FIVE-YEAR STATE PLAN TEMPLATE FOR STATE/TERRITORY

DEVELOPMENTAL DISABILITIES COUNCILS WITH GUIDANCE

1 DDC State Plan Template updated August 2022

SECTION I: COUNCIL IDENTIFICATION

PART A. State Plan Period: October 1, 2021 through September 30, 2026

PART B. Contact Person: Name the person to be contacted with questions about the Plan. 

Phone Number: Provide contact person’s direct phone number. 

E-mail: Provide contact person’s e-mail address.

PART C. Council Establishment: 

(i) Date of Establishment: Provide the exact date the Council was established. 

(ii) Authorization: State Statute Executive Order N/A

(iii) Authorization Citation: Provide the actual citation for the Statute or Executive Order 

establishing the Council. 

 

PART D: Council Membership. [Section 125(b)(1)-(6)]. 

(i) Council membership rotation plan: Provide information about the Council’s 

membership rotation plan, including Council terms and term limits, number of years 

a member can serve, how the Council informs the Governor of vacancies and other 

relevant information. 

Council Members: Provide full names of all Council members, beginning and ending 

dates of each appointment, (reflecting the initial appointment date), and category of 

membership using the codes provided. If there are vacant positions, insert the word 

“vacant” in the name columns, “O” for gender, D8 for race, and E1 or E2 (as 

appropriate, the category code for the vacant member, the initial date of the 

vacancy, and an end date for the term.

 

Begin with agency/organizational representatives (category A), then list public members (categories B 

and C). For people representing an agency/organization, provide the name of the agency/organization 

and the name of any official proxy/alternate. If more than one agency/organization representative 

represents a particular federal program (e.g. IDEA Part B and Part C) put that category code (A2) next 

to their name and identify the appropriate program in the space provided
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# Last 

Name

First 

Name

MI Gender

Provide 

drop 

down 

with 

Female, 

Male, 

Other

Race/

Ethnicity

Provide 

drop down 

with race, 

ethnicity 

selections

Geographi

cal

Provide 

drop 

down 

with 

urban or 

rural 

selections

Term 

number

Provide drop 

down with 

term 

selections 

(1st, 2nd, 

other)

Member 

Category

Provide a 

drop-down 

selection (by 

name – to 

mirror 

names 

associated 

with codes)

Date of 

appointment

Date current 

appointment 

ends

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25
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Part E. Council Staff. [Section 125(c)(8)(B)]. Provide information about all full-time and part-time 

Council staff positions. Indicate full-time or part-time; for part-time staff, indicate percentage. Fulltime staff on furlough should be counted as full-time staff. Do not include consultants. If the official 

classification of the staff member does not adequately describe the role of that position, include a 

working title (e.g., Council Executive Director, NOT Health Administrator IX).

Disability data of Council staff will be collected. Response is voluntary and information shared will be 

kept confidential and serve for data purposes only. Self-identification of disability will be captured in 

the following manner:

Y- Yes, has a disability (or previously had a disability)

N- No, does not have a disability

DWA- Does not wish to answer. 

# Position or Working 

Title

FT PT % 

PT

Last name of 

person in position

First name of 

person in position

M

I 

Gender

Provide 

drop 

down 

with 

Female, 

Male, 

Other

Race/ 

Ethnicity

Provide 

drop 

down 

with 

race, 

ethnicity 

selection

s 

Disability

Provide 

drop 

down 

with yes, 

no, does 

not wish 

to 

answer 

selection

s

1

2

3

4

5

6

7

8

9

1

0

SECTION II: DESIGNATED STATE AGENCY [Section 125(d)]. 

PART A. The Designated State Agency (DSA). 

The DSA is:

 The Council 

 Another agency: 

1. Agency Name:
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2. State DSA Official’s Name: 

3. Address:

4. Phone:

5. FAX:

6. E-mail: 

PART B. Direct Services. [Section 125(d)(2)(A)-(B)] 

If DSA is other than the Council, does it provide or pay for direct services to persons with 

developmental disabilities? 

