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REPORTING INSTRUMENT

OMB Control Number: 0985-NEW

Expiration Date: December 31, 2018

UNITED STATES DEPARTMENT OF HEALTH AND HUMAN SERVICES

ADMINISTRATION FOR COMMUNITY LIVING

INDEPENDENT LIVING ADMINISTRATION

SECTION 704 

ANNUAL PERFORMANCE REPORT

for

CENTERS FOR INDEPENDENT LIVING PROGRAM

(Title VII, Chapter 1, Subchapter C of the Rehabilitation Act of 1973, as 

amended)

Program Performance Report

INSTRUMENT

(To be completed by Centers for Independent Living)

Fiscal Year: ____________________________________

Grant #: _______________________________________

Name of Center: ________________________________

Acronym for Center (if applicable): ________________

State: _________________________________________

Counties Served: _______________________________

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 Office of Management and Budget (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 benefits (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 Administration for Community Living,

U.S. Department of Health and Human Services, 330 C Street, SW, Washington, DC 20201-0008, 

Attention Peter Nye, or email peter.nye@acl.hhs.gov. Note: Please do not return the completed Program 

Performance Report to this address.
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SUBPART I – ADMINISTRATIVE DATA

Section A– Sources and Amounts of Funds and Resources

Section 725(c)(8)(D) of the Act; 34 CFR 366.50(i)(4)

Indicate the amount received by the Center for Independent Living (CIL) as per each funding 

source. Enter “0” for none.

Item 1 - All Federal Funds Received

(A) Title VII, Ch. 1, Subchapter B $

(B) Title VII, Ch. 1, Subchapter C $

(C) Title VII, Ch. 2 $ 

(D) Other Federal Funds $

Item 2 - Other Government Funds 

(E) State Government Funds $

(F) Local Government Funds $

 

Item 3 - Private Resources

(G) Foundations, Corporations, or Trust Grants $

(H) Donations from Individuals $

(I) Membership Fees $

(J) Investment Income/Endowment $

(K) Fees for Service (program income, etc.) $

(L) Other resources (in-kind, fundraising, etc.) $

Item 4 - Total Income 

Total income = (A)+(B)+(C)+(D)+(E)+(F)+(G)+(H)+(I)+(J)+(K)+(L) $
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Item 5 - Pass Through Funds

Amount of other government funds received as pass-through funds to 

consumers (include funds, received on behalf of consumers, that are 

subsequently passed on to consumers, e.g., personal assistance 

services, representative payee funds, or Medicaid funds) $

Item 6 - Net Operating Resources

[Total Income (Section 4)<minus> amount paid out to Consumers

(Section 5) = Net Operating Resources $
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SUBPART II – NUMBER AND TYPES OF INDIVIDUALS WITH 

SIGNIFICANT DISABILITIES RECEIVING SERVICES 

Section 725(c)(8)(B) of the Act; 34 CFR 366.50(i)(2)

Section A – Number of Consumers Served During the Reporting Year

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

# of CSRs

(1) Enter the number of active CSRs carried over from September 30 of 

the preceding reporting year

(2) Enter the number of CSRs started since October 1 of the reporting 

year

(3) Add lines (1) and (2) to get the total number of consumers served

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

Include the number of consumer records closed out of the active CSR files during the reporting 

year because the individual has:

# of CSRs

(1) Moved

(2) Withdrawn

(3) Died

(4) Completed all goals set

(5) Other

(6) Add lines (1)+(2)+(3)+(4)+(5) to get total CSRs closed

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

Indicate the number of CSRs active on September 30th of the reporting year.

# of CSRs

Section A(3) <minus> Section (B)(6) = Section C
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Section D – IL Plans and Waivers

Indicate the number of consumers in each category below.

# of Consumers

(1) Number of consumers who signed a waiver

(2) Number of consumers with whom an Independent Living Plan (ILP)

was developed

(3) Total number of consumers served during the reporting year

Section E – Age

Indicate the number of consumers in each category below.

# of Consumers

(1) Under 5 years old 

(2) Ages 5 – 19 

(3) Ages 20 – 24

(4) Ages 25 – 59

(5) Age 60 and Older

(6) Age unavailable

Section F – Sex

Indicate the number of consumers in each category below.

# of Consumers

(1) Number of Females served

(2) Number of Males served
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Section G – Race and Ethnicity

Indicate the number of consumers served in each category below. Each consumer may be 

counted under ONLY ONE of the following categories in the Program Performance Report, 

even if the consumer reported more than one race and/or Hispanic/Latino ethnicity).

Please refer to the Instructions before completing.

