Reporting Instrument

OMB Control Number: 1820-0606

Expiration Date: May 31, 2008

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

INSTRUMENT

(To be completed by Centers for Independent Living)

Fiscal Year: _____2005-2006______________________

Grant #: ________H132A010057___________________

Name of Center: _Jackson Center for Independent Living

Acronym for Center (if applicable): ___JCIL_________

State: ___________Tennessee_______________________

Counties Served: __Madison, Chester, Hardeman, Haywood, Crockett, Gibson, Carroll and Henderson___________________________________

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	$ 10,000
(B) Title VII, Ch. 1, Part C	$ 228,875
(C) Title VII, Ch. 2	$ 0
(D) Other Federal Funds	$ 267,135

Item 2 - Other Government Funds

(E) State Government Funds	$ 170,000
(F) Local Government Funds	$ 26,167

Item 3 - Private Resources

(G) Foundations, Corporations, or Trust Grants	$ 25,102
(H) Donations from Individuals	$ 9,890
(I) Membership Fees	$ 0
(J) Investment Income/Endowment	$ 0
(K) Fees for Service (program income, etc.)	$ 74,937
(L) Other resources (in-kind, fundraising, etc.)	$ 1,378

Item 4 - Total Income

Total income = (A)+(B)+(C)+(D)+(E)+(F)+(G)+(H)+(I)+(J)+(K)+(L)

$813,484

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 payee funds, or Medicaid funds)

$229,488

Item 6 - Net Operating Resources

Total Income (Section 4) <minus> amount paid out to Consumers (Section 5) = Net Operating Resources

$583,996

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.

	# of CSRs
(1) Enter the number of active CSRs carried over from September 30 of the preceding reporting year	291
(2) Enter the number of CSRs started since October 1 of the reporting year	317
(3) Add lines (1) and (2) to get the total number of consumers served	608

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:

	# of CSRs
(1) Moved	5
(2) Withdrawn	0
(3) Died	9
(4) Completed all goals set	128
(5) Other	1
(6) Add lines (1)+(2)+(3)+(4)+(5) to get total CSRs closed	143

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

Indicate the number of CSRs active on September 30 of the reporting year.

	# of CSRs
Section A(3) <minus> Section (B)(6) = Section C	465

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	341
(2) Number of consumers with whom an ILP was developed	267
(3) Total number of consumers served during the reporting year	608

Section E – Age

Indicate the number of consumers in each category below.

	# of Consumers
(1) Under 5 years old	5
(2) Ages 5 – 19	18
(3) Ages 20 – 24	22
(4) Ages 25 – 59	362
(5) Age 60 and Older	200
(6) Age unavailable	1

Section F – Sex

Indicate the number of consumers in each category below.

	# of Consumers
(1) Number of Females served	273
(2) Number of Males served	335

Section G – Ethnicity

Indicate the number of consumers served in each category below. Individuals MUST select only one category.

	# of Consumers
(1) Hispanic or Latino	5
(2) Not Hispanic or Latino	603

Section H - Race

Indicate the number of consumers served in each category below. Individuals may select more than one category.

	# of Consumers
(1) American Indian or Alaska Native	0
(2) Asian	1
(3) Black or African American	199
(4) Native Hawaiian or Other Pacific Islander	0
(5) White	405

Section I – Disability

Indicate the number of consumers in each category below.

	# of Consumers
(1) Cognitive	20
(2) Mental/Emotional	32
(3) Physical	514
(4) Hearing	20
(5) Vision	22
(6) Multiple Disabilities	86
(7) Other

Section J – 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.

County Name	Number of County Residents Served
Madison	117
Crockett	17
Hardeman	17
Chester	16
Haywood	15
Henderson	22
Carroll	13
Gibson	29
Other	69

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 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.

Services	Consumers Requesting Services	Consumers Receiving Services
(A) Advocacy/Legal Services	4	4
(B) Assistive Technology	110	84
(C) Children’s Services	5	5
(D) Communication Services	4	4
(E) Counseling and Related Services
(F) Family Services
(G) Housing, Home Modifications, and Shelter Services	159	110
(H) IL Skills Training and Life Skills Training	2	2
(I) Information and Referral Services	37	37
(J) Mental Restoration Services
(K) Mobility Training
(L) Peer Counseling Services	28	28
(M) Personal Assistance Services	6	1
(N) Physical Restoration Services
(O) Preventive Services