1 

## REPORTING INSTRUMENT OMB Control Number: 1820
- 0606 Expiration Date: xx
- xx - 201 x **UNITED STATES DEPART MENT OF EDUCATION**  **OFFICE OF SPECIAL ED UCATION AND REHABILI**  **TATIVE SERVICES**

**REHABILITATION SERVI CES ADMINISTRATION** 



# SECTION 704 **ANNUAL PERFORMANCE R E**  **PORT For**  

# CENTERS FOR INDEPEND **ENT LIVING PROGRAM (Title VII, Chapter 1, Part C of the Rehabilitation Act of 1973, as amended)** 



# Part II **INSTRUMENT (To be completed by Centers for Independent Living)** 
**Fiscal Year: ____________________________________ Gran**  **t #: _______________________________________ 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 collect ion displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 35 ho ur s per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and co mpleting and reviewing the collection of information. The obligation to respond to this collection is required to o btain or retain benefit (P.L. 105
- 220 Section 410 Workforce I

nvestment Act). Send comments regarding the burden estimate or any other aspect of this collection of informat ion, including suggestions for reducing this burden, to Rehabilitation Services Admin istration, LBJ Basement, Attention: Timothy Beatty, PCP Room 5057, U.S. Department of Education, 400 Maryland Ave, SW, Washington, DC 20202
- 2800 or email timothy.beatty@ed.gov and reference the OMB Control Number 1820
- 0606. Chapter 1, Title VII of the Rehab ilitation Act.2



## 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) Indicate the amount received by the CIL as per each funding source. Enter “0” for none. **Item 1 -**  **All Federal Funds Received** (A) Title VII, Ch. 1, Part B $ (B) Title VII, Ch. 1, Part C $ (C) Title VII, Ch. 2 $ (D) Other Federal Funds $ **Item 2 -**  **Other Government Funds** (E) State Government Funds $ (F) Local Government Funds $ **Item 3**  **- Private Resources**  (G) Foundations, Corporations, or Trust Grants $ (H) Donations from Individuals $ (I) Membership Fees $ (J) I nvestment Income/Endowment $ (K) Fees for Service (program income, etc.) $ (L) Other resources (in
- kind, fundraising, etc.) $ **Item 4 -**  **Total Income** Total income = (A)+(B)+(C)+(D)+(E)+(F)+(G)+(H)+(I)+(J)+(K)+(L) $3

**Item 5 -**  **Pass Through Funds** Amount of other government funds received as pass through funds to consumers (include funds, received on behalf of consumers, that are subsequently

passed on to consumers, e.g., personal assistance services, representative pay ee funds, or Medicaid funds) $ **Item 6 -**  **Net Operating Resources** [Total I ncome (Section 4)<minus> amount paid out to Consumer s (Section 5) = Net Operating Resources $4



## SUBPART II

**– NUMBER AND TYPES OF**  **INDIVIDUALS WITH SIGNIFICANT DISABILI**  **TIES RECEIVING SERVI CES**  Section 725(c)(8)(B) of the Act; 34 CFR 366.50(i)(2) 

### Section A

**– Number of Consumers Served During the Rep**  **orting Year** In clude Consumer Service Records (CSRs) for all consumers served during the y ear. **# of CSRs** (1) Enter the number of active CSRs carried over from September 30 of the preceding reporting year (2) Enter the number of CSRs started since Octo ber 1 of the reporting ye ar (3) Add lines (1) and (2) to get the **total number of consumers served** 

### Section B

**– Number of CSRs Closed by September 30 of the Reporting Year**  In clude the number of consumer records closed out of the active CSR files during the reporting ye ar because the individual has: **# of CSRs** (1) Moved (2) Withdrawn (3) Died (4) Completed all goals set (5) Other (6) Add lines (1)+(2)+(3)+(4)+(5) to get **total CSRs closed** 

### Section C

**– Number of CSRs Active on September 30 of the Reporting Year**  Indic ate the number of CSRs active on September 30 th of the reporting ye ar. **# of CSRs** Section A(3) <minus> Section (B)(6) = Section C5



### Section D

**– IL Plans and Waivers**  Indicate the number of consumers in each category below. **# of Consumers** (1) Number of consumers who signed a waiver (2) Number of consumers with whom an IL P was developed (3) **Total number of consumers** served during the reporting ye ar 

### Section E

**– Age**  Indicate the number of consumers in each category below. **# of Consumers** (1) Under 5 ye ars old (2) Ages 5

– 19 (3) Ages 20

– 24 (4) Ages 25

– 59 (5) Age 60 and Older (6) Age unavailable 

### Section F

**– Sex**  Indicate the number of consumers in each category below. **# of Consumers** (1) Number of Females served (2) Number of Males served6



### Section G

**– Race And E**  **thnicity** Indicate the number of consumers served in each category below. **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). This**  **section reflects a new OMB directive. Please refer to the Instructions before completing.**  **# of Consumers** (1) American Indian or Alaska Native (2) Asian (3) Black or African American (4) Native Hawaiian or Other Pacific Islander (5) White (6 ) Hispanic/Latino of any race or Hispanic/ Latino only (7) Two or more races (8) Race and ethnicit y unknown 

