TABLE OF CONTENTSA.	Grant Activities (all grantees respond)	1B.	Partnership Activities (all grantees respond)	3C.	Planning and Infrastructure Development (all grantees respond)	6D.	Information and Referral/Assistance (all grantees respond)	7E.	Screening and Assessments (if applicable based on response to Question 1)	8F.	Resource Facilitation (if applicable based on response to Question 1)	9G.	Training (if applicable based on response to Question 1)	12H.	Other (if applicable based on response to Question 1)  	13I.	Narrative Responses	14

**INSTRUCTIONS:**  This electronic form has numerous fields that are pre-populated and auto-calculated to generate sums and percentages. This will save grantees time, and reduces the chance of arithmetical errors. Grantees will enter relevant information for year one of the grant; in subsequent grant years, grantees will only have to enter necessary edits rather than enter data from previous years. The data from past years will be saved and displayed for each grant year. This electronic form will be submitted with grantees’ financial reports. 

# A. **GRANT ACTIVITIES (all grantees respond)**

1. **Which activities did you carry out as part of your ACL project with program funding during this reporting period (select all that apply)? Note: Program funding refers to not only funds provided by ACL but also state matching funds.**

a. **Partnership Development** (Identifying and reaching out to new partners, coordinating and aligning activities, information exchange, collaboration on grant activities)

b. **Planning and Infrastructure Development** (state planning, state councils, needs assessment, surveillance, registry, IT systems)

c. **Information and Referral/Assistance** (Bringing people and services together, answering questions from individuals and families about human service resources, helping people get connected to public benefits, sharing information about available services like home care and adaptive equipment. Note: I&R is about bringing people and services together. Individuals may reach out once or many times, but I&R does not involve the ongoing partnerships of Resource Facilitation.)

d. **Screening and/or Assessment** (Using a standardized procedure, structured interview, or tool to elicit the lifetime history of TBI for an individual. Screening and/or assessments can be used for clinical, research, programmatic, or eligibility determination purposes.)

e. **Resource Facilitation** (May be called service coordination, service navigation, options counseling, or person centered counseling. It is a process that engages individuals in decision making about their options, preferences, values, and financial resources and helps connect them with services and supports they choose. Resource facilitation offers individuals one-on-one counseling for a relatively short duration until decisions are made and/or services are accessed.)

f. **Training** (Continuing education for professionals who may work with or provide services for people who have experienced a TBI, training for individuals who have experienced a TBI, training for caregivers, on-the-job training for agency staff, cross-training with partnering agencies)

g. **Other** (Describe) *Grantees will be able to add as many topics as needed*

2. **Did you target your grant activities to support people in a particular setting or particular population during this reporting period? If yes, please select all that apply.**

YES ___     NO ___  

a. Athletes

b. Children and youth (22 and younger)

c. Older adults (60 or over)

d. People who are homeless

e. People who are hospitalized 

f. People who are incarcerated or formerly incarcerated

g. Medicaid home and community-based services participants

h. Native Americans

i. Residents of nursing facilities, rehab facilities or ICFs/MR

j. Rural populations

k. People who experience a substance use disorder

l. Students

m. Veterans or current service members 

n. People who are victims of crime or domestic violence 

o. Other (describe) 

**3. Percent of your state’s counties reached through your grant’s activities during this reporting period:**

a. Total number of counties in state			#______  *We will obtain this information and have it  automatically populate to reduce burden on the grantees*

b. Counties reached					#______	_____% *  

* [% is auto calculated based on # of counties reached divided by total number of counties]        

4. **For each of your grant activities, please provide how much total program funding you spent in this reporting period, rounded to closest $100. Note: total program funding refers to funds provided by ACL as well as state matching funds. (This figure should match what you reported on the 424.)**

****

a. Partnership Development          			$______         ____%  *      

b. Planning and Infrastructure Development           	$______         ____%  *   

c. Outreach and Awareness   		 				$______         ____%  *   

d. Information and Referral/Assistance      	 			$______         ____%  *                                                                                                                                                                                                                                                                        

e. Screening  and/or Assessment           				$______         ____%  *                                                                                                                                                                                                                                                                                    

f. Resource Facilitation						$______         ____%  *                                                                                                                                                                                                                                                                                   

g. Training	   				 			$______         ____%  *                                                                                                                                                                                   

h. Other (describe)    _______      					$______         ____%  *     

i. Funds not yet spent including any carryover funds from last fiscal year $____       ____%  *     

j. Total Program Funding						$______ **    

* [% is auto calculated based on category total divided by sum of categories] ** [auto calculated by summing categories above]          