 No 

 Yes

 If yes, describe the general category of services the agency provides (e.g., Health, 

education, vocational, residential, etc.). 

PART C. Memorandum of Understanding/Agreement. [Section 125(d)(3)(G)] 

Does Your Council have a Memorandum of Understanding/Agreement with your DSA? 

 No 

 Yes 

PART D. DSA Roles and Responsibilities related to Council. [Section 125(d)(3)(A)-(G)] 

If DSA is other than the Council, describe how the DSA supports the Council. 

 

PART E. Calendar Year DSA was designated. [Section 125(d)(2)(B)] 
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SECTION III: COMPREHENSIVE REVIEW AND ANALYSIS [Section 124(c)(3)]

Overall, the Council’s Comprehensive Review and Analysis (CRA) should demonstrate a thorough 

understanding and analysis of the extent to which:

• Services, supports, and other assistance are available to individuals with developmental 

disabilities and their families, and 

• There are unmet needs for services, supports, and other assistance for those individuals and 

their families. 

How Council members and members of the public provided input into the development of the plan 

and how their feedback was used to developing the goals and objectives outlined in the five-year plan. 

EXECUTIVE SUMMARY OF THE CRA

Provide information for each item below:

a) Describe the Councils Planning process (explain how citizens provided input, how the 

planning process reached culturally diverse people, what data, research or information 

influenced the Council’s goal selection and a description of the process used to identify State 

plan goals and objectives)

b) Provide additional information on other federally assisted programs not included in the 

detailed CRA sections.

c) As needed and not described in other CRA sections, include information on other social 

policy, culture change, and funding issues. 

d) Provide citations or references to support the details provided in CRA sections.

Poverty Rate Percentage

The poverty rate can come from the Census Bureau, or some other source based upon the current 

Federal Poverty Guidelines.

PART A. State Information 

(i) Racial and Ethnic Diversity of the State Population:

 Complete the chart below by entering information from the Census Bureau or some other 

source on the racial and ethnic diversity in the State. 

Race/Ethnicity Percentage of Population

American Indian and Alaska Native alone

Asian, alone

Black or African American alone

Hispanic or Latino (of any race)
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Native Hawaiian and Other Pacific Islander 

alone

Some other race alone

Two or more races:

Two races including Some other race

Two races excluding Some other race, and 

three or more races

White, alone

Upload the US Census Chart or other reliable data from State/Territory.

(iii) State Disability Characteristics

a) Prevalence of Developmental Disabilities in the State:

☐1.58% Larson, S.A., Lakin, K.C., Anderson, L., Kwak, N., Lee, J., & Anderson, D. (2001). 

Prevalence of mental retardation and developmental disabilities: Estimates from the 

1994/1995 National Health Interview Survey Disability Supplements. American Journal on 

Mental Retardation, 106(3), 231-252.

☐Other rate – provide the citation for the source.

b) Residential Settings:

Use the information to inform the review of residential services and numbers of people with 

developmental disabilities living in the different types of residential settings. In terms of the 

definitions, A. should include foster/host homes and other similar non-family home settings 

with paid caregivers while C. and D. should not.

Upload the residential chart for the state/territory

c) Demographic Information about People with Disabilities 

Upload Chart S1810 from the American Community Survey for State/Territory

Upload Chart 1811 from the American Community Survey

PART B. Portrait of the State Services [Section 124(c)(3)(A)(B)]: 
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Use the following sub-sections to describe the state’s services, supports, and other assistance available 

to people with developmental disabilities and their families. Only submit sections that will support the 

goals and objectives, keep all required and completed sub-sections on file should ACL request the 

information.

(i) Health/Healthcare:

• Describe available medical assistance, maternal and child health care, services for children 

with special health care needs, mental health services for children and adults, institutional 

care options, and other comprehensive health and mental health services. 

• To the extent available also include information on public/private insurance access, 

prevention and wellness initiatives, and long-term services and supports.

