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SUBPART IIA – ADMINISTRATIVE DATA
Subpart IIAI – Sources and Amounts of Funds and Resources

(A) Federal Funds

(1) Ch. 1, Part B, Title VII
(2) Ch. 1, Part C, Title VII
(3) Ch. 2, Title VII
(4) Other Federal Funds

(B) Other Government Funds

(5) State Government Funds*
(6) Local Government Funds*
*Include 'pass through' funds.

(C) Private Resources

(7) Foundations, Corporation, or Trust Grants
(8) Donations from Individuals
(9) Membership Fees
(10) Investment Income/Endowment
(11) Fees for Service (program income, etc.)
(12) Other resources (in-kind, fund raising, etc.)

(D) Total Resources (sum of lines 1-12)
(E) Amount of total resources that “pass through” to Consumers, e.g., personal assistance services funds
(F) Net Operating Resources (D) - <minus> (E) = (F)

SUBPART IIB – NUMBERS AND TYPES OF INDIVIDUALS WITH SIGNIFICANT DISABILITIES RECIVING SERVICES EITHER DIRECTLY FROM THE DSU OR THROUGH GRANTS OR CONTRACTS (Section 13, 704(m)(B) and (D); 34 CFR 364.53)

Subpart IIBI – Consumers Served During the Reporting Year

(A) CSRs carried from previous year
(B) CSRs started since Oct. 1 of the reporting year
(C) Total consumers served: (A) + (B) =(C)

Subpart IIBII – Consumer CSRs Closed by September 30 of the Reporting Year

(A) Moved
(B) Withdrew
(C) Died
(D) Completed all goals set
(E) Other
(F) Total Closed CSRs: (A) + (B) + (C) + (D) + (E) = (F)

Subpart IIBIII – Consumer CSRs Active on September 30 of the Reporting Year

Subpart IBI (C) - <minus> Subpart IBII (F) = Subpart IBIII

Subpart IIBIV – Consumer Plans and Waivers
(A) Number of individuals who signed a waiver
(B) Number of individuals with whom an ILP was developed

Subpart IIBV – Age
(A) Under 6
(B) 6 – 17
(C) 18 – 22
(D) 23 – 64
(E) 65 & Over
(F) Unknown

Subpart IIBVI – Gender
(A) Female
(B) Male

Subpart IIBVII – Ethnicity (Select one)
(A) Hispanic or Latino
(B) Not Hispanic or Latino

Subpart IIBVIII – Race (Choose one or more)
(A) American Indian or Alaska Native
(B) Asian
(C) Black or African American
(D) Hispanic or Latino
(E) Native Hawaiian or Other Pacific Islander
(F) White
Unknown

Subpart IIBIX - Disability
(A) Cognitive
(B) Mental/Emotional
(C) Physical
(D) Hearing
(E) Vision
Sensory (form used by some centers)
(F) Multiple Disability
(G) Other

SUBPART IIC – INDIVIDUAL AND COMMUNITY ACHIEVEMENTS AND SERVICES

Subpart IICI – Individual Consumer Achievements
(Goals Set -- Goals Met)
(A) Self-Advocacy/Self-Empowerment
(B) Communication
(C) Mobility/Transportation
(D) Community Services
(E) Educational
(F) Vocational
(G) Self-Care
(H) Information Access/Technology
(I) Personal Resource Management
Residential (form used by some centers)
(J) Other

Subpart IICII – Individual Services
(A) Advocacy/Legal Services
(B) Assistive Devices/Equipment Services
(C) Children’s Services
(D) Communication Services
(E) Counseling and Related Services
(F) Family Services
(G) Housing, Home Modifications, and Shelter Services
(H) IL Skills Training and Life Skills Training Services
(I) Information and Referral Services
(J) Mental Restoration Services
(K) Mobility Training Services
(L) Peer Counseling Services
(M) Personal Assistance Services
(N) Physical Restoration Services
(O) Preventive Services
(P) Prostheses and Other Appliances
(Q) Recreational Services
(R) Rehabilitation Technology Services
(S) Therapeutic Treatment
(T) Transportation Services
(U) Youth Services
(V) Vocational Services
(W) Other Services

Subpart IICIII – Individual Consumers in Community Based-Living
(A) How many individuals were successfully relocated from nursing homes or other institutions to community-based living arrangements?

(B) How many individuals for whom IL services prevented the necessity of entering nursing homes or other institutions and therefore continued living in community-based living arrangement?