5. **Did your project use any evidence-based practices in your grant activities during this reporting period? If yes, please describe**

YES ___     NO ___  

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

# B. **PARTNERSHIP ACTIVITIES (all grantees respond)**

6. **Which organizations in your state received funding through the ACL State Partnership Program in this reporting period to carry out and/or support grant activities (primary awardee and subawarded partners)? Note: “program funds” refers to not only funds provided by ACL but also state matching funds.**

a. Primary Grantee

*To relieve burden, ACL will fill in a.i and a.ii based on existing information from Notice of Award. Grantee will be able to edit if it is incorrect.*

	        i. Name of organization ___________________

ii. Type of organization (select one):

· State Vocational Rehabilitation Agency, 

· State Department of Education, 

· State Department of Criminal Justice, 

· State Unit on Aging,

· State Developmental Disabilities

· Mental Health Agency,

· Other State Agency, 

· University Center on Excellence for Developmental Disabilities. 

· University, 

· Other: 

_____________________________________________________________ 

b. Funded Partner 1

	        i. Name of organization ___________________

ii. Type of organization (select one):

· State Medicaid Agency, 

· State Vocational Rehabilitation Agency, 

· State Department of Education, 

· State Department of Criminal Justice, 

· State Unit on Aging,

· State Developmental Disabilities or Mental Health Agency,

· Other State Agency, 

· State Independent Living Council, 

· State DD Council, 

· State Brain Injury Association, 

· County or Local Government Entity, 

· Community-Based Services Organization (e.g. CAA, ADRC, AAA, CIL), 

· Public Health Clinic, 

· VA Medical Center, 

· Other Health Care Provider,

· University, 

· Private Business/Employer, 

· Other __________

iii. Is this partner new this reporting period? Y/N 

c.   Add another Funded Partner*Grantees can add as many funded partners as they need.*

7. **Which organizations do you consider partners in supporting program activities that did not receive program funds (unfunded partners) during this reporting period?**

                    a. Unfunded Partner 1

	        i. Name of organization ___________________

ii. Type of organization (select one):

· State Medicaid Agency, 

· State Vocational Rehabilitation Agency, 

· State Department of Education, 

· State Department of Criminal Justice, 

· State Unit on Aging,

· State Developmental Disabilities or Mental Health Agency,

· Other State Agency, 

· State Independent Living Council, 

· State DD Council, 

· State Brain Injury Association, 

· County or Local Government Entity, 

· Community-Based Services Organization (e.g. CAA, ADRC, AAA, CIL), 

· Public Health Clinic, 

· VA Medical Center, 

· Other Health Care Provider,

· University, 

· Private Business/Employer, 

· Other __________

iii. Is this partner new this reporting period? 

b. Unfunded Partner 2

	     i. Name of organization

· State Medicaid Agency, 

· State Vocational Rehabilitation Agency, 

· State Department of Education, 

· State Department of Criminal Justice, 

· State Unit on Aging,

· State Developmental Disabilities or Mental Health Agency,

· Other State Agency, 

· State Independent Living Council, 

· State DD Council, 

· State Brain Injury Association, 

· County or Local Government Entity, 

· Community-Based Services Organization (e.g. CAA, ADRC, AAA, CIL), 

· Public Health Clinic, 

· VA Medical Center, 

· Other Health Care Provider,

· University, 

· Private Business/Employer, 

· Other __________

     iii. Is this partner new this reporting period?

c. Add another unfunded partner*Grantees will be able to add as many unfunded partners as they need.***8*.*Is there anything else you would like to let ACL know about your Partnership activities during this reporting period?**

*This question is not mandatory.*

# C. **PLANNING AND INFRASTRUCTURE DEVELOPMENT (all grantees respond)**

9. **Please list your advisory board members for this project period and place a check by their affiliations. You may check all that apply if a person represents two or more affiliated entities.**

· Person who has experienced a TBI (Survivor)