• To the extent available, include data regarding the number of children and adults with 

developmental disabilities and, as applicable, their families receiving each type of such health 

services and supports

• Information about health is required per Section 124(c)(3)(A)(i).

(ii) Employment: 

• Describe job training, job placement, worksite accommodation, vocational rehabilitation, and 

other work assistance incentive and benefits programs that are available to people with 

developmental disabilities. You may choose to include information about “school to work” 

transition efforts here. 

• To the extent available also include information on competitive, integrated employment 

efforts; sheltered workshops; Employment First policies/efforts; and sub-minimum wage. 

• To the extent available, include data regarding the number of youth and adults with 

developmental disabilities receiving each type of such employment services and supports

• Information about employment is required per Section 124(c)(3)(A)(ii).

(iii) Informal and formal services and supports: 

• Describe available social, child welfare, aging, independent living, and other such services not 

described elsewhere that are available to people with developmental disabilities and their 

families.

• To the extent available, also include information on family support efforts/policies, peer 

support initiatives, faith-based community efforts, volunteer activities, home and communitybased services, and long-term services and supports.

• To the extent available, include data regarding the number of children and adults with 

developmental disabilities and, as applicable, their families receiving each type of such 

services and supports.

• Information about informal and formal services and supports is required per Section 

124(c)(3)(A)(iii).

(iv) Interagency Initiatives: 
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• Describe the extent to which agencies operating other federally assisted State programs 

(including activities authorized under section 101 or 102 of the Assistive Technology Act of 

1998 (29 U.S.C. 3011, 3012)) pursue interagency initiatives to improve and enhance 

community services, individualized supports, and other forms of assistance for individuals 

with developmental disabilities.

• To the extent available, also include information on other state collaborations, such as the 

state early learning councils required under the Head Start program, State Interagency 

Coordinating Councils required under Part C of IDEA, Work Investment Boards, Centers for 

Independent Living, State Rehabilitation Council, Aging and Disability Resource Centers and 

other relevant state-established Councils, Committees, and/or Cabinets. 

• As possible, include specific information about participation of individuals with 

developmental disabilities, family members, and organizations representing people with 

disabilities on these Councils, Committees and/or Cabinets. Information about interagency 

initiatives is required per Section 124(c)(3)(B).

Describe how the UCEDD(s) and P&A will collaborate with the Council (other 

than the planned objective activity) to achieve outcomes consistent with the 

Council purpose (with each other, with one or another. Information about 

DD Network collaboration is required per Section 124(c)(3)(D).

(v) Quality Assurance: 

• Provide information on training in leadership, self-advocacy, and self-determination, access to 

person-centered planning services, monitoring of services, supports, and assistance to 

prevent abuse, neglect, sexual or financial exploitation, violation of legal or human rights, and 

inappropriate use of restraints or seclusion; interagency coordination and systems integration 

efforts that result in improved and enhanced services, supports, and other assistance.

(vi) Education/Early Intervention: 

• Provide information on general and special education services; early intervention services; 

early childhood services; private school services; education supports; and teacher training.

(vii) Housing: 

• Provide information on the availability of affordable, accessible, integrated housing; housing 

supports and services; and services related to renting, owning, or modifying a residence.

(viii) Transportation: 

• Provide information on accessible public transportation services, paratransit services, and/or 

programs that promote community accessibility.

(ix) Childcare: 

• Provide information on before-school, after-school, and early care services in communities.

(x) Recreation: 
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• Provide information on recreational, leisure, and social activities in communities that are 

available to individuals with developmental disabilities.

PART C. Analysis of State Issues and Challenges [Section 124(c)(3)(C)]:

Use the sub-sections to summarize the Councils’ comprehensive analysis of the extent to which 

individuals with developmental disabilities directly benefit from the available community services, 

supports, and other assistance provided in the state. Focus on the ability of individuals with 

developmental disabilities to access and use services provided in their communities; to participate in 

opportunities, activities, and events offered in their communities; and to contribute to community life. 

