REPORTING INSTRUMENT

OMB Control Number: 0985-0043

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

STATE INDEPENDENT LIVING 

SERVICES PROGRAM

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

amended)

INSTRUMENT

(To be completed by Designated State Entities

and Statewide Independent Living Councils)

Reporting Fiscal Year: _____________________________

State: ___________________________________________

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 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 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 and reference the OMB Control Number 0985-

0043. Note: Please do not return the completed Program Performance Report to this address.
2

SUBPART I – ADMINISTRATIVE DATA

Section A – Sources and Amounts of Funds and Resources

Sections 704(c) and 704(m)(3) and (4) of the Act

Indicate amount received by the DSE 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 – For Section 723 states Only $

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

(H) Other resources $

Item 4 - Total Income 

Total income = (A)+(B)+(C)+(D)+(E)+(F)+(G)+(H) $

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, Medicaid funds, etc.) $
3

Item 6 - Net Operating Resources

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

(Section 5) = Net Operating Resources $
4

Section B – Distribution of Title VII, Chapter 1, Subchapter B Funds 

Section 713 of the Act; 45 CFR 1329.10

What Activities were 

Conducted with Subchapter B Funds?

Expenditures of 

Subchapter B 

Funds for 

Services by DSE 

Staff

Expenditures for 

Services 

Rendered By 

Grant or 

Contract

(1) Provided resources to the SILC to carry out its 

functions $ $

(2) Provided IL services to individuals with 

significant disabilities $ $

(3) Demonstrated ways to expand and improve IL 

services $ $

(4) Supported the general operation of CILs that 

are in compliance with the standards and 

assurances set forth in subsections (b) and (c) 

of section 725 of the Act $ $

(5) Supported activities to increase capacity to 

develop approaches or systems for providing 

IL services $ $

(6) Conducted studies and analyses, gathered 

information, developed model policies, and 

presented findings in order to enhance IL 

services $ $

(7) Provided training regarding the IL philosophy $ $

(8) Provided outreach to unserved or underserved 

populations, including minority groups and 

urban and rural populations $ $
5

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

Sections 704(f) and 713 of the Act

Enter the requested information for all DSE grants or contracts, funded at least in part by Subchapter B funds, in the chart below. If a 

column is not applicable to a particular grant or contract, enter “N/A.” If there were no non-Subchapter B funds provided to this 

grantee or contractor for the purpose listed, enter “$0” in that column. Add more rows as necessary. 

Name of Grantee or 

Contractor

Use of Funds

(based on the activities listed in 

Subpart I, Section B)

Amount of 

Subchapter 

B Funds 

Amount of 

NonSubchapter 

B Funds 

Consumer 

Eligibility 

Determined By 

DSE or 

Provider

Consumer 

Service Records 

(CSRs) Kept 

With 

DSE or 

Provider

Total Amount of Grants 

and Contracts $ $
6

Section D - Grants or Contracts for Purposes Other than Providing IL 

Services or for the General Operation of Centers

Section 713 of the Act

Describe the objectives, activities and results for each Subchapter B grant or contract awarded 

for purposes other than IL services or the general operation of centers. 

Section E – Monitoring Title VII, Chapter 1, Subchapter B Funds

Provide a summary of the program or fiscal review, evaluation and monitoring conducted by the 

state of any of the grantees/contractors receiving Subchapter B funds during the reporting year. 

Section F – Administrative Support Services and Staffing 

Section 704(c)(2) and 704 (m)(2) and (4) of the Act

Item 1 – Administrative Support Services

Describe any administrative support services, including staffing, provided by the DSE to the Part 

B Program.

Item 2 – Staffing

Enter requested staff information for the DSE and service providers listed in Section C, above 

(excluding Subchapter C funded CILs):

Type of Staff

Total Number 

of FTEs

FTEs filled by 

Individuals with 

Disabilities

Decision-Making Staff

Other Staff

Section G – For Section 723 States ONLY

Section 723 of the Act, 45 CFR 1329.12

Item 1 – Distribution of Subchapter C Funds to Centers

In the chart below, please provide the following information: 

A) name of each center within your state that received Subchapter C funding during the 

reporting year; 

B) amount of Subchapter C funding each center received; 
7

C) whether the Subchapter C funding included a cost-of-living increase; 

D) whether the Subchapter C funding included any excess funds remaining after cost-ofliving increases were provided; 

E) whether any of the centers received its Subchapter C funding pursuant to a competition 

for a new center in the state; and 

F) whether the center was the subject of an onsite compliance review conducted by the DSE 

during the reporting year. 

