SELF-ADMINISTERED FORM
STATE COUNCILS ON DEVELOPMENTAL DISABILITIES
INSTRUCTIONS:
In addition to questions that can be answered through personal interview, there is some information that is best collected with a form like this. For the most part, the information requested requires consolidation of information you are already collecting.
The form is divided into separate sections, one section for each of the key functions1 all State Councils on Developmental Disabilities (DD Councils) implement. We would appreciate it if you would provide us with information that responds to the questions for each key function. When documentation is required, please append to this form.
So that data from all DD Councils can be rolled up to the national level, it is important that all DD Councils that complete this questionnaire use the same time period [REPORTING PERIOD]. Therefore, please answer all questions using the following REPORTING PERIOD:
From [to be completed by _____]
M M D D Y Y Y Y
To [to be completed by_____}
M M D D Y Y Y Y
We are providing you with a CD that contains this form, as well as a paper copy of the form. Please feel free to complete this form by computer or with a pen. If you complete this form by computer, please save it as a Word file and send it to _________________ as an attachment. Documentation should be sent to _________ in the self-addressed envelope we have provided.
If you complete this form with a pen or pencil, please return the form with all documentation to _________________ in the self-addressed envelope we have provided.
If you have any questions, please do not hesitate to call ____________ at ____________.
ID Number
[Completed by _________]
Name of Program _________________________________________________________
Executive Director ________________________________________________________
Name and contact information of person (people) completing form:
Name |
Section Completed |
Telephone Number |
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State Plan Development |
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Self-advocacy and Leadership |
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Community Capacity Development |
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Governance and Management |
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A. State Plan Development
All questions in this section refer to the following reporting period:
From [to be completed by _____]
M M D D Y Y Y Y
To [to be completed by_____}
M M D D Y Y Y Y
1. What are the goals and objectives stated in the State Plan and amendments?
PLEASE LIST.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
2. What are the DD Council’s long-term systems change2 goals? PLEASE LIST.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
3. What were the DD council’s short-term systems change objectives3 during the reporting period? PLEASE LIST.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
4. What populations or communities were expected to benefit from DD Council’s systems short-term objectives during the reporting period? PLEASE LIST.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
What self-advocacy and leadership development activities4 did the DD Council implement during the reporting period? PLEASE LIST.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
6. What community capacity development activities5 did the DD Council implement during the reporting period? PLEASE LIST.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
7. What activities related to identifying or testing promising practices did the DD Council implement during the reporting period? PLEASE LIST.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
8. What advocacy activities6 did the DD Council implement during the reporting period? PLEASE LIST.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
ID Number
[Completed by _________]
Self-advocacy and Leadership
All questions in this section refer to the following reporting period:
From [to be completed by _____]
M M D D Y Y Y Y
To [to be completed by_____}
M M D D Y Y Y Y
9. How many people with developmental disabilities and/or family members participated in Council-supported self-advocacy and leadership development education, training, and/or technical assistance?
Don’t know [CHECK, IF APPLICABLE.]
10. Overall, how satisfied do you think recipients of self-advocacy activities were with the type of assistance they received last year?
Highly satisfied
Satisfied
Somewhat satisfied
Not at all satisfied
PLEASE PROVIDE DOCUMENTATION.7
Don’t know [CHECK, IF APPLICABLE.]
ID Number
[Completed by _________]
C. Community Capacity Development8
All questions in this section refer to the following reporting period:
From [to be completed by _____]
M M D D Y Y Y Y
To [to be completed by_____}
M M D D Y Y Y Y
How many people participated in community capacity development activities supported by the DD Council during the reporting period?
Don’t know [CHECK, IF APPLICABLE.]
12. Overall, how satisfied do you think recipients of self-advocacy activities were with the type of assistance they received last year?
Highly satisfied
Satisfied
Somewhat satisfied
Not at all satisfied
PLEASE PROVIDE DOCUMENTATION.9
Don’t know [CHECK, IF APPLICABLE.]
Identification of Promising and Effective Practices
No questions
ID Number
[Completed by _________]
E. Governance and Management
All questions in this section refer to the following reporting period:
From [to be completed by _____]
M M D D Y Y Y Y
To [to be completed by_____}
M M D D Y Y Y Y
How many DD Council members comprise your Council?
14. How many DD Council members:
a. Have a developmental disability?
Don’t know [CHECK, IF APPLICABLE.]
b. Have a cognitive disability?
Don’t know [CHECK, IF APPLICABLE.]
c. Have expertise in policy and laws related to people with disability?
Don’t know [CHECK, IF APPLICABLE.]
d. Have expertise in business or finance?
Don’t know [CHECK, IF APPLICABLE.]
e. Represent a minority in the state?
Don’t know [CHECK, IF APPLICABLE.]
How many DD Council members attended at least the minimum number of Council meetings required in the Council’s attendance policy?
No attendance policy on minimum number of council meetings required. [CHECK, IF APPLICABLE.]
1 Key functions are groups of activities carried out by the DD Network programs. Taken together, they cover all key aspects of program activity.
2 Systems change includes improvements in community capacity, coordination of systems, and customization of supports and services to people with developmental disabilities and their families and results in changes to (or maintenance of) legislation, policy, and funding. Long-term goals cover a multiple-year period (e.g., 5 years or more).
3 Short-term objectives are developed to achieve long-term goals. They are explicit and are intended to be accomplished over a maximum period of 1 year.
4 Self-advocacy and leadership development activities include the support or provision of education, training, technical assistance, outreach, and public awareness. These activities provide people with developmental disabilities and/or family members with knowledge and skills to obtain supports and services and advocate for systems change so that their choices can meet desired lifestyle goals, including integration into the community, choice and independence.
5 Community capacity development activities provide communities with the capacity to support the inclusion of people with developmental disabilities in every aspect of community life. Capacity building includes increasing community awareness, knowledge, skills, and abilities and improving the infrastructure for service delivery throughout the State.
6 DD Council advocacy efforts consist of activities to facilitate changes to the service delivery and support systems in the state in order to improve community access and promote self-determination and independence for people with developmental disabilities and their families.
7 Documentation is tangible evidence – such as a report to the DD Council, summary of survey results; audit or performance review results.
8 Community capacity development consists of providing communities with the capacity to support the inclusion of people with developmental disabilities in every aspect of community life. Capacity building includes increasing community awareness, knowledge, skills, and abilities and improving the infrastructure for service delivery throughout the State.
9 Documentation is tangible evidence – such as a report to the DD Council, summary of survey results; audit or performance review results.
| File Type | application/msword |
| File Title | SELF-ADMINISTERED FORM |
| Author | jjohnson1 |
| Last Modified By | jjohnson1 |
| File Modified | 2009-06-25 |
| File Created | 2009-06-25 |