Describe how people experience the services and supports they receive or do not receive, and how 

they view their lives rather the service system. Summarize the Council’s analysis of obstacles that 

impact the ability of people with developmental disabilities and their families in the state to fully 

participate in and contribute to their community through full integration and inclusion in economic, 

political, social, cultural, and education activities. Fields required are noted by the * sign. 

(i) Criteria for eligibility for services*: 

• Summarize the Council’s analysis of the eligibility criteria used to determine access to 

specialized services provided by State agencies that may exclude individuals with 

developmental disabilities from receiving services. 

• This may include if available an analysis of eligibility criteria for generic services, waiver 

services, early intervention services, special education services, employment services, and 

long-term services and supports.

• Information about eligibility for services is required per Section 124(c)(3)(C)(ii).

(ii) Analysis of the barriers to full participation of unserved and underserved groups of individuals 

with developmental disabilities and their families*:

• State what populations are identified by the Council as unserved and underserved. This may 

include populations such as: gender, individuals from racial and ethnic minority backgrounds; 

Lesbian Gay, Bi-Sexual, Transgender, Queer, and Questioning (LGBTQQ), disadvantaged 

individuals, people who speak a primary language other than English, individuals from 

underserved geographic areas (rural or urban); specific groups of individuals within the 

population of individuals with developmental disabilities, including individuals who require 

assistive technology in order to participate in and contribute to community life; or some other 

group. 

• Describe the process the Council used to identify the unserved and underserved population in 

the State and the rationale for identifying these population(s) over others. 

• Review and analyze barriers to full participation of unserved and underserved groups is 

required per Section 124(c)(3)(C)(iii).

• Review and summarize the needs for the identified unserved and underserved population(s) 

including the needs of individuals with developmental disabilities from culturally and 

linguistically diverse backgrounds.
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(iii) The availability of assistive technology*: 

• Summarize the Council’s analysis of the availability of assistive technology, assistive 

technology services, rehabilitation technology, and/or the availability of information about 

these three things, to individuals with developmental disabilities.

• This may include if available information about access to generic technologies, such as 

universally designed technology, smart home-based technology, monitoring technology, etc. 

• Information about the availability of assistive technology is required per Section 

124(c)(3)(C)(iv).

(iv) Waiting Lists*: 

Numbers on Waiting Lists in the State:

• Provide the number of people waiting for residential services per 100,000. 

• To the extent possible, include state data on all other types of waitlists per 100,000. 

• Information on the number of people with developmental disabilities on waiting lists for 

services is required per Section 124(c)(3)(C)(v). 

 Upload the RISP Chart or other residential services waiting list data

a) Entity who maintains wait-list data in the state: 

Case management authorities

Providers

Counties

State Agencies

Other__________________________________

b) There is a statewide standardized data collection system in place: 

yes

no

c) Individuals on the waitlist are receiving (select all that apply) 

No services

Only case management services

Inadequate services

d) To the extent possible, provide information about how the state places or prioritizes 

individuals to be on the waitlist:

Include if available whether the state has uniform statewide guidance regarding waitlists, 

whether the state breaks the wait-list into categories or tiers, how individuals are prioritized, 
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breakdowns by urgency of need, demographic characteristics, wait-lists for specific services, 

order of selection policy, evaluation policy, etc. 

Comprehensive services but are waiting for preferred options (e.g., persons in nursing 

facilities, institutions, or large group homes waiting for HCBS)

Other___________________________________

e) Description of the state’s wait-list definition, including the definitions for other wait lists: 

Use space below to provide any information or data available related to the response above: 

f) Individuals on the waitlist have gone through an eligibility and needs assessment: 

yes

no

Use space below to provide any information or data related to the response above: 

g) There are structured activities for individuals or families waiting for services to help them 

understand their options or assistance in planning their use of supports when they become 

available (e.g., person-centered planning services): 

yes

no

h) Specify any other data or information related to wait-lists: 

Provide any other relevant information that is available related to the waitlists in the state.

i) Summary of Waiting List Issues and Challenges 

Based on the information provided in items a – h, describe the Councils’ analysis of the issues, 

challenges, and limitations, if any related to the state waiting list(s). 

