# InSTRUCTIONS

OMB Control Number:  1820-0606

Expiration Date: xxxx xx, xxxx

**United States Department of Education**

**Office of special education and rehabilitatiVE services**

**Rehabilitation services administration**

**Section 704**

**annual performance report**

**For**

**Centers for Independent Living Program**

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

**Part II**

**INSTRUCTIONS**

**(To be completed by Centers for Independent Living)**

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

###### TABLE OF CONTENTS

# Frequently Asked Questions

**Question:** What is the Purpose of 704 Report, Part II?

**Answer:**  The purpose of this report is to:

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

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

C) Assure CIL compliance with the standards, assurances and compliance indicators in section 725(b) and (c) of the Act and 34 CFR 366, subparts F and G.

D) Collect information necessary for issuance of continuation awards for qualified CILs under title VII, chapter 1, Part C. 

E) Collect the data required by Section 13, 706, 721, and 725 of the Act for the CIL program.

F) Serve as the basis for on-site reviews of the CILs funded under Part C. 

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

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

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

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

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

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

The structure of Part II is as follows:

Subpart I – Administrative Data:  A report on resources received and expended during the reporting year.

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

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

Subpart IV – Extent of CIL Compliance with the Six Evaluation Standards: This subpart asks for evidence of compliance with the CIL’s six evaluation standards, including community options and capacity-building activities.  Data is provided in tables and through narrative description. 

Subpart V – Annual Program and Financial Planning Objectives: This subpart describes the CIL’s progress in achieving its work plan goals and objectives, a comparison between the CIL’s reporting year and prior years’ activities, and a description of the work plan for the year following the reporting year.

Subpart VI – Training and Technical Assistance Needs: This subpart asks the CIL to identify its priority training and technical assistance needs. 

Subpart VII – Additional Information: This subpart offers CILs the opportunity to describe any accomplishments, activities, challenges and comments not included elsewhere in the report.

Subpart VIII – Signatures:  Signatures, printed names, titles and phone numbers of the CIL director and board chairperson.

**Question:**  Who Must Complete the 704 Rreport, Part II?

**Answer:**  Only centers for independent living receiving title VII, Part C funding must complete Part II of the 704 Report.  Each title VII, Part C grant funds a separate center.  The following applies in the case of two centers who share the same governing board: If the two centers are separate and complete CILs and each receives its own Part C grant, then both centers must complete individuals 704 Reports.   

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

**Answer:**

Section 722 states**:**

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

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

CILs must also forward a copy of the 704 Report, Part II to their Statewide Independent Living Council.  Please contact the SILC in your state for the preferred format.

Section 723 states:

Part C funded CILs will submit their Part II Reports to the DSU and the SILC.  The section 723 states will forward the original (hard) signed copy and one electronic (WORD) copy of the CILs’ Part II Reports to RSA (along with the states’ Part I Report) and one electronic (WORD) copy to ILRU.  (Section 723 states are no longer responsible for aggregating the Part II data into their Part I Report.)

**Question:**  When Must the CILs Submit the 704 Part II Report to RSA?

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

Part C funded CILs in section 722 states must submit the 704 Report, Part II to RSA postmarked by December 31, for the preceding federal fiscal year. 

Part C funded CILs in section 723 states must submit the 704 Report, Part II to the DSU in the state with sufficient time for the DSU to review the report and submit it, along with its Part I report, to RSA postmarked by January 31, for the preceding federal fiscal year. 

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

**Answer:**

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

**GLOSSARY OF TERMS**

ActThe Rehabilitation Act of 1973, as amended.

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

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

Community-basedThese living arrangements include apartments,

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

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

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

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

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

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

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

ILIndependent Living

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

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

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

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

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

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

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

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

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

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

SPILA State Plan of Independent Living jointly 

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

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

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

Underservedpopulations of individuals with significant 

Populationsdisabilities who:

(1) have cognitive and sensory impairments;

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

(3) live in rural areas; or

(4) have been identified by the eligible agency as unserved or underserved with a center’s project area

##### Instructions:  704 Report, Part II

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

1) When a question/section requests a description, list, or other non-data information but does not apply to your center for independent living (CIL or center), a “not applicable” response is appropriate.

