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SUBPART I A:  Administrative Data
I-Resource (a)
    Federal Funds (1) Ch 1, Part B, Title VII
    Federal Funds (2) Ch 1, Part C, Title VII (723 States)
    Federal Funds (3) Ch 2, Title VII
    Federal Funds (4) Other Federal Funds
I-Resource (b)
    Other Government Funds (5) state goverment funds
    Other Government Funds (6) local goverment funds
I-Resource (c)
    Private Resources (7) Foundation, corporation or trust grants
    Private Resources (8) Donations from individuals
    Private Resources (9) Memberships
    Private Resources (10) Investment income, endowment
I-Resource (c) cont.
    Private Resources (11) Fees for service (program income)
    Private Resources (12) Other resources (in-kind items, etc.)
I-Resource (d)
    Total resources (Sum of lines 1-12)
I-Resource (e)
    Amount of total resources that "pass through" to consumers, e.g., personal assistant service funds
I-Resource (f)
    Net operating resources
 

SUBPART I A:  Administrative Data
II-Allocation of Funds (a)
    Part B, Ch 1 Funds (a)
    Part B, Ch 1 Funds (a) Fund the resource plan for the SILC
    Part B, Ch 1 Funds --Direct by DSU
    Part B, Ch 1 Funds --Grant or Contract
II-Allocation of Funds (b)
    Part B, Ch 1 Funds (b) Provided IL services directly or through grant or contract
    Part B, Ch 1 Funds  Direct by DSU
    Part B, Ch 1 Funds Grant or contract
II-Allocation of Funds (c)
    Part B, Ch 1 Funds (c) Demonstrate ways to expand and improve IL services
    Part B, Ch 1 Funds Direct by DSU
    Part B, Ch 1 Funds Grant or Contract
II-Allocation of Funds (d)
    Part B, Ch 1 Funds Support the general operation of CILs
    Part B, Ch 1 Funds Direct by DSU
    Part B, Ch 1 Funds Grant or Contract
II-Allocation of Funds (e)
    Part B, Ch 1 Funds Support activities to increase capacity to develop
    Part B, Ch 1 Funds Direct by DSU
    Part B, Ch 1 Funds Grant or Contract
II-Allocation of Funds (f)
    Part B, Ch1 Funds (f) Conduct studies and analysis, gather information
    Part B, Ch1 Funds Direct by DSU
    Part B, Ch1 Funds Grant or Contract
II-Allocation of Funds (g)
    Part B, Ch 1 Funds Train regarding IL philosophy
    Part B, Ch1 Funds  Direct by DSU
    Part B, Ch1 Funds  Grant or Contract
II-Allocation of Funds (h)
    Part B, Ch1 Funds Provide outreach to unserved or underserved populations
    Part B, Ch1 Funds Direct by DSU
    Part B, Ch1 Funds Grant or Contract

IV--Grants, Contracts or other Arrangements
IV--Grants, Contracts or other Arrangements for Use of Part B Funds--Total amount of G/C Part B, Ch II
IV--Grants, Contracts or other Arrangements for Use of Part B Funds--Total amounts of G/C Other fund
IV--Grants, Contracts or other Arrangements for Use of Part B Funds--Total amounts of G/C--Nonfed sources

V--Staffing--SILC/CIL Programs
    Decisionmaking staff--Total FTE
    Decisionmaking staff--Person with disabilities
    Decisionmaking staff--Number who are minority
V--Staffing--SILC/CIL Programs
    Other Staff--Total FTE
    Other Staff--Persons with disabilities
    Other Staff--Number who are minority

I--Consumers Served During Year
    (a) CSRs carried from previous year
    (b) CSRs started since Oct. 1 of report year
    (c) Total consumers served

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-5years
(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)  23-54
(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)  Other

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 I C-Types of Services Provided
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 and related 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 (including cross-disability)
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

IV - Composition of the Council (a)
(1) State total number of persons on Council
(2) State number of Council members with disabilities
(3) State number of persons on Council who are ex-officio
(4) State number of perons on Council who represent CIL's

IV - Composition of the Council (b)
(5) State number of voting members on Council
(6) State number of Council members with disabilities
(7) State number of disability groups
(7a) Does Council include members from minority groups?

IV - Composition of the Council (c)
(8) Does the Council have voting membership?
(9) Do Council members provide statewide representation?
(10) Is the Council Chairperson elected --voting member of Council?

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