### Section H

**– Disability**  Indicate the number of consumers in each category below. **# of Consumers** (1) Cognitive (2) Mental/Emotional (3) Phy sical (4) Hearing (5) Vision (6) Multiple Disabilities (7) Other7



### Section I

**– Individuals Served by County During the Reporting Year**  Section 704(m)(4)(D) of the Act List each count y within the CIL’s service area, as indicated in the CIL’s application for Part C fund s and the approved SPIL. Add additional rows as necessary . For each county , indicate how many individuals residing in that count y were served by the CIL during the reporting ye ar. **County Name Number of County**  **Residents Served**8



## 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 **Subpart III contains new data requests. Please refer to the I nstructions 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.

**Services Consumers**  **Requesting Services**  **Consumers**

**Receiving Services**  (A) Advocacy

/L egal Services (B) Assistive Technology (C) Children’s Services (D) Communication Services (E) Counseling and Related Services (F) Famil y Services (G) Housing, Home Modifications, and Shelter Services (H) IL Skil ls Training and L ife Skills Training (I) Information and Referral Services (J) Mental Restoration Services (K) Mobility

Training (L) Peer Counseling Services (M) Personal Assistance Services (N) Phy sical Restoration Services (O) Prev entive Services (P) Prostheses, Orthotics, and Other Appliances (Q) Recreational Services (R) Rehabilitation Technology Services9

**Services Consumers**  **Requesting Services**  **Consumers**

**Receiving Services**  (S) Therapeutic Treatment (T) Transportation Services (U) Youth/Transition Services (V) Vocational Service s (W) Other 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. **Significant Life Area Goals Set**  **Goals Achieved**  **In**

**Progress** (A) Self
- Advocacy

/Self
- Empowerment (B) Communication (C) Mobi lity

/Transportation (D) Community
- Based L iving (E) Educational (F) Vocational (G) Self
- care (H) In formation Access/Technology (I) Personal Resource Management (J) Relocation from a Nursing Home or Institution to Community
- Based Living (K) Community

/Social Participation (L) Other10

**Item 2**

**– Im**  **proved 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 y ear. 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 pr eviously

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 ye ar.

**Areas # of Consumers** 

**Requiring Access # of Consumers** 

**Achieving Access # of Consumers** 

**Whose Access is in Progress**  (A) Transportation (B) Health Care Services (C) Assistive Technology Note: For most IL servi ces, 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 solel y through information and referral (I&R) services. To d ocument 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 as sistive technology
. **(B) I&R Information** To inform RSA 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**  **Achievemen ts**  Please provide an y additional description or explanation concerning individual services or achievements reported in subpart III, including outstanding success stories and/or major obstacles encountered.11



## 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: **Total Number of Board**  **Members Number of Board** 

**Members with Significant**  **Disabilities**

**(B) Staff Composition** Enter requested staff information in the table below: **Total Number**  **of FTEs**  **FTEs**

**Fill ed by**  **Individuals with**  **Disabilities FTEs Filled** 

**by Individuals From**  **Minority Populations**  **Decision -**  **Making Staff** 
**Other Staff Item 2**  **- Self** 

**- Help and Self** 

**- Advocacy**  34 CFR 366.63(a)(2) Briefl y describe how the CIL has promoted self
- help and self

- advocacy

among individuals with significant disabilities during the reporting ye ar.12

**Item 3 -**  **Peer Relationships and Peer Role Models** 34 CFR 366.63(a)(3) Briefl y describe how, during the reporting year, the CIL has promoted the development of peer rela tionships and peer role models among individuals with significant disabilities.
**Item 4 -**  **Equal Access** 34 CFR 366.63(a)(4) (A) Briefl y describe how, during the reporting ye ar, the CIL has ensured equal access of individuals with significant disabiliti es, including communication and ph ys ical access, to the center's services, programs, activities, resources, and facilities, whether publicly or privatel y funded. Equal access, for the purposes of this indicator, means that the same access is provided to a ny individual with a significant disability regardless of the individual’s ty pe of significant disability
. (B) Briefl y describe how, during the reporting ye ar, the CIL has advocated for and conducted activities that promote the equal access to all servic es, 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 provide d 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) Briefl y describe how, during the reporting year, the CIL has ensured the availa bility 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) Briefl y desc ribe how, during the reporting y ear, 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 restriction s based on the particular t ype or types of significant disability and in a manner that is neither targeted nor limited to a particular ty

pe of significant disability
.13



### Section C

**– Compliance Indicator 3: Independent Living Goals**  Section 725(b)(3) of th e Act; 34 CFR 366.63 (c) **Item 1**

**– Consumer Information**  Briefl y 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 b y the center. **Item 2**

**– Consumer Service Record Requirements**  Briefl y describe how, during the reporting y ear, 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) **This section contains new data requests. Please refer to the Instructi ons 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 ye ar. For each activity , identify the primary disability

issue(s) addresse d as well as the ty pe of activit y conducted. Describe the primary objective(s) and outcome(s) for each activity . Add more rows as necessary
. **Issue Area**  **Activity**

**Type Hours** 

**Spent Objective(s)**  **Outcomes(s)**14

**Item 2**

**– Description of Community Activities**  For the community

activities mentioned above, provide additional details such as the role of the CI L staff board members and/or consumers, names of an y partner organizations and further descriptions of the specific a ctivities, 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, describe how information and referral services a nd 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 an y i nnovative practices (not mentioned elsewhere in this report) to enhance the availabil ity and effectiveness of IL services. 