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

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

**COVER PAGE:**

Please complete the following sections on the instrument cover page:

1) Fiscal Year: Enter the federal reporting year covered by the report.

2) Grant #: Enter the pr/award (grant) number for the grantee as listed in block #5 on the grant award notification form. 

3) Name of Center: Enter the official name of the grantee as it appears on the grant award notification. 

4) Acronym for Center: Enter the acronym for the center, if applicable.

5) State: Enter the state in which the center provides services. 

6) Counties Served: Enter the counties served by the center.

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)

List the amounts of all resources received by the CIL from items 1 through 3 during the federal fiscal reporting year. In item 2 include “pass through” funds received from state or local governments.  “Pass through” funds are funds, received by the CIL on behalf of consumers, that are subsequently passed on to consumers, e.g., personal assistance services, representative payee funds, or Medicaid funds.  Round off to the nearest dollar amount any funds ending with cents.  Example: $4,240,010.87 ($4,240,011)

(1) Add lines 1(a) through 3(l) to get the amount of total income received by the CIL.  Record this amount in item 4. 

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

(3) Subtract the amount in item 5 from the amount in item 4 to get the total of net operating resources for the CIL.  Enter this amount in item 6.

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

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 reporting year.

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

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

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

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

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

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

(2) Withdrawn - the consumer has stated they are no longer interested in receiving services at this time.

(3) Died.

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

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

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

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

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

## Section D – IL Plans and Waivers

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

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

(3) Add the total number of consumers who signed a waiver to the total number of consumers who developed ILPs.  Enter this figure in line D(3).  D(1) + D(2) = D(3).  

Note: This is the total number of consumers served during the reporting year and **MUST** equal the “number of consumers served” in Section A, line 3 above.

## Section E – Age 

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

## Section F – Sex

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

## Section G – Race and Ethnicity

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

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

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

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

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

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

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

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

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

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

## Section H – Disability

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

**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 Part C funds and the approved 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.  Place a “0” in the column if no individuals residing in that county received IL services during the reporting year.

SubPart III – Individual Services and Achievements 

Section 13, 725(c)(8)(C) of the Act; 34 CFR 366.50(i)(3) Government Performance Results Act (GPRA) Performance Measures

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

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

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

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

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

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

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

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

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

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

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

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

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

*Detailed instructions for completing subpart III follow below*:

## Section A – Individual Services

List the number of consumers requesting and the number of consumers receiving each of the following services during the reporting year, including the IL core services.  The total of these numbers is not expected to equal the number of active CSRs during the reporting year, as a consumer may receive multiple services during the reporting year.  Also, individuals who receive information and referral (I&R) services only may not have a CSR.    

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

R) Rehabilitation Technology Services – Provision of, or assistance to obtain through other sources, adaptive modifications, such as wheelchairs and lifts, which address the barriers confronted by individuals with significant disabilities with respect to education, rehabilitation, employment, transportation, IL and/or recreation.

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

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

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

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

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

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

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

Please complete the columns as follows:

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

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

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

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

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

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

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

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

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

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

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

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

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

**(A) Table:**

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

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

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

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

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

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

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

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

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

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

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

**SUBPART IV – 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**

In the chart provided, report the total number of CIL board members and the number of board members with significant disabilities.

(B) Staff Composition

In the first column of the chart, report the total Full Time Equivalents (FTEs) for the employees who are in the staff and decision-making positions of the CIL. In the second column, report the total FTEs for the staff and decision-making positions filled by individuals with disabilities, and in the third column, report the total FTEs for the staff and decision-making positions filled by individuals from minority populations.

· In calculating FTEs, a CIL may exclude personal assistants, readers, drivers, and interpreters employed by the center from its FTE calculations.  To compute FTEs, determine the number of hours (excluding overtime) for which all employees were actually paid during the last six months of the reporting year.  Multiply the hours worked by 2 (two), divide by 2080 (approximate number of hours worked by an FTE), the subsequent total is the equivalent fraction of the FTEs. 

# 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 (e.g. by conducting activities to train individuals with significant disabilities in self-advocacy). 

# 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 (e.g., by using individuals with significant disabilities who have achieved IL goals as instructors in its training programs or as peer counselors).