(v) Analysis of the adequacy of current resources and projected availability of future resources to 

fund services*:

• Using available tools and/or data, summarize the State’s current resources to fund services 

for people with developmental disabilities and their families. 

• In reviewing the State resources, Councils may want to:

o Include information about the State’s fiscal resources to fund home and communitybased services, long-term services and supports, education services, employment 

services, transportation services, etc.

o Estimate the State’s future resources for funding services (sources for this type of 

information may be the State’s proposed budget, studies of State spending trends, etc.). 
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o Use data from the National Core Indicators project, the State of the State in 

Developmental Disabilities study, the Annual Residential Services and Trends Report, 

the Annual Report on Day and Employment Supports, and the Special Education 

Expenditure Project.

• Information about resources is required per Section 124(c)(3)(C)(vi).

(vi) Analysis of the adequacy of health care and other services, supports, and assistance that 

individuals with developmental disabilities who are in facilities receive *: 

• Provide information that describes the Council’s analysis of the adequacy of health care and 

other services, supports, and assistance that people with developmental disabilities who are 

in facilities receive. This description should be based in part on each independent review 

(pursuant to section 1902(a)(30)(C) of the Social Security Act (42 U.S.C. 1396a(a)(30)(C))) of an 

Intermediate Care Facility within the State, which the State shall provide to the Council not 

later than 30 days after the availability of the review. 

• Adequacy may be described in terms of quality and/or population served versus need.

• Facilities can include state-run institutions, privately run institutions, intermediary care 

facilities, nursing homes or some other type of facility identified by the Council. 

• Information about health care and other services, supports, and assistance is required per 

Section 124(c)(3)(C)(vii).

(vii) To the extent that information is available, the adequacy of home and community-based waivers 

services (authorized under section 1915(c) of the Social Security Act (42 U.S.C. 1396n(c)))*:

• Summarize the Council’s analysis of the adequacy of services provided through home and 

community-based waivers for people with developmental disabilities authorized under 

Section 1915(c) of the Social Security Act. 

• Adequacy may be described in terms of quality and/or population served versus need.

• Information about home and community-based waivers services is required per Section 

124(c)(3)(C)(viii).

PART D. 5-YEAR GOALS [Section 124(4); Section 125(c)(5)]

Identify the 5-year state plan goals, objectives, and expected 5-year goal outcomes. 

Part E. Rationale for Goal Selection [Section 124(c)(3)(E)]: 

• Provide a rationale for the Council’s selection of specific goals based on and related to the 

information in Part A and information from the CRA provided in Parts B and C; including 

rationale for strategies selected to address the goals. There should be a direct relationship 

• Goal (s)

• Expected Goal Outcomes – (expected outcomes should be reflected for the 5-year goals)

• Objective (s)
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between the goals and the needs identified based on the data collected and/or reviewed and 

feedback from a wide range of diverse stakeholders. 

• Given that the DD Act provides a broad mandate to address needs in the State, it is essential 

that Councils prioritize their work. Not all the issues identified and analyzed in Parts B and C can 

be addressed by the Council. Include a brief explanation of how the Council prioritized issues to 

be addressed in the Plan. 

• The rationale is required per Section 124(c)(3)(E).

 

Evaluation Plan [Section 125(C)(3) And (7)]

Provide a description of how the Council will examine progress made in achieving the goals 

of the State/Territory plan. 

Describe the Evaluation Methodology

o Define the procedures the Council will use to monitor progress in meeting its goals 

including tracking the progress to address the targeted disparity.

o Discuss Council activities that will measure or otherwise address the Council’s 

effectiveness.

o The evaluation plan should not be limited to measuring the progress of the 

performance measures. The evaluation plan should also measure the extent to

which the intended sub-outcomes for the given objective are being met. This is 

above and beyond the performance measures. The performance measures are 

solely a snapshot of a piece of data that should be assessed in the larger context of 

the intended sub-outcome measures of the objective and achievement of the goal.

o Councils are encouraged to develop its own methods and measures for determining 

progress, such as annual benchmarks for the goals that are tied to measuring 

outcomes.

