 721(b)(3) of the Act 

Please choose up to 10 priority needs that reflect the technical assistance and training needs of the SILC.  Using the column on the right, indicate the SILC’s top priorities rating items 1 through 10, with 1 being the top priority.  Report any comments or clarifications using the blank space at the end of the subpart.  The needs identified will be used to design CIL and SILC training opportunities offered through the training and technical assistance program.  Please provide any additional comments in the write-in space provided.

# Subpart VI – SPIL Comparison and Updates, Other Accomplishments and Challenges

Section 704(m)(4) of the Act; 34 CFR 76.140

## Section A – Comparison of Reporting Year Activities with the SPIL

## Item 1 – Comparison with SPIL goals and objectives

## Describe progress made in achieving the objectives and goals outlined in the most recently approved SPIL. Discuss goals achieved and/or in progress as well as barriers encountered. 

## Item 2 – Updates to SPIL Information 

Provide any changes to the information contained in the currently approved SPIL.  In particular, discuss any changes that may have occurred to the DSU administration of the SILS program, SILC placement, legal status, membership or autonomy, SILC budget, or the statewide network of centers.  

Note: An amendment to the SPIL is required, in addition to this update, if there has been a significant and relevant change in the information or assurances in the plan, the administration or operation of the plan; or the organization, policies, or operations of the DSU (if the change materially affects the information or assurances in the plan).

## Section B – Significant Activities and Accomplishments

Describe any significant activities and accomplishments achieved by the DSU and SILC during the reporting year and not included elsewhere in the report, e.g. brief summaries of innovative practices, improved service delivery to consumers, etc.

## Section C – Substantial Challenges

Describe any substantial problems encountered by the DSU and SILC not included elsewhere in this report and discuss resolutions/attempted resolutions.  Examples include difficulty in outreach efforts, disagreements between the SILC and the DSU, complications recruiting SILC members, complications working with other State agencies or organizations within the State.

## Section D – Additional Information

Provide any other information, comments or explanations of the reporting year activities and data that were not previously included in other sections of the report.  Please include any suggestions that may be helpful to other state agencies, SILCs, CILs and RSA.

# SUBPART VII - SIGNATURES

Provide signatures, printed names, titles and phone numbers of DSU director(s) and SILC chair.

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