| OMB Control Number: 0985-0022 Exp. 12/30/20 |
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| Grantee name |
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| Grant ID |
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| Reporting period (start date - end date) |
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| Report submission date |
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| ALL LIGHT GREEN CELLS SHOULD BE COMPLETED. DO NOT ADD OR MODIFY ROWS OR COLUMNS. |
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People living with dementia |
Caregivers |
Total |
| TOTAL SERVED - Cumulative and unduplicated from grant start date |
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0 |
| Age |
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| Under 60 |
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0 |
| 60+ |
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0 |
| Age missing |
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0 |
| Gender |
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| Female |
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0 |
| Male |
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0 |
| Gender missing |
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0 |
| Geographic location |
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| Urban |
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0 |
| Rural |
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0 |
| Geographic location missing |
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0 |
| Ethnicity |
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| Hispanic or Latino |
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0 |
| Not Hispanic or Latino |
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0 |
| Ethnicity missing |
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0 |
| Race |
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| Participants may check more than one race category so total may be greater than the total served above |
| American Indian or Alaskan Native |
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0 |
| Asian or Asian American |
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0 |
| Black or African American |
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0 |
| Native Hawaiian or other Pacific Islander |
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0 |
| White |
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0 |
| Race missing |
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0 |
| Minority Status |
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| Minority |
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0 |
| Not minority |
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0 |
| Minority status missing |
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0 |
| Military Status |
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| Served in the military |
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0 |
| Has not served in the military |
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0 |
| Military status missing |
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0 |
| Relationship to caregiver |
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| Spouse or partner |
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0 |
| Parent |
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0 |
| Other caregiver |
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0 |
| No caregiver |
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0 |
| Relationship Missing |
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0 |
| Living arrangement |
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| Lives alone, has an identified caregiver |
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0 |
| Lives alone, no identified caregiver |
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0 |
| Lives with a caregiver |
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| Lives with someone who is not a caregiver |
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| Living arrangement missing |
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0 |
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| For questions about categories and definitions, see [insert link to Definitions and FAQs document] or contact your Resource Center staff person. |
PROFESSIONALS TRAINED, BY FUNCTION
Cumulative and unduplicated from grant start date |
Number of professionals trained |
| Information and referral providers, options counselors |
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| Case managers, care coordinators, discharge planners |
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| Other dementia-related program providers (e.g. caregiver skills trainers, support group facilitators, adult day services staff) |
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| Direct care workers (e.g. certified nursing assistants, personal care attendants, companions) |
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| Medical care providers (e.g. physicians, nurse practitioners, physicians assistants) |
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| Allied health providers (e.g. occupational therapists, pharmacists, dietitians) |
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| Volunteers (e.g. Meals on Wheels, friendly visitors) |
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| First responders (paid and unpaid) |
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| Legal professionals |
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| Financial professionals (e.g. bank tellers, financial planners) |
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| Community businesses (e.g. retail store employees, café baristas, hairdressers) |
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| Clergy, other members of faith community |
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| Students preparing for dementia-related work |
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| Other |
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| Profession missing |
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| TOTAL TRAINED |
0 |
| ALL LIGHT GREEN CELLS SHOULD BE COMPLETED. DO NOT ADD OR MODIFY ROWS OR COLUMNS |
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| Training data should not include outreach and awareness activities. Persons trained should not include persons with dementia, caregivers, or the general public. |
| For questions about categories and definitions, see [insert link to Definitions and FAQs document] or contact your Resource Center staff person. |
| SERVICES & EXPENDITURES - Cumulative from grant start date |
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| Total Units of Direct Service Delivered |
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| Persons with Dementia and Caregivers |
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| Professionals Trained |
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| Percentage of Total Budget Spent on: |
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| Direct Service Expenses |
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| Administrative Expenses |
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| Other Programmatic Expenses |
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ALL LIGHT GREEN CELLS SHOULD BE COMPLETED.
DO NOT ADD OR MODIFY ROWS OR COLUMNS |
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| If your project is not meeting direct service and/or expenditure requirements by the end of this reporting period (reflected in the numbers above), please describe -- in the box to the right -- why the project has not met these requirements and confirm that the project will meet these requirements by the end of the grant. Information on expenditure requirements can be found in the Notice of Award. |
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| For questions about categories and definitions, see [insert link to Definitions and FAQs document] or contact your Resource Center staff person. |