Describe how the evaluation method will be made accessible and culturally and linguistically 

competent.

Describe how you will determine the effectiveness of strategies used and overall progress 

towards objectives and goals.
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Describe how the Council is involved in reviewing and commenting on progress towards the 

State plan goals, objectives.

Describe the evaluation and reporting of self-advocacy goal/objectives

Describe how you will determine satisfaction with Council funded projects and activities.

Logic Model

Develop a 5-year logic model that presents the logical connections between

DD Council activities and desired DD Council outcomes. The logic model should reflect an 

understanding of the relationships among the resources a DD Council has to operate, the 

strategies/activities the DD Council plans to implement, and the outputs and outcomes the

DD Council expects to achieve.

SECTION V: PROJECTED COUNCIL BUDGET [Section 124(c)(5) (B) and 125(c)(8)]

Goal Subtitle B $ Other(s) $ TOTAL

1. Goal 

2. Goal 

3. Goal

4. Goal

5. Goal

6. General management 

(Personnel, Budget, Finance, 

Reporting)

7. Functions of the DSA

8. TOTAL $ $ $

Provide the budgeted amount for each goal, federal dollars, and other funds.

A Council State plan budget is required for the first fiscal year of the state plan and annually thereafter. 

The budget is a projection of planned spending organized by goals and includes funds anticipated to be 

expended for staff activities implementing the state plan as well as planned activities, general 

management, and designated state agency functions. Additionally, Councils will indicate the amount 

of non-federal funds they expect to receive directly for state plan activities. 

Column information:
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Subtitle B $

This column should represent the amount of federal funds the Council has planned to use on specified 

goals, general management, and functions of the DSA.

Other(s) $

This column should represent the amount of other funds the Council has planned to use on specified 

goals, general management, and functions of the DSA.

Total

This column should be the total of columns Subtitle B$ and Other(s) $.

Line-item information:

The “General management” item refers to the administrative costs for the Council. 

The “Functions of the DSA” item refers to the amount of money a DSA can request for reimbursement 

of costs to support the Council. Subtitle B funds (federal funds cannot exceed 5% of Council grant 

award or $50,000, whichever is less, up to 1⁄2 of expenses found to be necessary for the proper and 

efficient exercise of the functions of the Designated State Agency). Costs in this category are 

considered administrative costs.

The Subtitle B$ amount for General management and Functions of the DSA cannot exceed 30% of the 

Council’s annual award.

SECTION VI: ASSURANCES [Section [124(c)(5)(A)-(N)]

Obtain the appropriate signatures for the Assurances for the 5-year State plan. Indicate assurances 

have been obtained and keep the original copy of the Assurances on file should OIDD request them. 

Assurances must be obtained at the beginning of the 5 -year plan, unless there have been substantive 

changes to the plan, or the Council Chairperson or Designated State Agency has changed since the 

assurances have last been signed.

 Written and signed assurances have been obtained to support this plan and are available to the 

Administration on Intellectual and Developmental Disabilities, Administration for Community Living,

United States Department of Health and Human Services, regarding compliance with all requirements 

specified in Section 124 (C)(5)(A) – (N) in the Developmental Disabilities Assurance and Bill of Rights Act

upon request. 

Approving Officials for Assurances

For the Council (if the Council is its own DSA, the Chairperson)

For the State or Territory (DSA is to assist the DD Council in obtaining assurances)
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SECTION VII: PUBLIC INPUT AND REVIEW [Section 124(d)(1)] 

The DD Act requires public input and review of the Council Plan. Provide information on how the 

Council received and used public input on the Plan.

(i) Describe how the Council made the plan available for public review and comment. Include how the 

Council provided appropriate and sufficient notice in accessible and cultural and linguistically 

competent formats of the opportunity for review and comment. 

(ii) Describe the revisions made to the Plan to consider and respond to significant comments. 