Name of CIL 

Amount of 

Subchapter C 

Funding 

Received 

Cost of 

Living 

Increase? 

(Yes/No)

Excess 

Funds 

After Cost 

of Living 

Increase?

(Yes/No)

New 

Center? 

(Yes/No)

Onsite 

Compliance 

Review of 

Center?

(Yes/No)

Add additional rows as necessary.

Item 2 – Administrative Support Services

Section 704(c)(2) of the Act

Describe the administrative support services used by the DSE to administer the Subchapter C 

program.

Item 3 – Monitoring and Onsite Compliance Reviews

Section 723(g), (h), and (i)

Provide a summary of the monitoring activities involving Subchapter C centers conducted by the 

state during the current reporting year, including the onsite reviews of at least 15% of centers 

receiving Subchapter C funds under section 723. The summary should include, at least, the 

following:

A) centers’ 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 for centers.

Item 4 – Updates or Issues

Provide any updates to the administration of the Subchapter C program by the DSE, if any, 

including any significant changes in the amount of earmarked funds or any changes in the order 
8

of priorities in the distribution of Subchapter C funds. Provide a description of any issues of 

concern addressed by the DSE in its administration of the Subchapter C program. 
9

SUBPART II – NUMBER AND TYPES OF INDIVIDUALS WITH 

SIGNIFICANT DISABILITIES RECEIVING SERVICES 

Section 704(m)(4) of the Act; 45 CFR 1329.12(a)(3–4)

In this section, provide data from all service providers (DSE, grantees, contractors) who received 

Subchapter B funds and who were listed in Subpart I, Section C of this report, except for the 

centers that receive Subchapter C funds. Subchapter C centers will provide this data themselves 

on their annual CIL PPRs.

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
10

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

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 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
11

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).

This section reflects a new OMB directive. 

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
12

SUBPART III – INDIVIDUAL SERVICES AND 

ACHIEVEMENTS FUNDED THROUGH TITLE VII, CHAPTER 

1, SUBCHAPTER B FUNDS

Sections 13 and 704(m)(4); 45 CFR 1329.12(a)(3–4); Government Performance Results Act 

(GPRA) Performance Measures

Subpart III contains new data requests. Please refer to the Instructions before completing.

Section A – Individual Services and Achievements

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

each of the following IL services. Include all consumers who were provided services during the 

reporting year through Subchapter B funds, either directly by DSE staff or via grants or contracts 

with other providers. Do not include consumers who were served by any centers that received 

Subchapter C funds during the reporting year.

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
13

Services

Consumers 

Requesting

Services

Consumers 

Receiving 

Services

(P) Prostheses, Orthotics, and Other Appliances

(Q) Recreational Services

(R) Rehabilitation Technology 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
14

Significant Life Area Goals Set

Goals 

Achieved

In 

Progress

(K) Community/Social Participation

(L) Other

Item 2 – Improved Access to Transportation, Health Care 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 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 document that follow-up contacts with these consumers 

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

(B) I&R Information

To inform ACL 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.
15

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. 
16

SUBPART IV – COMMUNITY ACTIVITIES AND 

COORDINATION

Section 704(i), (l), and (m)(4) of the Act; 45 CFR 1329.17(c)

Section A – Community Activities

Item 1 – Community Activities Table

In the table below, summarize the community activities involving the DSE, SILC and CILs in 

the Statewide Network of Centers (excluding Subchapter C fund recipients) during the reporting 

year. For each activity, identify the primary disability issue(s) addressed as well as the type of 

activity conducted. Indicate the entity(ies) primarily involved and the time spent. Describe the 

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

Subpart IV contains new data requests. Please refer to the Instructions before completing.

Issue 

Area

Activity 

Type

Primary 

Entity

Hours 

Spent Objective(s) Outcomes(s)

Item 2 – Description of Community Activities

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

the DSE, SILC, CIL, and/or consumers, names of any partner organizations and further 

descriptions of the specific activities, services and benefits.