**Item 4 - Equal Access**

34 CFR 366.63(a)(4)

**(A) Equal Access Regardless of Type of Disability**

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) Equal Access for Individuals with Disabilities**

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 Cross-Disability Basis

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

In your answer to this question, briefly address the following three categories when you describe how, during the reporting year, the CIL has met this compliance indicator.  For example, you may describe CIL policies, practices, by-laws, manuals, staff training initiatives, etc.

· IL services are provided to eligible individuals or groups of individuals without restrictions based on the particular type or types of significant disability of an individual or groups of individuals, unless the restricted IL service (other than the IL core services) is unique to the significant disability of the individuals to be served;   

· IL services are provided to individuals with a diversity of significant disabilities and to individuals who are members of populations that are unserved or underserved; and

· IL core services are provided to individuals with significant disabilities in a manner that is neither targeted nor limited to a particular type of significant disability.

# Section C – Compliance Indicator 3: Independent Living Goals

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

**Item 1 – Consumer Information**

In your answer to this question, briefly address the following four categories when you describe how, during the reporting year, the CIL has met this compliance indicator.  For example, you may describe CIL policies, practices, by-laws, manuals, staff training initiatives, etc.  

· a CSR that contains all the required information is maintained for each consumer; 

· the development and achievement of IL goals selected by individuals with significant disabilities who request assistance from the center are facilitated;

· opportunities are provided for consumers to express satisfaction with the center’s services and policies and any consumer satisfaction results are provided to the governing board and the SILC; and

· consumers are notified of their right to develop or waive an ILP.

In reference to the consumer satisfaction requirements, CILs may show compliance by providing a brief summary of the methods used to assess consumers’ satisfaction (e.g., focus groups, written survey, telephone survey, public meeting, etc.) and discussing any major findings from the most recent consumer satisfaction assessment.  If applicable, you may describe the CIL’s action plan to address specific areas for improvement identified through the consumer satisfaction assessment. 

**Item 2 – Consumer Service Record Requirements**

In your answer to this question regarding the composition of CSRs, briefly address the following three categories of required contents of CSRs when you describe how, during the reporting year, the CIL has met this compliance indicator.  For example, you may describe CIL policies, practices, by-laws, manuals, staff training initiatives, etc.

· IL goals that consumers receiving services at the center believe they have achieved;

· Number of ILPs developed by consumers; and

· Number of waivers signed by consumers.

# Section D – Compliance Indicator 4: Community Options and Community Capacity

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

# Item 1 – Community Activities Table

In the table provided give a summary of the community activities involving the CIL board members or staff during the reporting year.  Add more rows as needed.  For each activity, complete the following columns:

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

· increasing accessibility to transportation

· increasing access to appropriate health care

· increasing the availability /access to assistive technology

· increasing opportunities for affordable, accessible housing units

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

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

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

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

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

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

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

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

· Note: CILs must demonstrate at least one activity in each of the five categories listed above. 

Column 3 (Number of Hours) – report the number of hours spent by CIL board members or staff on each activity.  Please round to nearest whole hour.  **A sample table is provided below.**

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

Column 4 (Objectives) – provide a brief narrative describing the primary objective(s) of the activity.  Include, wherever possible, quantifiable data such as the number of people the activity is expected to benefit.  **A sample table is provided below.**

Column 5 (Outcomes) – provide a brief narrative describing the primary outcome(s) of the CIL activity including, wherever possible, the number of people who actually benefited from the activity.  **A sample table is provided below.**

###### SAMPLE TABLE

# Item 2 – Description of Community Activities

# For the community activities mentioned above, provide 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, briefly 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: Resource Development Activities

Section 725(b)(7) of the Act; 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 1 of title VII of the Act.

###### 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.  

## SUBPART VI - TRAINING AND TECHNICAL ASSISTANCE NEEDS

Section 721(b)(3) of the Act 

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

# SUBPART 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, e.g. brief summaries of innovative practices, improved service delivery to consumers, etc.  Please do not include information mentioned elsewhere in this report.

### Section B – Additional Information

Provide any additional information, comments or explanations, including suggestions that may be helpful to other CILs, SILCs, state agencies or RSA.  Please do not include information mentioned elsewhere in this report.

# SUBPART VIII - SIGNATURES

Please provide signatures, printed names, titles and telephone numbers of the CIL director and board chairperson.

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