# Reporting Instrument

OMB Control Number: 0985-0043

Expiration Date: January 31, 2021

**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.**

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

### Item 2 - Other Government Funds 

### Item 3 - Private Resources

### Item 4 - Total Income  

### Item 5 – Pass-Through Funds

Item 6 - Net Operating Resources

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

Section 713 of the Act; 45 CFR 1329.10

## 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. 

## 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):

## 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; 

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-of-living 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.  

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 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.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 

# 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.

## 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:

## 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.

## Section D – IL Plans and Waivers

Indicate the number of consumers in each category below.

## Section E – Age

Indicate the number of consumers in each category below.

## Section F – Sex

Indicate the number of consumers in each category below.

## 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.**

## Section H – Disability

Indicate the number of consumers in each category below.

# 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.

## 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.

**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.  

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.

**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; 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.**

### 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.

# 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.

### Item 2 – SILC Composition Requirements

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

## 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.

**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. 

**(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. 

# 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.

SubPART VII - signatures

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

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