Section B – Working Relationships among Various Entities

Describe DSE and SILC activities to maximize the cooperation, coordination, and working 

relationships among the independent living program, the SILC, and CILs; and the DSE, 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.
17

SUBPART V – STATEWIDE INDEPENDENT LIVING COUNCIL 

(SILC) 

Section 705 of the Act; 45 CFR Part 1329.14–16 

Section A - Composition and Appointment

Item 1 – Current SILC Composition

In the chart below, provide the requested information for each SILC member. 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.

Name of SILC 

member

Employed by

CIL, State 

Agency or 

Neither

Appointment 

Category 

Voting or 

Non-Voting

Term Start 

Date

Term End 

Date
18

Item 2 – SILC Composition Requirements

Please provide the information requested in the chart below. Include any current vacancies in a 

particular appointment category.

SILC Composition

# of SILC 

members

(A) How many members are on the SILC?

(B) How many members of the SILC are individuals with disabilities not 

employed by a state agency or a center for independent living?

(C) How many members of the SILC are voting members?

(D) How many of the voting members of the SILC are individuals with 

disabilities not employed by a state agency or a center for independent 

living?

Section B – SILC Membership Qualifications

Section 705(b)(4) of the Act; 45 CFR 1329.14(a)

Item 1 – Statewide Representation

Describe how the SILC is composed of members who provide statewide representation.

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. 

Item 3 – Knowledgeable about IL

Describe how SILC members are knowledgeable about centers for independent living and 

independent living services.
19

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 provided by the DSE, if any.

Section D – SILC Duties

Section 705(c); 45 CFR 1329.15

Item 1 – SILC Duties

Provide a summary of SILC activities conducted during the reporting year related to the SILC’s 

duties listed below:

(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, 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. 

(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. 
20

(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.

Item 2 – Other Activities

Describe any other SILC activities funded by non-Subchapter B funds.

Section E – Training and Technical Assistance Needs 

Section 721(b)(3) of the Act 

Please identify the SILC’s training and technical assistance needs. The needs identified in this 

chart will guide the priorities set by ACL for the training and technical assistance provided to 

CILs and SILCs. 

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
21

Training and Technical Assistance Needs

Choose up to 10 

Priority Needs —

Rate items 1–10 

with 1 being most 

important

Assistive Technologies

General Overview

Data Collecting and Reporting 

General Overview

704 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

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
22

Training and Technical Assistance Needs

Choose up to 10 

Priority Needs —

Rate items 1–10 

with 1 being most 

important

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 & 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
23

Training and Technical Assistance Needs

Choose up to 10 

Priority Needs —

Rate items 1–10 

with 1 being most 

important

Outreach to Unserved/Underserved Populations

General Overview

Disability 

Minority 

Institutionalized Potential Consumers

Rural 

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)
24

SUBPART VI – STATE PLAN FOR INDEPENDENT LIVING 

(SPIL) COMPARISON AND UPDATES, OTHER 

ACCOMPLISHMENTS AND CHALLENGES OF THE 

REPORTING YEAR

Section 704(n) of the Act

Section A – Comparison of Reporting Year Activities with the SPIL

Item 1 – Progress in Achieving Objectives and Goals

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 – SPIL Information Updates

If applicable, describe any changes to the information contained in the SPIL that occurred during 

the reporting year, including the placement, legal status, membership or autonomy of the SILC; 

the SILC resource plan, the design of the statewide network of centers; and the DSE 

administration of the ILS program.

Section B– Significant Activities and Accomplishments

If applicable, describe any significant activities and accomplishments achieved by the DSE and 

SILC not included elsewhere in the report, e.g. brief summaries of innovative practices, 

improved service delivery to consumers, etc.

Section C – Substantial Challenges

If applicable, describe any substantial problems encountered by the DSE and SILC, not included 

elsewhere in this report, and discuss resolutions/attempted resolutions, e.g., difficulty in outreach 

efforts; disagreements between the SILC and the DSE; complications recruiting SILC members; 

complications working with other state agencies or organizations within the state.

Section D – Additional Information

Include any additional information, suggestions, comments or explanations not included 

elsewhere in the report.
25

SUBPART VII - SIGNATURES

Please sign and print the names, titles and telephone numbers of the DSE directors(s) and SILC 

chairperson.

SIGNATURE OF SILC CHAIRPERSON DATE

NAME AND TITLE OF SILC CHAIRPERSON PHONE NUMBER

SIGNATURE OF DSE DIRECTOR DATE

NAME AND TITLE OF DSE DIRECTOR PHONE NUMBER