· Family member of person who has experienced a TBI

· Center for Independent Living/State Independent Living Council representative

· Aging and Disability Resource Center representative

· Protection & Advocacy agency representative

· Long-term care ombudsman representative

· TBI Model Systems representative

· Other (describe) _______

10. **Estimate the number of people in your state who have experienced a TBI and who are now receiving home and community-based services and supports through a Medicaid TBI waiver and/or other state-funded programing during this reporting period.**#______

Briefly describe the data sources you used, their associated dates, and the methodology you used to calculate these estimates:

____________________________________________________________________________________________________________________________________________________________

Notes about data provided: (e.g., unknown because none of our partners collect this information, data are incomplete because only some of our partners collect this information. Please describe.)____________________________________________________________________________________________________________________________________________________________

11. **Is there anything else you would like to let ACL know about your planning and infrastructure activities during this reporting period? These activities may include needs assessments, state plans, and registries***This question is not mandatory.*

*The Sections below will only appear to those grantees who indicated in Question 1 that they carry out these activities.*

# D. **Information and Referral/Assistance**

**12. How many unduplicated I&R/A contacts were made in this reporting period (across all funded partners providing grant-related I&R/A)? Note: “funded partners” refers to partners receiving funds from ACL as well as designated state matching funds. Please enter a positive number, zero, or unknown.**

a. Total number of contacts regarding TBI received in reporting period # _______

b**.**Total number of residents in service area   #________

Notes about data provided: (e.g., unknown because none of our partners collect this information, data are incomplete because only some of our partners collect this information. Please describe.)____________________________________________________________________________________________________________________________________________________________________

**13. To what types of services did you make referrals for I&R/A callers who have experienced a TBI, their family members, or other professionals and service providers during this reporting period across all funded partners providing grant-related I&R/A? Please select an option for each type of referral.**

ANSWER OPTIONS: COMMONLY/OCCASIONALLY/NEVER/UNKNOWNTBI 

a. grant-funded resource facilitation, service coordination 

b. Other type of resource facilitation, service coordination (provided by other unfunded partners or other organizations such as an ADRC, CIL, TBI association or other)

c. Aging services

d. Behavioral health services	

e. Brain injury support groups

f. Caregiver supports

g. Independent living services

h. Domestic violence help services

i. Employment counseling

j. Educational counseling or school disability services

k. General medical services

l. Homeless services provider

m. Housing supports

n. Medicaid waiver services 

o. Physical, occupational, recreational or speech therapy

p. Legal or advocacy services

q. Transportation services

r. Social Security

s. Veteran’s hospital or clinic 

t. Vocational rehabilitation services

u. In-home services and supports

v. Other: ____________________ 		

**14. Is there anything else you would like to let ACL know about your I&R activities during this reporting period?***This question is not mandatory*.

# E. **Screening and Assessments (if applicable based on response to Question 1)**

**15. How many unduplicated people did you and your partners screen or assess to identify their likelihood of TBI during this reporting period (across all funded partners providing grant-related screening and assessment)? Please enter a positive number, zero or unknown in every field.**

    a.****Total number of unduplicated people screened or assessed this reporting period   # ______

    b. Number of people screened who were identified as having a history of TBI: #_______

· Number of people under age 22	#_______

· Number of people between 22-59	#_______

· Number of people 60 or older   	#_______

· Number of veterans of any age	#_______

**16. Select which standardized instruments you or your partners used for screening and assessment procedures during this reporting period. (Select all that apply)**

**17. Of the people who have experienced a TBI whom you screened in this reporting period, how many were living in these following settings at the time of their screening? Please enter a positive number, zero or unknown in every field.**

a. Homeless							#______

b. With parent or grandparent					#______   

c. With immediate family					)	#______   

d. With friends or other extended family 				#______    

e. Prison or jail    							#______  

f. Transitional living program or temporary housing		#______   

g. Nursing facility or supervised living program			#______  

h. Assisted-living settings 						#______  

i. Other: ___________________					#______  

Notes about data provided: (e.g., unknown because none of our partners collect this information, data are incomplete because only some of our partners collect this information. Please describe.)____________________________________________________________________________________________________________________________________________________________________

**18. Of the people who have experienced a TBI whom you screened during this reporting period how many were in competitive, integrated employment and/or in school at the time of the screening? Please enter a positive number, zero (0), or unknown in every field.**

a. Competitive, integrated employment				 #______              

b. In school or training                  					 #______              

Notes about data provided: (e.g., unknown because none of our partners collect this information, data are incomplete because only some of our partners collect this information. Please describe.)____________________________________________________________________________________________________________________________________________________________________