### Section F

**– Compliance Indicator 6: IL Resource Development Activities**  Section 725(b)(7); 34 CFR 366.63(f) Briefl y describe the CIL’s resource development activities conducted during the reporting ye ar to expand f unding from sources other than chapter 1of title VII of the Act.15



## 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 propos ed goals and objectives and the progress made in achieving them during the reporting ye ar. **Item 2**

**– Challenges**  Describe an y substantial challenges or problems encountered b y the CIL, and the resolutions/attempted resolutions. **Item 3**

**– Comparison wit**  **h 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 ye ars, e.g., recent trends. 

### Section B

**– Work Plan for the Year Following the Reporting Year**  **Item 1**

**– Annual Wor**  **k Plan** List the CIL’s annual work plan goals, objectives and action steps planned for the ye ar following the reporting ye ar. **Item 2**

**– SP**  **IL Consistency** Explain how these work plan goals, objectives and action steps are consistent with the approved SPI L.16



## SUBPART VI **- TRAINING AND TECHNICAL ASSISTANCE**  **NEEDS** Section 721(b)(3) of the Act. 

### Training And Technical Assistance Needs **Choose up to 10 Priority Needs**  **--- Rate items 1**  **- 10 with**  **1 being most important**  **Advocacy/Leadership Development** Gen eral Overview Community

/Grassroots Organizing In dividual Empowerment Sy stems Advocacy Le gislative Process **Applicable Laws** General overview and promulgation of various disability laws Americans with Disabilities Act Air
- Carrier’s Access Act Fair Housing Act In dividuals with Disabilities Education I mprovement Act Medicaid/Medicare/PAS/waivers/long
- term care Rehabilitation Act of 1973, as amended Social Security

Act W orkforce Investment Act of 1998 Ticket to Work and Work I ncentives Improvement Act of 1999 Government Performance Results Act of 1993 **Assistive Technologies** General Overview **Data Collecting and Reporting** General Overview 704 Reports Performance Measures contained in 704 Report Dual Reporting Requirements Case Service Record Documentation **Disability Awareness and Information** Specific Issues **Evaluation** General Overview CI L Standards and Indicators Community

Needs Assessment Consumer Satisfaction Survey s Focus Groups Outcome Measures17

**Financial: Grant Management** General Overview Federal Regulations Budgeting Fund Accounting **Financial: Resource Development** General Overview Diversification of Funding Base Fee
- for
- Service Approaches For Profit Subsidiaries Fund
- Raising Events of Statewide Campaigns Grant W riting **Independent Living Philosophy** General Overview **Innovative Programs** Best Practices Specific Examples **Management Information Systems** Computer Skills Software **Marketing and Public Relations** G eneral Overview Presentation/Workshop Skills Community

Awareness **Networking Strategies** General Overview Electronic Among CILs & SILCs Community

Partners **Program Planning** General Overview of Program Man agement and Staff Development CI L Executive Directorship Skills Building Conflict Management and Alternative Dispute Resolution First
- Line CIL Supervisor Skills Building IL Skills Modules Peer Mentoring Program Des ig n Time Management Team Building **Outreach to Unserved/Underserved Populations** General Overview Disability Minority In stitutionalized Potential Consumers Rural18

Urban **SILC Roles/Relationship to CILs**  General Overview Development of State Plan for Independent Living Im plementation (monitor & review) of SPIL Public Meetings Role and Responsibilities of Executive Board Role and Responsibilities of General Me mbers Collaborations with In
- State Stakeholders **CIL Board of Directors** General Overview Roles and Responsibilities Policy Development Recruiting/Increasing Involvement **Volunteer Programs** General Overview **Opti onal Areas and/or Comments (write**  **- in)** 19



## SUBPART VII

**– ADDITIONAL INFORMATION**  Section 704(m)(4)(D) of the Act 

### Section A

**– Other Accomplishments, Activities and Challenges**  Describe an y additional significant accomplishments, activities and/or cha llenges 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 include d elsewhere in the report.20



## SUBPART VIII **- SIGNATURES**  Please sign and print the names, titles and telephone numbers of the CIL director and board chair.

SI GNATURE OF CENTER DI RECTOR DATE

NAME AND TITLE OF CENTER DIRECTOR PHONE NUMBER

SI GN ATURE OF CENTER BOARD CHAI RPERSON DATE

NAME AND TITLE OF CENTER BOARD CHAI RPERSON PHONE NUMBER