Reporting Instrument

OMB Control Number: 1820-0606

Expiration Date: March 31, 2006

UniTed States Department of Education

Office of Special Education and Rehabilitation Services

Rehabilitation Services Administration

Section 704

annual performance report

For

Centers for Independent Living Program

(Title VII, Part B of the Rehabilitation Act of 1973, as amended)

Part II

INSTRUMENT

Fiscal Year: ____________________________________

Grant #: _______________________________________

Name of Center: ________________________________

Acronym for Center (if applicable): ________________

State: _________________________________________

Counties Served: _______________________________

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) Investment 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)

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)

Item 6 - Net Operating Resources

[Total Income (Section 4)<minus> amount paid out to Consumers

(Section 5) = Net Operating Resources

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

	# of CSRs
(1) Enter the number of CSRs carried over from September 30 of the preceding reporting year
(2) Enter the number of CSRs started since October 1 of the reporting year
(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

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
(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

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

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

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 ILP was developed
(3) *Total number of consumers* served during the reporting year

Section E – Age

Indicate the number of consumers in each category below.

	# of Consumers
(1) Under 5 years old
(2) Ages 5 – 19
(3) Ages 20 – 25
(4) Ages 26 – 64
(5) Age 65 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 served

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
(2) Not Hispanic or Latino

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
(2) Asian
(3) Black or African American
(4) Native Hawaiian or Other Pacific Islander
(5) White

Section I – Disability

Indicate the number of consumers in each category below.

	# of Consumers
(1) Cognitive
(2) Mental/Emotional
(3) Physical
(4) Hearing
(5) Vision
(6) Multiple Disabilities
(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

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
(B) Assistive Devices/Equipment Services
(C) Children’s Services
(D) Communication Services
(E) Counseling and Related Services