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SUBPART II A: Applicant Self Evaluation

I-Compliance Indicator 1-Philosophy  (a)
(a) Consumer Control
 1-i Governing board is composed of individuals with significant disabilities
 1-ii CIL Employees:  Decisionmaking positions:  Total
 1-ii CIL Employees:  Decisionmaking positions:  Persons with Disabilities
 1-ii CIL Employees:  Decisionmaking positions:  Number of Minority Employees
I-Compliance Indicator 1-Philosophy  (b)
 1-ii CIL Employees: Staff positions:  Total
 1-ii CIL Employees:  Staff positions:  Persons with Disabilities
 1-ii CIL Employees:  Staff positions:  Number of Minority Employees
(b) Self-help and self-advocacy
I-Compliance Indicator 1-Philosophy  (c-d)
(c) Development of peer relationships and peer role models
(d) Equal Access (1) Including communication and physical access to CIL's services
(d) Equal Access (2) Advocates for and conducts activities that promote
(d) Equal Access (3) Makes available as appropriate in alternative formats
 

II-Compliance Indicator 2-Provision of Services on a Cross-Disability Basis
(a) Provides IL services to eligible individuals
(b) Provides IL services to individuals with a diversity of significant disabilities
(c) Provides IL core services to individuals with significant disabilities that is not targeted
 

III-Compliance Indicator 3-IL Goals (a)
(a-1) CIL maintains documentation concerning eligibility for services
(a-2) Either an ILP or a waiver of the ILP
(a-3) IL goals or objectives established with the consumer
(a-4) Records of the IL goals considered by the consumer to have been achieved
III-Compliance Indicator 3-IL Goals (b)
(b-1) The CIL notifies all consumer of their right to develop or waive the development of an ILP
(b-2) On the number of ILPs developed by consumers receiving services from the CIL
(b-3) CIL facilitates development and achievement of IL goals selected by individuals with significant disability who request assistance from the CIL
(b-4) CIL provides opportunities for consumers to express satisfaction with services and policies and provides results to its governing board and SILC
(b-5) On the number of waivers signed by consumers receiving services from the CIL stating that ILP is unnecessary
 

IV-Compliance Indicator 4-Community Options and Community Capacity
(a) Community advocacy
(b) Technical assistance to the community
(c) Public information and education
(d) Aggressive outreach to consumers that are unserved or underserved
(e) Collaboration with service providers, other agencies
 

V-Compliance Indicator 5-IL Core Services and other IL Services
(a) Provides information and referral to all who request these types of assistance
(b-1) Provides to individuals:  IL skills training
(b-2) Provides to individuals:  Peer counseling (including cross-disability peer counseling)
(b-3) Provides to individuals:  Individual and systems advocacy
(b-4) Provides to individuals:  A combination of any two or more other IL services

VI Compliance Indicator 6-Resource Development Activities
(a) Conducted resource development activities during the reporting year
 

 SUBPART II D-Sources and Amounts of Resources for the Operation of the CIL During the Reporting Year

I-Resources (a)
(a-1)  Federal Funds:  Chap. 1, part B, Title VII
(a-2)  Federal Funds:  Chap. 1, part C, Title VII
(a-3)  Federal Funds:  Chap. 2, Title VII
(a-4)  Other Federal Funds
I-Resources (b)
(b-5)  State government funds
(b-6)  Local government funds
(c-7)  Foundation, corporation or trust grants
(c-8)  Donations from individuals
I-Resources (c)
(c-9)  Memberships
(c-10)  Investment income, endowment
(c-11)  Fees for service (program income)
(c-11)  Other resources
I-Resources (d)
(d)  Total resources (sum of lines 1-12)
(e)  Amount of total resources that "pass through" to consumers
(f)  Net resources (line (d) minus line (e))

SUBPART II F-Numbers and Types of individuals with Significant Disabilities Receiving Services Through the CIL
I. Consumers served during the year
(a) Active CSRs carried over from September 30 of the preceding year.
(b) New CSRs initiated during the year.
(c) Total number of consumers served during the year.

II. Consumers Inactive @ Sept. 30 (a)
(a)  Moved
(b)  Withdrew
(c)  Died
II. Consumers Inactive @ Sept. 30 (d)
(d)  Inactive because goals met
(e)  Other
(f)  Total

III  Consumers Active (I total minus II total)

IV Time Consumer Active
(a)  Less than 12 months
(b)  12 months-2 years
(c)  2 years-5 years
(d)  Over 5 years
(e)  Total

V Consumer Achievements
(a) Number of individuals to whom an offer was made to develop an ILP but who waived the offer.
(b) Number of individuals with whom an ILP was developed
V Consumer Goals and Objectives (a)
(a) Self-care
(b) Communication
V Consumer Goals and Objectives (b)
(c) Mobility
(d) Residential
V Consumer Goals and Objectives (c)
(e) Educational
(f) Vocational
V Consumer Goals and Objectives (d)
(g) Other

VI  Age
(a)  Under 6
(b)  6-17
(c)  18-22
(d)  23-55
(e)  55 & over

VII  Gender
(a)  Female
(b)  Male

VIII Race/ethnicity
(a) White (non-Hispanic)
(b) Black (non-Hispanic)
(c) American Indian or Alaskan Native (including Native Hawaiians)
(d) Asian or Pacific Islander
(e) Hispanic

IX Disability
(a)  Cognitive
(b)  Mental
(c)  Physical
(d)  Sensory
(e)  Multiple disability

X Living arrangements
(a) Institution
(b) Dependent: w/family or friends
(c) Assisted Living
(d) Independent
(d) Other

XI Source of Personal Assistance Services Reimbursement (a)
(a)  Part B, Ch. 1, Title VII
(b) Part C, Ch 1, Title VII
(c) Medicaid Waiver program
(d) Medicaid
XI Source of Personal Assistance Services Reimbursement (a)
(e) Title XX
(f)  Other
(g) None available

 SUBPART II G-Types of Services Provided Through the CIL and the Number of Individuals with Significant Disabilities Receiving Each Type of Service
I. Community services (a)
(a) Information and referral
(b) Community and systems advocacy
I. Community services (b)
(c) Outreach
(d) Publications
I. Community services (c)
(e) Community education
(f) Maintaining registries
I. Community services (d)
(g) Other
(h) Total (a-g)

II - Individual Services (a)
(a) Advocacy/legal services
(b) Assistive devices/equipment
(c) Children's services
(d) Communication services
II - Individual Services (b)
(e) Counseling services
(f) Family services
(g) Housing and shelter services
(h) Information and referral services
II - Individual Services (c)
(i) IL Skills Training and Life Skills Services and Training
(j) Mental Restoration
(k) Mobility training
(l) Peer Counseling
II - Individual Services (d)
(m) Personal assistance services
(n) Physical rehabilitation
(o) Preventative services
(p) Prostheses and other appliances
II - Individual Services (e)
(q) Recreational services
(r) Rehabilitation technology
(s) Therapeutic treatment
(t) Transportation
II - Individual Services (f)
(u) Youth Services
(v) Vocational services
(w) Other

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