# of Consumers

(1) American Indian or Alaska Native

(2) Asian 

(3) Black or African American

(4) Native Hawaiian or Other Pacific Islander

(5) White

(6) Hispanic/Latino of any race or Hispanic/Latino only 

(7) Two or more races

(8) Race and ethnicity unknown 

Section H – Disability

Indicate the number of consumers in each category below.

# of Consumers

(1) Cognitive

(2) Mental/Emotional

(3) Physical

(4) Hearing

(5) Vision

(6) Multiple Disabilities

(7) Other
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Section I – Individuals Served by County During the Reporting Year

Section 704(m)(4)(D) of the Act

List each county within the CIL’s service area, as indicated in the CIL’s application for 

Subchapter C funds and the approved State Plan for Independent Living (SPIL). Add additional 

rows as necessary. For each county, indicate how many individuals residing in that county were 

served by the CIL during the reporting year. 

County Name Number of County 

Residents Served
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SUBPART III – INDIVIDUAL SERVICES AND 

ACHIEVEMENTS 

Sections 13 and 725(c)(8)(C) of the Act; 34 CFR 366.50(i)(3); Government Performance Results 

Act (GPRA) Performance Measures

Please refer to the Instructions before completing.

Section A – Individual Services

For the reporting year, indicate in the table below how many consumers requested and received 

each of the following IL services. 

Services

Consumers 

Requesting

Services

Consumers 

Receiving 

Services

(A) Advocacy/Legal Services

(B) Assistive Technology

(C) Children’s Services

(D) Communication Services

(E) Counseling and Related Services

(F) Family Services

(G) Housing, Home Modifications, and Shelter Services

(H) IL Skills Training and Life Skills Training 

(I) Information and Referral Services

(J) Mental Restoration Services

(K) Mobility Training 

(L) Peer Counseling Services

(M) Personal Assistance Services

(N) Physical Restoration Services

(O) Preventive Services

(P) Prostheses, Orthotics, and Other Appliances

(Q) Recreational Services

(R) Rehabilitation Technology Services
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Services

Consumers 

Requesting

Services

Consumers 

Receiving 

Services

(S) Therapeutic Treatment

(T) Transportation Services

(U) Youth/Transition Services

(V) Vocational Services

(W) Other Services

Section B – Increased Independence and Community Integration

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

Indicate the number of consumers who set goals related to the following significant life areas, the 

number whose goals are still in progress, and the number who achieved their goals as a result of 

the provision of IL services.

Significant Life Area Goals Set

Goals 

Achieved

In 

Progress

(A) Self-Advocacy/Self-Empowerment

(B) Communication

(C) Mobility/Transportation 

(D) Community-Based Living

(E) Educational

(F) Vocational

(G) Self-care

(H) Information Access/Technology

(I) Personal Resource Management

(J) Relocation from a Nursing Home or Institution 

to Community-Based Living

(K) Community/Social Participation

(L) Other
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Item 2 – Improved Access to Transportation, Health Care Services, and Assistive 

Technology 

(A) Table

In column one, indicate the number of consumers who required access to previously unavailable 

transportation, health care services, or assistive technology during the reporting year. Of the 

consumers listed in column one, indicate in column two, the number of consumers who, as a 

result of the provision of IL services (including the four core services), achieved access to 

previously unavailable transportation, health care services, or assistive technology during the 

reporting year. In column three, list the number of consumers whose access to transportation, 

health care services or assistive technology is still in progress at the end of the reporting year. 

Areas

# of Consumers 

Requiring Access

# of Consumers 

Achieving Access

# of Consumers 

Whose Access is 

in Progress

(A) Transportation

(B) Health Care Services

(C) Assistive Technology

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 (I&R) services. To 

document these instances as successful outcomes, providers are not required to create CSRs for 

these consumers but must be able to report that follow-up contacts with these consumers showed 

access to previously unavailable transportation, health care and assistive technology.

(B) I&R Information

To inform ILA how many service providers engage in I&R follow-up contacts regarding access 

to transportation, health care services or assistive technology, please indicate the following:

The service provider did ___ / did not ___ engage in follow-up contacts with I&R recipients 

to document access gained to previously unavailable transportation, health care or assistive 

technology.