ANNUAL WORK PLANNING 

Annual Work Plan Template with Guidance

State Plan Goals [Section 124(4); Section 125(c) (5)]

Goal # 

Provide the goal number and goal statement. 

Goal Statement:

 

Area of Emphasis: 

For each goal, check all the area(s) of emphasis that relate to the goal. 

☐ Quality Assurance

☐Education and Early Intervention 

☐Child Care

☐Health 

☐Housing 

☐Transportation 

☐Recreation
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☐ Formal and Informal Community Supports

Activities to be used in achieving each goal: 

Check all that apply.

☐Outreach 

☐Training

☐Technical Assistance

☐Supporting and Educating Communities

☐Interagency Collaboration and Coordination

☐Coordination with Related Councils, Committees and Programs

☐Barrier Elimination, systems design, and redesign

☐Coalition Development and Citizen Participation

☐Informing Policymakers 

☐Direct Service Demonstrations (Demonstration of New Approaches to Services and Supports) 45 CFR 

1326.30 (e)(1-3)

a) Describe the approach to be demonstrated

b) Estimate the length of the activity

c) Describe strategies to locate on-going funding from other sources after 5 years

The State plan may provide for funding projects to demonstrate new approaches to direct services 

that enhance the independence, productivity, and integration and inclusion into the community of 

individuals with developmental disabilities. Direct service demonstrations must be short-term, with 

a strategy to locate on-going funding from other sources after five years. Any State desiring to 

receive assistance beyond five years, under this subtitle, shall include in the State plan the 

information listed in paragraphs (e)(1) through (3) of this section, and OIDD reserves the right as 

the overseeing agency to deny the continuation of the demonstration project beyond five years.

☐Other Activities

This goal addresses: 

Check each box that applies.

☐ Individual/Family Advocacy

☐ System Change

☐ Self-Advocacy Requirement

☐ Targeted Disparity

☐ DD Network Collaboration

☐ Rights of Individuals 

☐ Capacity Building
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Collaborators Planned for this goal (if known) 

Identify all organizations/agencies the Council plans to work with and/or has commitments from in 

addressing the goal.

☐ State Protection and Advocacy System

☐ University Center(s)

☐ State DD agency

☐ Independent Living/Centers for Independent Living

☐ Traumatic Brain Injury 

☐ Other [text box to enter the name of the “other entity”.

Objective: Enter each objective separately

For each federal fiscal year, Council staff will develop an annual work plan. Council staff will select the 

objectives they plan to implement from the 5-year goal section of the state plan template. For each 

objective selected, Council staff will identify key activities, expected outputs and outcomes for the 

objective, data and evaluation measurement(s), and the performance measure(s) that will be targeted 

for each objective.

Key Activities: Enter each key activity separately.

Identify the major activities the Council will use to reach the objective and support progress towards 

the 5-year goal. 

General management activities should not be included as a key activity. General management is 

typically defined as any activity that is a standard part of implementing the DD Council program. 

Examples of general management activities are Council meetings, RFP and contracting activities, staff, 

and committee work activities to review the state plan, awarding grants, paying invoices. 

Examples or key activities include Conduct community engagement events, develop a quarterly

newsletter to share advocacy information/opportunities, train self-advocates on leadership skills and 

public speaking.

Expected Outputs: enter each expected output separately. 

Outputs are the measurable things a key activity produced. Examples of expected outputs are number 

of training curriculum developed, number of training sessions conducted, number of communities 

identified to increase accessibility to services, supports and other assistance. 
FIVE YEAR STATE PLAN TEMPLATE GUIDELINES

DEVELOPMENTAL DISABILITIES COUNCILS

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Expected Objective Outcomes: each expected objective outcome separately.

These are the effects a key activity produced for people with developmental disabilities and their 

families, and outcomes from issues the Council addressed through an activity. Examples include 

People with DD and their families in rural areas are more knowledgeable about services and access 

new services to meet their needs; community education efforts increased volunteerism opportunities 

by 10% in “ABC” community; policymaker education and information increased affordable housing 

options.

