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SUBPART I A - ADMINISTRATIVE DATA

I Resources
(A) Federal Funds
(1) Ch. 1, part B, Title VII
(2) Ch. 1, part C, Title VII (723 States)
(3) Ch. 2, Title VII
(4) Other Federal Funds

(B) Other Government Funds
(5) State Government funds
(6) Local Government funds

(C) Private Resources
(7) Foundation, corporation, or trust grants
(8) Donations from Individuals
(9) Memberships
(10) Investment Income/Endowment
(11) Fees for Service (program income)
(12) Other resources (in-kind items, etc.)

(D) Total Resources (sum of lines 1 - 12)

(E) Amount of total resources that ?pass through to
Consumers, e.g., personal assistance service funds

(F) Net operating resources
(Line D minus line E)

V - Staffing
Report the total number of FTE employed in the SILS and CIL programs administered by the DSU(s) and by service providers other than CILs reporting in 704 Part II reports submitted to RSA. Report the total decision making and other staff, the number of FTE filled by individuals with disabilities, and the number of minority FTE who are employed.

SUBPART IB: NUMBERS AND TYPES OF INDIVIDUALS WITH SIGNIFICANT DISABILITIES RECEIVING SERVICES EITHER DIRECTLY FROM THE DSU OR THROUGH GRANTS OR CONTRACTS

I 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

II Consumers inactive on September 30th of the reporting year

(A) Moved
(B) Withdrew
(C) Died
(D) Inactive because goals were met
(E) Other
(F) Total

III Consumers (CSRs) active on September 30th of the reporting year

IV Consumer Achievements
(A) Number of individuals declining offer to develop ILP
(B)Number of individuals with whom an ILP was developed

V Consumer Goals and Objectives Established and Achieved
(A) Self-care: Goals Set Goals Met
(B) Communication: Goals Set Goals Met
(C) Mobility: Goals Set Goals Met
(D) Residential: Goals Set Goals Met
(E) Educational: Goals Set Goals Met
(F) Vocational: Goals Set Goals Met
(G) Other: Goals Set Goals Met

VI Age Information
(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 Hawaiian)
(D) Asian or Pacific Islander
(E) Hispanic

IX Disability
(A) Cognitive
(B) Mental/Emotional
(C) Physical
(E) Hearing
(F) Vision
(G) Multiple Disability

X - Community-Based Living
(A) Individuals successfully relocated from nursing homes or other institutions to community-based living arrangements
(B) Individuals for whom IL services prevented the necessity of entering nursing homes or other institutions and therefore continued living in a community-based living arrangements

SUBPART IC: TYPES OF SERVICES PROVIDED AND THE NUMBER OF INDIVIDUALS WITH SIGNIFICANT DISABILITIES RECEIVING SERVICES EITHER DIRECTLY BY THE DSU(s) OR THROUGH GRANTS, CONTRACTS, OR OTHER ARRANGEMENTS

I Community Services (this section is optional)
(A) Information and Referral: Total Hours
(B) Community and Systems Advocacy: Total Hours
(C) Outreach: Total Hours
(D) Publications: Total Hours
(E) Community Education: Total Hours
(F) Maintaining Registries: Total Hours
(G) Other: Total Hours
(H) Total

II Individuals Services
(A) Advocacy
(B) Legal
(C) Childrens
(D) Communication
(E) Counseling and Related
(F) Family
(G) Housing, Home Modifications and Shelter (e.g. moving people out of nursing homes/institutions into integrated housing)
(H) Information and Referral
(I) IL Skills Training and Life Skills Training
(J) Mental Restoration
(K) Mobility Training
(L) Peer Counseling (including Cross-disability Peer Counseling)
(M) Personal Assistance Services
(N) Physical Rehabilitation
(O) Preventative Services
(P) Prostheses and other
(Q) Recreational
(R) Rehabilitation Technology
(S) Therapeutic Treatment
(T) Transportation
(U) Youth
(V) Vocational
(W) Other

V. Composition of the SILC

(1) State the total number of persons on the SILC.
(2) State the number of SILC members with disabilities, as defined in 34 CFR 364.4(b), and not employed by a State agency or a CIL.
(3) Is a representative of the DSU an ex-officio member of the SILC?
(4) State the number of voting members on the SILC.
(5) State the number of different disability groups (physical, mental, cognitive, sensory, or multiple) represented by members of the SILC (up to five).
(6) Is a CIL director chosen by CIL directors within the State appointed to the SILC?
(7) Does the SILC include representatives from other State agencies that provide services for individuals with disabilities?
(8) Does the council have a voting membership that is knowledgeable about CILs and IL services?
(9) Do Council members provide statewide representation?
(10) Is the Council Chairperson elected from among the voting members of the Council by the voting members of the Council or the Governor, pursuant to section 705(b)(5) of the Act?
(11) Is there one or more section 121 (formerly 130) project in the State?
(12) If #11 is answered as “Y”, does the Council include at least 1 representative of the directors of the section 121 projects. 

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