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. 
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SUBPART IV – Extent of CIL Compliance with the Six Evaluation 

Standards

Section 725(b) and section 725(c)(8)(A) of the Act; 34 CFR 366.63

Section A – Compliance Indicator 1: Philosophy

Item 1 - Consumer Control

34 CFR 366.63(a)(1); 34 CFR 366.50(i)(5) and (6)

(A) Board Member Composition

Enter requested governing board information in the table below:

Total Number 

of Board 

Members

Number of Board 

Members with 

Significant 

Disabilities

(B) Staff Composition

Enter requested staff information in the table below:

Total 

Number

of

FTEs

FTEs

Filled by 

Individuals 

with 

Disabilities

FTEs Filled 

by Individuals 

From 

Minority 

Populations 

Decision-Making 

Staff

Other Staff

Item 2 - Self-Help and Self-Advocacy

34 CFR 366.63(a)(2)

Briefly describe how the CIL has promoted self-help and self-advocacy among individuals with 

significant disabilities during the reporting year. 
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Item 3 - Peer Relationships and Peer Role Models

34 CFR 366.63(a)(3)

Briefly describe how, during the reporting year, the CIL has promoted the development of peer 

relationships and peer role models among individuals with significant disabilities. 

Item 4 - Equal Access 

34 CFR 366.63(a)(4)

(A) Briefly describe how, during the reporting year, the CIL has ensured equal access of 

individuals with significant disabilities, including communication and physical access, to the 

center's services, programs, activities, resources, and facilities, whether publicly or privately 

funded. Equal access, for the purposes of this indicator, means that the same access is provided 

to any individual with a significant disability regardless of the individual’s type of significant 

disability.

(B) Briefly describe how, during the reporting year, the CIL has advocated for and conducted 

activities that promote the equal access to all services, programs, activities, resources, and 

facilities in society, whether public or private, and regardless of funding source, for individuals 

with significant disabilities. Equal access, for the purposes of this indicator, means that the same 

access provided to individuals without disabilities is provided in the center’s service area to 

individuals with significant disabilities.

Item 5 – Alternative Formats

34 CFR 366.63(a)(4)

Briefly describe how, during the reporting year, the CIL has ensured the availability in 

alternative formats of all of its written policies and materials and IL services, as appropriate.

Section B – Compliance Indicator 2: Provision of Services on a CrossDisability Basis

Section 725(b)(2) of the Act; 34 CFR 366.63(b)

Briefly describe how, during the reporting year, the CIL has ensured that IL services are 

provided to eligible individuals with a diversity of significant disabilities and individuals who are 

members of populations that are unserved or underserved, without restrictions based on the 

particular type or types of significant disability and in a manner that is neither targeted nor 

limited to a particular type of significant disability. 
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Section C – Compliance Indicator 3: Independent Living Goals

Section 725(b)(3) of the Act; 34 CFR 366.63 (c)

Item 1 – Consumer Information

Briefly describe how, during the reporting year, the CIL has ensured that consumers have the 

opportunity to develop and achieve their goals (either with or without an ILP) and that the 

consumer has the opportunity to express satisfaction with the center and such consumer 

satisfaction results are evaluated by the center.

Item 2 – Consumer Service Record Requirements

Briefly describe how, during the reporting year, the CIL ensured that each consumer’s CSR 

contains all of the required information. 

Section D – Compliance Indicator 4: Community Options and Community 

Capacity

Section 725(b)(4) and (6) of the Act; 34 CFR 366.63(d)

Please refer to the Instructions before completing.

Item 1 – Community Activities Table

In the table below, summarize the community activities involving the CIL’s staff and board 

members during the reporting year. For each activity, identify the primary disability issue(s) 

addressed as well as the type of activity conducted. Describe the primary objective(s) and 

outcome(s) for each activity. Add more rows as necessary.

Issue 

Area

Activity 

Type

Hours 

Spent

Objective(s) Outcomes(s)
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Item 2 – Description of Community Activities

For the community activities mentioned above, provide additional details such as the role of the 

CIL staff board members and/or consumers, names of any partner organizations and further 

descriptions of the specific activities, services and benefits.

Section E – Compliance Indicator 5: IL Core Services and Other IL Services

Section 725(b)(5) of the Act; 34 CFR 366.63(e)

In addition to the data provided in Subpart III, describe how information and referral services 

and the other IL core and other IL services are provided to those who request such services in 

formats accessible to the individual requesting the services. Describe any innovative practices 

(not mentioned elsewhere in this report) to enhance the availability and effectiveness of IL 

services. 

Section F – Compliance Indicator 6: IL Resource Development Activities

Section 725(b)(7); 34 CFR 366.63(f)

Briefly describe the CIL’s resource development activities conducted during the reporting year to 

expand funding from sources other than Chapter 1of Title VII of the Act.
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SUBPART V – ANNUAL PROGRAM AND FINANCIAL 

PLANNING OBJECTIVES

Section 725(c)(4) of the Act

Section A – Work Plan for the Reporting Year

Item 1 – Achievements

Discuss the work plan’s proposed goals and objectives and the progress made in achieving them 

during the reporting year. 