Data Evaluation and Measurement 

Identify the data you will evaluate and measure (examples of data include program records, pre and 

post-tests, surveys, interviews, focus groups) for activities conducted under the objective. Note: Data 

evaluation and measurement should NOT be the same as items listed under “Expected Objective 

Outcomes”.

Project the performance measure(s) that will be targeted for each objective. Fill out the chart below.

For more detailed information on projecting performance measures, refer to the Document for Council 

Staff (OIDD DD Council Performance Measures with guidance). For information about connecting the 

state plan development tools, refer to Linking the 5 Year Plan, Logic Model and Annual Work Plan. 

Individual & Family Advocacy IA (Also known as IFA)

IA CODE (IA) TARGETED #

IA 1.1 (OUTPUT MEASURE)

# of people with DD who participated in 

council supported activities designed to 

increase their knowledge of how to take part 

in decisions that affect their lives, the lives of 

others, and/or systems

IA 1.2 (OUTPUT MEASURE)

# of family members who participated in 

council supported in activities designed to 

increase their knowledge of how to take part 

in decisions that affect the family, the lives of 

others, and/or systems

IA 2.1 (OUTCOME MEASURE)

% of people with DD who report 

increasing their advocacy as a result of 

Council work

IA 2.2 (OUTCOME MEASURE)

% of family members who report increasing 

their advocacy as a result of council work.

IA 2.3 (SUB-OUTCOME MEASURE)
FIVE YEAR STATE PLAN TEMPLATE GUIDELINES

DEVELOPMENTAL DISABILITIES COUNCILS

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IA CODE (IA) TARGETED #

% of people who are better able to 

say what they want, what services and 

supports they want or say what is important 

to them

IA 2.4 (SUB-OUTCOME MEASURE)

% of people who are participating 

now in advocacy activities

IA 2.5 (SUB-OUTCOME MEASURE)

% of people who are on cross disability 

coalitions, policy boards, advisory boards, 

governing bodies and/or serving in 

leadership positions

IA 3.1 (SATISFACTION)

% of people with developmental disabilities 

satisfied with a project activity

IA 3.2 (SATISFACTION)

% of individuals and families satisfied with 

Council supported activities

System Change (SC) 

Systemic change activities are defined as a sustainable, transferable, and replicable change in some 

aspect of service or support availability, design or delivery that promotes positive or meaningful 

outcomes for individuals with developmental disabilities and their families. 

SC CODE (SC) TARGETED #

SC 1: OUTPUT MEASURE

# OF COUNCIL SYSTEM CHANGE EFFORTS

SC 1.1 (SUB-OUTPUT MEASURE)

# of policy and/or procedures created or changed 

SC 1.2(SUB-OUTPUT MEASURE)

# of statute and/or regulations created or changed

SC 1.3 

LEAVE BLANK

SC 1.3.1(SUB-OUTPUT MEASURE)

# of promising practices created 

SC 1.3.2(SUB-OUTPUT MEASURE)

# of promising practices supported

SC 1.3.3(SUB-OUTPUT MEASURE)

# of best practices created

SC 1.3.4(SUB-OUTPUT MEASURE)
FIVE YEAR STATE PLAN TEMPLATE GUIDELINES

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SC CODE (SC) TARGETED #

#of best practices supported through Council activities

SC 1.4 (SUB-OUTPUT MEASURE)

#of people trained or educated through Council

systemic change initiatives

SC 1.5 (SUB-OUTPUT MEASURE)

# of council supported systems change activities with

organizations actively involved

SC 2.1 (OUTCOME MEASURE)

# of Council efforts led to improvement

SC 2.2(OUTCOME MEASURE)

# of Council efforts implemented

SC 2.1.1 – SUB OUTCOME MEASURES

# of policy, procedure, statute, regulation changes 

improved

SC 2.1.2 SUB OUTCOME MEASURES

# of policy, procedure, statute, regulation changes 

implemented

SC 2.1.3 SUB OUTCOME MEASURES

# of promising and/or best practices improved

SC 2.1.4 SUB OUTCOME MEASURES

# of promising and/or best practices implemented