**19. Is there anything else you would like to let ACL know about your screening and assessment activities this reporting period?**

*This question is not mandatory.*

# F. **RESOURCE FACILITATION (if applicable based on response to Question 1)**

**20. For how many unduplicated people who have a TBI did you or your partners provide resource facilitation in this reporting period (across all funded partners providing grant-related resource facilitation)? Please enter a positive number, zero (0), or unknown in every field.**

Total number of unduplicated people who have experienced a TBI who were provided with resource facilitation in this reporting period 	#_______

· Number of people under age 22	#_______

· Number of people between 22-59	#_______

· Number of people 60 or older	#_______

· Number of veterans of any age	#_______

Notes about data provided: (e.g., unknown because none of our partners collect this information, data are incomplete because only some of our partners collect this information. Please describe.)___________________________________________________________________________________________________________________________________________________________

**21. What types of referrals did you make for people who have experienced a TBI and who received resource facilitation during this reporting period? Please select a response for each type of referral**

ANSWER OPTIONS: COMMONLY/OCCASIONALLY/NEVER/UNKNOWN

a. TBI grant-funded resource facilitation, service coordination

b. Other type of resource facilitation, service coordination (provided by other unfunded partners or other organizations such as an ADRC, CIL, TBI association or other)

c. Aging services

d. Behavioral health services	

e. Brain injury support groups

f. Caregiver supports

g. Independent living services

h. Domestic violence help services

i. Employment counseling

j. Educational counseling or school disability services

k. General medical services

l. Homeless services provider

m. Housing supports

n. Medicaid waiver services

o. Physical, occupational, recreational or speech therapy

p. Legal or advocacy services

q. Transportation services

r. Social Security

s. Veteran’s hospital or clinic 

t. Vocational rehabilitation services

u. In-home services and supports

v. Other: ____________________ 	                       

**22. Of the people who have experienced a TBI for whom you provided resource facilitation this reporting period, how many were living in these different settings at the time you worked with them? Please enter a positive number, zero (0), or unknown in every field.**

a. Homeless								#______

b. With parent or grandparent						#______             

c. With immediate family						#______               

d. With friends or other extended family 				#______    

e. Prison or jail    							#______  

f. Transitional living program or temporary housing			#______              

g. Nursing facility or supervised living program				#______	             

h. Assisted-living settings 						#______               

i. Other: ___________________					#______               

Notes about data provided: (e.g., unknown because none of our partners collect this information, data are incomplete because only some of our partners collect this information. Please describe.)____________________________________________________________________________________________________________________________________________________________________

**23. Of the people who have experienced a TBI for whom you provided resource facilitation this reporting period, how many were in competitive, integrated employment and/or in school while receiving resource facilitation? Please enter a positive number, zero (0), or unknown in every field.**

a. Competitive, integrated employment				 #______              

b. In school or training                  					 #______              

Notes about data provided: (e.g., unknown because none of our partners collect this information, data are incomplete because only some of our partners collect this information. Please describe.)____________________________________________________________________________________________________________________________________________________________________

**24. Of the people who have experienced a TBI for whom you provided resource facilitation this reporting period, how many did you support through a transition from an institutional setting (e.g. criminal justice system, nursing facility) into the community? Please enter a positive number, zero (0), unknown, or not applicable in every field.**

a. Number transitioning from criminal justice system to community		#______

b. Number transitioning from nursing facility/medical facility to community	#______

c. Number transitioning from another setting to community (describe)		#______

____________________________________________________________________________________________________________________________________________________________

Notes about data provided: (e.g., unknown because none of our partners collect this information, data are incomplete because only some of our partners collect this information. Please describe.)____________________________________________________________________________________________________________________________________________________________

**25. Is there anything else you would like to let ACL know about your resource facilitation efforts    during this period?***This question is not mandatory.*