Subpart IICIV – Community Change Achievements
(Goals Set -- Goals Met)
(A) Community Integration
(B) Collaboration
(C) Educational
(D) Housing Opportunities/Home Modification
(E) Information Access/Technology
(F) Mobility/Transportation
(G) Personal Assistant Services
(H) Physical/Attitudinal Barrier Removal
(I) Vocational
(J) Other

Subpart IICV – Community Services
Information and Referral (form used by some centers)
(A) Community and Systems Advocacy
(B) Outreach Efforts
(C) Publications
(D) Community Education/Integration Services
(E) Maintaining Registries/Libraries/Databases
(F) Collaboration/Networking
(G) Other Services
(H) Grand Total Hours [Add (A) through(G)]

SUBPART IID – APPLICANT SELF-EVALUATION BASED ON THE SIX COMPLIANCE INDICATORS

Subpart IIDI – Compliance Indicator 1: Philosophy

(A) Consumer Control
(1) Please complete the chart below

CIL Employees

Decision Making Positions
Total Positions
Number of Persons with Disabilities
Number of Persons who are Minorities

Staff Positions
Total Positions
Number of Persons with Disabilities
Number of Persons who are Minorities

(2) Over 50 percent of the CIL’s Governing Board is composed of individuals with significant disabilities

(B) Self-Help and Self-Advocacy
During the reporting year the CIL has conducted activities that promote self-help and self-advocacy among individuals with significance disabilities.

(C) Development of Peer Relationships and Peer Role Models
During the reporting year the CIL has conducted activities that promote the development of peer relationships and peer role models among individuals with significant disabilities as instructors and counselors in its programs.

(D) Equal Access

(1) Ensures equal access to the CIL’s services, programs, activities, resources, and facilities, whether publicly or privately funded. Equal access means that the same access is provided to the individual with a disability regardless of the individual’s type of disability.

(2) The CIL advocates for and conducts activities that promote equal access to all services, programs, activities, resources, and facilities in society, whether public or private, and regardless of funding sources for individuals with significant disabilities. Equal access means that the same access is provided to the individual with a disability regardless of the individual’s type of disability.

(3) The CIL makes available, as appropriate, all written policies, materials, and IL services in alternative formats.

Subpart IIDII – Compliance Indicator 2: Provision of Services on a Cross-Disability Basis

The Center provides the following:

(A) IL services to eligible individuals or groups of individuals without restrictions based on the particular types of disabilities that the individuals or groups of individuals may have.

(B) IL services to individuals with a diversity of significant disabilities, and individuals who are members of populations that are unserved or underserved by programs under Title VII of the Act.

(C) IL core services to individuals with significant disabilities in a manner that is neither targeted nor limited to a particular type of disability.

Subpart IIDIII – Compliance Indicator 3: Independent Living Goals

(A) The CIL maintains a CSR for each consumer that contains:

(1) Documentation concerning eligibility or ineligibility of services
(2) Either an ILP or a waiver of the ILP
(3) IL goals or objectives established with the consumer

(B) The CIL maintains documentation indicating:

(1) The CIL notifies all consumers of their right to develop or waive the development of the ILP
(2) The number of ILPs developed by consumers receiving services from the CIL
(3) The CIL facilitates the development and achievement of IL goals selected by individuals with significant disabilities who request assistance from the CIL
(4) The CIL provides opportunities for consumers to express satisfaction with the CIL’s services and policies in facilitating their achievement of IL goals and provides any results to its governing board and the SILC
(5) The number of waivers signed by consumers receiving services from the CIL stating that an ILP is unnecessary

Subpart IIDIV – Compliance Indicator 4: Community Options and Community Capacity

(A) During the reporting year, the CIL promoted:

(1) Increased availability and improved quality of community-based programs that serve individuals with significant disabilities
(2) Removal of any existing architectural, attitudinal, communication, environmental, or other type of barrier that prevents the full integration of individuals with significant disabilities into society

(B) During the reporting year, the CIL performed at least one activity in each of the following categories:

(1) Community Advocacy
(2) Technical assistance to the community on making services, programs, activities, resources, and facilities in society accessible to individuals with significant disabilities
(3) Public Information and Education
(4) Aggressive outreach to consumers who are members of populations of individuals with significant disabilities that are unserved or underserved by programs under Title VII of the Act in the CIL’s services area
(5) Collaboration with service providers, other agencies and organizations that could assist in improving the options available for individuals with significant disabilities to participate in the services, programs, activities, resources, and facilities in the services area

Subpart IIDV – Compliance Indicator 5: IL Core Services and Other IL Services

(A) The CIL provides Information and Referral (I & R) services to all individuals who request this type of assistance or service from the center, in formats accessible to the individual requesting these services

(B) As appropriate in response to requests, the CIL provides to individuals with significant disabilities who are eligible for IL services from the CIL the following services:

(1) IL Skills Training
(2) Peer Counseling Services (including cross-disability peer counseling)
(3) Individual and Systems Advocacy
(4) As appropriate, two or more of the IL services defined in Title VII, section 6(17) of the Act

Subpart IIDVI – Compliance Indicator 6: Resource Development Activities

The CIL conducts resource development activities to obtain funding from sources other than Chapter 1 of Title VII of the Act

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