| Element: CURRENT |
Element: FUTURE |
| Title VI, Parts A/B and C |
Title VI, Parts A/B and C |
| Title VI, Part A/B only |
Title VI, Part A/B only |
| Tribal Organization |
Grantee Name |
| Address |
(not in future form) |
| (not in current form) |
Telephone |
| (not in current form) |
Email address |
| Part A/B Grant No. |
Part A/B Grant No. |
| Part C Grant No |
Part C Grant No |
| Report Period |
Report Period |
| STAFFING INFORMATION |
| Full-time staff |
Full-time staff |
| Part-time staff |
Part-time staff |
| NUTRITION SERVICES |
| Congregate Meals |
| UNDUPLICATED NUMBER of eligible persons who received one or more congregate meal |
Unduplicated number of eligible persons who received one or more Congregate Meal(s). |
| TOTAL NUMBER of congregate meals served |
Total number of Congregate Meals served. |
| Home-Delivered Meals |
| UNDUPLICATED NUMBER of eligible persons who received one or more home-delivered meal |
Unduplicated number of eligible persons who received one or more Home-delivered Meal(s). |
| TOTAL NUMBER of home-delivered meals provided |
Total number of Home-delivered Meals provided. |
| Other Nutrition Services |
| Nutrition Education (units) |
Total number of sessions of Nutrition Education. |
| (not in current form) |
Total number of persons who received Nutrition Counseling. |
| Nutrition Counseling (units) |
Total number of hours of Nutrition Counseling. |
| SUPPORTIVE SERVICES |
| UNDUPLICATED NUMBER of eligible Indians who received one or more of the supportive services below |
(not in future form except where noted below) |
| Access Services |
| Information/Referral (contacts) |
Total number of contacts of Information/Assistance. |
| Outreach (contacts) |
Total number of Outreach activities |
| (not in current form) |
Unduplicated number of persons receiving Case Management. |
| Case Management (hour) |
Total number of hours of Case Management. |
| (not in current form) |
Unduplicated number of persons receiving Transportation. |
| Transportation (one way trips) |
Total one-way trips of Transportation. |
| LEGAL ASSISTANCE |
(not in future form) |
| (not in current form) |
Unduplicated number of persons receiving Homemaker Services. |
| Homemaker Service (hours) |
Total number of hours of Homemaker Services. |
| (not in current form) |
Unduplicated number of persons receiving Personal Care/Home Health Aid Services. |
| Personal Care/Home Health Aid Service (hours) |
Total number of hours of Personal Care/Home Health Aid Service. |
| (not in current form) |
Unduplicated number of persons receiving Chore Services. |
| Chore Service (hours) |
Total number of hours spent on Chore Services. |
| Visiting (contacts) |
Total number of contacts of Visiting. |
| Telephoning (contacts) |
Total number of contacts of Telephoning. |
| Family Support (contacts) |
(not in future form) |
|
Other Supportive Services |
| (not in current form) |
Total number of Social Events held. |
| (not in current form) |
Total number of persons receiving Health Promotion and Wellness activities. |
| HEALTH PROMOTION AND WELLNESS (hours) |
(not in future form) |
| OMBUDSMAN SERVICES |
(not in future form) |
| (not in current form) |
Total number of visits to persons in nursing facilities/homes or residential care communities |
| ALL OTHERS |
Optional space for other supportive services offered that are not listed above |
|
FINANCE |
|
Part A/B Spending |
| (not in current form) |
Total amount of funds spent on Congregate and Home-delivered Meals. |
| (not in current form) |
Total amount of funds spent on Supportive Services Programming. |
| (not in current form) |
Optional explanation of elements included in total amount of funds |
|
What other sources of funds help you support your Elder services |
| (not in current form) |
Tribal funds |
| (not in current form) |
State funds |
| (not in current form) |
Title III funds |
| (not in current form) |
Other grants |
| (not in current form) |
Donations |
| TITLE VI, PART C REPORT |
| STAFFING INFORMATION |
| Full-time staff |
Full-time staff |
| Part-time staff |
Part-time staff |
|
CAREGIVER CHARACTERISTICS |
| (not in current form) |
Unduplicated number of caregivers to Elders or individuals of any age with Alzheimer’s disease and related disorders. |
| (not in current form) |
Unduplicated number of Elder caregivers caring for children under the age of 18. |
| (not in current form) |
Unduplicated number of Elder caregivers providing care to adults 18-59 years old with disabilities |
| CAREGIVER SUPPPORT SERVICES |
| Unduplicated Number Information about available services |
(not in future form) |
| (not in current form) |
Total number of activities of Information Services provided. |
| Total Number Information about available services |
Total number of contacts of Information and Assistance provided. |
| Unduplicated Number Assistance in gaining access to available services |
(not in future form) |
| Total Number Assistance in gaining access to available services |
(not in future form) |
| Unduplicated Number Individual Counseling |
Unduplicated number of caregivers receiving Counseling (e.g. formal and/or informal counselors). |
| Total Number Individual Counseling |
Total number of hours of Counseling. |
| Unduplicated Number Support Groups |
(not in future form) |
| Total Number Support Groups |
Total number of sessions of Support Group. |
| Unduplicated Number Caregiver Training |
Unduplicated number of persons served in Caregiver Training. |
| Total Number Caregiver Training |
Total number of hours of Caregiver Training. |
| (not in current form) |
Supplemental Services: Home Modification/Repairs |
|
Supplemental Services: Consumable Items |
| Lending Closet |
Supplemental Services: Lending Closet |
| (not in current form) |
Supplemental Services: Homemaker/Chore/Personal Care Service |
| (not in current form) |
Supplemental Services: Financial Support |
| Other |
Supplemental Services: Other |
|
RESPITE |
| Unduplicated Number Respite |
Unduplicated number of caregivers of Elders provided Respite Care. |
| Total Number Respite |
Total number of hours of Respite Care for caregivers of Elders. |
| (not in current form) |
Unduplicated number of caregivers of children under the age of 18 provided Respite Care. |
| (not in current form) |
Total number of hours of Respite Care for caregivers of children under the age of 18. |
| (not in current form) |
Unduplicated number of caregivers of adults 18-59 years old with disabilities provided Respite Care. |
| (not in current form) |
Total number of hours of Respite Care for caregivers of adults 18-59 years old with disabilities. |
|
FINANCE |
|
Part C Spending |
| (not in current form) |
Total amount of funds spent on the Caregiver Program. |
| (not in current form) |
Total amount of funds spent on Respite Care. |
|
STORYTELLING |
| (not in current form) |
Please share an example of how your Title VI program has helped an individual or your community (1500 words or less): |
| Briefly describe your coordination activities in providing supportive services for caregivers |
(not in future form) |
| Briefly describe the standards and quality assurance mechanisms you are using. |
(not in future form) |