# G. **Training (if applicable based on response to Question 1)**

**26. How many unduplicated people in the following categories did you train in this reporting period (across all funded partners that provide training with grant funds)? Please enter a positive number, zero (0), unknown or not applicable in every field.***Please give each person only one designation for purposes of this question. If someone falls under more than one category, please choose the most appropriate and relevant one for the circumstances*

a. Staff providing grant-related services						# _______

· Staff providing I&R/A						# _____

· Staff conducting Screenings/Assessments				# _______

· Staff providing Resource Facilitation					# _______

b. Clinical/medical providers							# _______

· Physicians									# _______

· Emergency medical services providers/first responders 			# _______

· Other clinical/medical providers  						# _______

c. Coaches or other athletics personnel

d. Domestic violence services staff							# _______

e. Family, friends, informal caregivers						# _______

f. Homeless services organization staff						# _______

g. Individuals who have experienced a TBI						# _______

h. In-home services and supports staff  						# _______

i. Law enforcement personnel							# _______

j. Prison or criminal justice system staff						# _______

k. Protection and advocacy staff							# _______

l. Residential rehabilitation center staff						# _______

m. Nursing home staff								# _______

n. Universities, colleges, or school staff (excluding school coaches) 			# _______

o. Veterans & military organization staff						# _______

p. Other:______________________						# _______

Notes about data provided: (e.g., unknown because none of our partners collect this information, data are incomplete because only some of our partners collect this information. Please describe.)____________________________________________________________________________________________________________________________________________________________________

**27.  Please list the number of unduplicated grant-sponsored trainings that occurred this reporting period, by topic area and number of attendees. Please enter a positive number, zero (0), unknown, or not applicable in every field. Note: “grant-sponsored trainings” refers to those using ACL funding and/or state matching funds.**

a. TBI Basics 						#______ 	# attended: _____

b. Aging and TBI						#______ 	# attended: _____

c. Assistive technology 					#______ 	# attended: _____

d. Athletics						#______ 	# attended: _____

e. Behavioral health and TBI				#______ 	# attended: _____

f. Caregiving  						#______ 	# attended: _____

g. Children and TBI					#______ 	# attended: _____

h. Concussions & mild TBI 					#______ 	# attended: _____

i. Criminal justice and TBI					#______ 	# attended: _____

j. Diagnosis 						#______ 	# attended: _____

k. Educational issues 					#______ 	# attended: _____

l. Employment and training of people with TBI		#______ 	# attended: _____

m. Identification, screening, assessment			#______ 	# attended: _____

n. Independent living					#______ 	# attended: _____

o. Opioids and TBI						#______ 	# attended: _____

p. Neurobehavioral aspects of TBI				#______ 	# attended: _____

q. Public Policy						#______ 	# attended: _____

r. Person Centered Planning/Counseling			#______ 	# attended: _____

s. Community-based services and support resources	#______ 	# attended: _____

t. Treatment and therapies				#______ 	# attended: _____

u. Others: ______________				#______ 	# attended: _____

Notes about data provided: (e.g., unknown because none of our partners collect this information, data are incomplete because only some of our partners collect this information. Please describe.)____________________________________________________________________________________________________________________________________________________________________

**28. Is there anything else you would like to let ACL know about your training activities during this reporting period?***This question is not mandatory.*

# H. **Other (if applicable based on response to Question 1) *****The title of this activity will automatically populate from Question 1.*

**29. How many unduplicated people did you work with or support through ____ activity during this reporting period? Please enter a positive number, zero (0), or unknown in every field.**

Total number of people who have experienced a TBI who participated in __activity    # ______

· Number of people under age 22				      #_______

· Number of people between 223-59				     #_______

· Number of people 60 or older			   	     #_______

Notes about data provided: (e.g., unknown because none of our partners collect this information, data are incomplete because only some of our partners collect this information. Please describe.)____________________________________________________________________________________________________________________________________________________________________

# I. **Narrative Responses**

30. **Please describe the TBI mentoring and work group activities your program led or participated in during this reporting period.**

31. **Did you use the services of the TBI Coordinating Center during this reporting period? [Yes/No] *If yes, please describe these services.****If you did not use the services of the TBI Coordinating Center during this reporting period, please explain why not.*

32. **How would you describe the quality of services provided by the TBI Coordinating Center during this reporting period?**

33. **Is there anything else you would like to let ACL know about your project?**

Public Burden Statement: 

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 (OMB 0985-NEW).  Public reporting burden for this collection of information is estimated to average [8] hours per response, including time for gathering and maintaining the data needed and completing and reviewing the collection of information.  The obligation to respond to this collection is required to retain or maintain benefits under the statutory authority [Traumatic Brain Injury Reauthorization Act of 2018  (P.L. 115-377)]. 

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