Item 2 – Challenges

Describe any substantial challenges or problems encountered by the CIL, and the 

resolutions/attempted resolutions.

Item 3 – Comparison with Prior Reporting Year

34 CFR 366.50(i)(7)

As appropriate, compare the CIL’s activities in the reporting year with its activities in prior 

years, e.g., recent trends. 

Section B – Work Plan for the Year Following the Reporting Year

Item 1 – Annual Work Plan

List the CIL’s annual work plan goals, objectives and action steps planned for the year following 

the reporting year.

Item 2 – SPIL Consistency

Explain how these work plan goals, objectives and action steps are consistent with the approved 

SPIL. 
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SUBPART VI - TRAINING AND TECHNICAL ASSISTANCE 

NEEDS

Section 721(b)(3) of the Act. 

Training and Technical Assistance Needs

Choose up to 10 

Priority Needs ---

Rate items 1–10 with 

1 being most 

important

Advocacy/Leadership Development

 General Overview

 Community/Grassroots Organizing

 Individual Empowerment

 Systems Advocacy

 Legislative Process

Applicable Laws

 General overview and promulgation of various disability laws

 Americans with Disabilities Act

 Air-Carrier’s Access Act

 Fair Housing Act

 Individuals with Disabilities Education Improvement Act

 Medicaid/Medicare/PAS/waivers/long-term care

 Rehabilitation Act of 1973, as amended

 Social Security Act

 Workforce Investment Act of 1998

 Ticket to Work and Work Incentives Improvement Act of 1999

 Government Performance Results Act of 1993

Assistive Technologies

 General Overview

Data Collecting and Reporting 

 General Overview

 Program Performance Reports

 Performance Measures contained in Program Performance Report

 Dual Reporting Requirements

 Case Service Record Documentation

Disability Awareness and Information

 Specific Issues

Evaluation

 General Overview

 CIL Standards and Indicators

 Community Needs Assessment

 Consumer Satisfaction Surveys

 Focus Groups

 Outcome Measures
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Financial: Grant Management

 General Overview 

 Federal Regulations

 Budgeting

 Fund Accounting

Financial: Resource Development

 General Overview 

 Diversification of Funding Base

 Fee-for-Service Approaches

 For Profit Subsidiaries

 Fund-Raising Events of Statewide Campaigns

 Grant Writing

Independent Living Philosophy

 General Overview

Innovative Programs

 Best Practices

 Specific Examples

Management Information Systems

 Computer Skills

 Software 

Marketing and Public Relations

 General Overview

 Presentation/Workshop Skills

 Community Awareness

Networking Strategies

 General Overview

 Electronic

 Among CILs & Statewide Independent Living Councils (SILCs)

 Community Partners

Program Planning

 General Overview of Program Management and Staff Development

 CIL Executive Directorship Skills Building

 Conflict Management and Alternative Dispute Resolution

 First-Line CIL Supervisor Skills Building

 IL Skills Modules

 Peer Mentoring

 Program Design

 Time Management

 Team Building

Outreach to Unserved/Underserved Populations

 General Overview

 Disability 

 Minority 

 Institutionalized Potential Consumers

 Rural 
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 Urban 

SILC Roles/Relationship to CILs

 General Overview

 Development of State Plan for Independent Living

 Implementation (monitor & review) of SPIL

 Public Meetings

 Role and Responsibilities of Executive Board

 Role and Responsibilities of General Members

 Collaborations with In-State Stakeholders

CIL Board of Directors

 General Overview

 Roles and Responsibilities

 Policy Development

 Recruiting/Increasing Involvement

Volunteer Programs

 General Overview

Optional Areas and/or Comments (write-in)
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SUBPART VII – ADDITIONAL INFORMATION 

Section 704(m)(4)(D) of the Act

Section A – Other Accomplishments, Activities and Challenges

Describe any additional significant accomplishments, activities and/or challenges not included 

elsewhere in the report, e.g. brief summaries of innovative practices, improved service delivery 

to consumers, etc.

Section B – Additional Information

Provide additional information, comments, explanations or suggestions not included elsewhere in 

the report. 
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SUBPART VIII - SIGNATURES

Please sign and print the names, titles and telephone numbers of the CIL director and board 

chair.

SIGNATURE OF CENTER DIRECTOR DATE

NAME AND TITLE OF CENTER DIRECTOR PHONE NUMBER

SIGNATURE OF CENTER BOARD CHAIRPERSON DATE

NAME AND TITLE OF CENTER BOARD CHAIRPERSON PHONE NUMBER