# Reporting Instrument

OMB Control Number:  0985-NEW

				Expiration Date: December 31, 2018

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**UNITED STATES DEPARTMENT OF HEALTH AND HUMAN SERVICES**

###### ADMINISTRATION FOR COMMUNITY LIVING

**INDEPENDENT LIVING ADMINISTRATION**

**SECTION 704**

**ANNUAL PERFORMANCE REPORT**

**for**

**CENTERS FOR INDEPENDENT LIVING PROGRAM**

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

**Program Performance Report**

**INSTRUMENT**

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

### Fiscal Year: ____________________________________

### Grant #: _______________________________________

**Name of Center: ________________________________**

**Acronym for Center (if applicable): ________________**

**State: _________________________________________**

**Counties Served: _______________________________**

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number.  Public reporting burden for this collection of information is estimated to average 35 hours per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  The obligation to respond to this collection is required to obtain or retain benefits (P.L. 105-220 Section 410 Workforce Investment Act).  Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Administration for Community Living, U.S. Department of Health and Human Services, 330 C Street, SW, Washington, DC 20201-0008, Attention Peter Nye, or email peter.nye@acl.hhs.gov.  Note: Please do not return the completed Program Performance Report to this address.

# 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)

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Indicate the amount received by the Center for Independent Living (CIL) as per each funding source.  Enter “0” for none.

### Item 1 - All Federal Funds Received

### Item 2 - Other Government Funds 

### Item 3 - Private Resources

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### Item 4 - Total Income  

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### Item 5 - Pass Through Funds

### Item 6 -  Net Operating Resources

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# SubPart II – Number and Types of Individuals with significant disabilities receiving services 

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

## Section A – Number of Consumers Served During the Reporting Year

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

## 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).***

**Please refer to the Instructions before completing.**

## Section H – Disability

Indicate the number of consumers in each category below.

## 

## Section I – Individuals Served by County During the Reporting Year

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

List each county within the CIL’s service area, as indicated in the CIL’s application for Subchapter C funds and the approved State Plan for Independent Living (SPIL).  Add additional rows as necessary.  For each county, indicate how many individuals residing in that county were served by the CIL during the reporting year.  

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# SubPart III – Individual Services and Achievements 

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

**Please refer to the Instructions before completing.**

## Section A – Individual Services

For the reporting year, indicate in the table below how many consumers requested and received each of the following IL services.  

## 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 Services, and Assistive Technology**

**(A) Table**

In column one, indicate the number of consumers who required access to previously unavailable transportation, health care services, or assistive technology during the reporting year.  Of the consumers listed in column one, indicate in column two, the number of consumers who, as a result of the provision of IL services (including the four core services), achieved access to previously unavailable transportation, health care services, or assistive technology during the reporting year.  In column three, list the number of consumers whose access to transportation, health care services or assistive technology is still in progress at the end of the reporting year.  

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

**(B) I&R Information**

To inform ILA how many service providers engage in I&R follow-up contacts regarding access to transportation, health care services or assistive technology, please indicate the following:

The service provider did ___  / did not ___ engage in follow-up contacts with I&R recipients to document access gained to previously unavailable transportation, health care or assistive technology.

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

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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

Enter requested governing board information in the table below:

###### (B) Staff Composition

Enter requested staff information in the table below:

**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.  

**Item 3 - Peer Relationships and Peer Role Models**

34 CFR 366.63(a)(3)

Briefly describe how, during the reporting year, the CIL has promoted the development of peer relationships and peer role models among individuals with significant disabilities.  

**Item 4 - Equal Access**

34 CFR 366.63(a)(4)

(A) Briefly describe how, during the reporting year, the CIL has ensured equal access of individuals with significant disabilities, including communication and physical access, to the center's services, programs, activities, resources, and facilities, whether publicly or privately funded.  Equal access, for the purposes of this indicator, means that the same access is provided to any individual with a significant disability regardless of the individual’s type of significant disability.

(B) Briefly describe how, during the reporting year, the CIL has advocated for and conducted activities that promote the equal access to all services, programs, activities, resources, and facilities in society, whether public or private, and regardless of funding source, for individuals with significant disabilities. Equal access, for the purposes of this indicator, means that the same access provided to individuals without disabilities is provided in the center’s service area to individuals with significant disabilities.

**Item 5 – Alternative Formats**

34 CFR 366.63(a)(4)

Briefly describe how, during the reporting year, the CIL has ensured the availability in alternative formats of all of its written policies and materials and IL services, as appropriate.

**Section B – Compliance Indicator 2: Provision of Services on a Cross-Disability Basis**

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

Briefly describe how, during the reporting year, the CIL has ensured that IL services are provided to eligible individuals with a diversity of significant disabilities and individuals who are members of populations that are unserved or underserved, without restrictions based on the particular type or types of significant disability and in a manner that is neither targeted nor limited to a particular type of significant disability.  

**Section C – Compliance Indicator 3: Independent Living Goals**

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

**Item 1 – Consumer Information**

Briefly describe how, during the reporting year, the CIL has ensured that consumers have the opportunity to develop and achieve their goals (either with or without an ILP) and that the consumer has the opportunity to express satisfaction with the center and such consumer satisfaction results are evaluated by the center.

**Item 2 – Consumer Service Record Requirements**

Briefly****describe how, during the reporting year, the CIL ensured that each consumer’s CSR contains all of the required information. 

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

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

**Please refer to the Instructions before completing.**

**Item 1 – Community Activities Table**

In the table below, summarize the community activities involving the CIL’s staff and board members during the reporting year.  For each activity, identify the primary disability issue(s) addressed as well as the type of activity conducted.  Describe the primary objective(s) and outcome(s) for each activity.  Add more rows as necessary.

### 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.

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

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

In addition to the data provided in Subpart III, describe how information and referral services and the other IL core and other IL services are provided to those who request such services in formats accessible to the individual requesting the services.  Describe any innovative practices (not mentioned elsewhere in this report) to enhance the availability and effectiveness of IL services.  

**Section F – Compliance Indicator 6: IL Resource Development Activities**

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

Briefly describe the CIL’s resource development activities conducted during the reporting year to expand funding from sources other than Chapter 1of Title VII of the Act.

**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. 

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**SUBPART VII – ADDITIONAL INFORMATION**

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

## Section A – Other Accomplishments, Activities and Challenges

Describe any additional significant accomplishments, activities and/or challenges not included elsewhere in the report, e.g. brief summaries of innovative practices, improved service delivery to consumers, etc.

### Section B – Additional Information

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

# SubPART VIII - signatures

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

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