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SUBPART IA – ADMINISTRATIVE DATA
Subpart IAI – 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 IAIII – Provision of Services

(A) Does the DSU provide community IL services using part B funds directly or though grant or contract to a service provider other than a CIL reporting in 704 Part II?
(B) Does the DSU directly provide IL services to individuals with significant disabilities; directly determine eligibility for such individuals; and the CSRs for those individuals are maintained outside a CIL reporting in 704 Part II?

Subpart IAV - Staffing

Decision Making Staff: Total NumberofFTEs
Decision Making Staff: Total Number of Persons with Disabilities
Decision Making Staff: Total Number of Persons Who are Minorities
Staff Positions: Total NumberofFTEs
Staff Positions: Total Number of Persons with Disabilities
Staff Positions: Total Number of Persons Who are Minorities

SUBPART IB – 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 IBI – 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 IBII – 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 IBIII – Consumer CSRs Active on September 30 of the Reporting Year
Subpart IBI (C) - <minus> Subpart IBII (F) = Subpart IBIII

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

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

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

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

Subpart IBVIII – Race
(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

Subpart IBIX - Disability
(A) Cognitive
(B) Mental/Emotional
(C) Physical
(D) Hearing
(E) Vision
(F) Multiple Disability
(G) Other

SUBPART IC – INDIVIDUAL AND COMMUNITY ACHIEVEMENTS AND SERVICES

Subpart ICI – Individividual
(A) Self-Advocacy/Self-Empowerment ual Consumer Achievements: Goals Set Goals Met
(B) Communication: Goals Set Goals Met
(C) Mobility/Transportation: Goals Set Goals Met
(D) Community Services: Goals Set Goals Met
(E) Educational: Goals Set Goals Met
(F) Vocational: Goals Set Goals Met
(G) Self-Care: Goals Set Goals Met
(H) Information Access/Technology: Goals Set Goals Met
(I) Personal Resource Management: Goals Set Goals Met
(J) Other: Goals Set Goals Met
Residential: Goals Set Goals Met

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

Subpart ICV – Community Services
(A) Community and Systems Advocacy
(B) Outreach Efforts
(C) Publications
(D) Community Education/Integration Services
(E) Maintaining Registries/Libraries/Databases
(F) Collaboration/Networking

Subpart IDV – SILC Composition

(A) What is the total number of persons on the SILC?
(B) How many SILC members have disabilities, as defined in 34 CFR 364.4(b), and are not employed by a State agency or a CIL?
(C) Is a representative of the DSU an ex-Officio member of the SILC?
(D) How many voting members are on the SILC?
(E) State the number of different disability groups (physical, mental, cognitive, hearing, vision, or multiple) represented by members of the SILC.
F) Is a CIL director chosen by CIL directors within the State appointed to the SILC?
(G) Does the SILC include representatives from other State agencies that provide services for individuals with disabilities?
(H) Does the SILC have a voting membership that is knowledgeable about CILs and IL services?
(I) Do SILC members provide statewide representation?
(J) Is the SILC Chairperson elected from among the voting members of the SILC pursuant to section 705(b)(5) of the Act?
(K) Are there one or more section 121 projects in the State?
(L) If (K) above is answered “yes”, does the SILC include at least one representative from the directors of the section 121 projects?

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