Title VI PPR

Paperwork Reduction Act Public Burden Statement:
According to the Paperwork Reduction Act of 1995 5 CFR § 1320.8(b)(3), no persons are required to respond to a
collection of information unless such collection displays a valid OMB control number (OMB 0985-0007). Public reporting
burden for this collection of information is estimated to average 3.5 hours per response, including time for gathering,
maintaining the data needed, completing, and reviewing the collection of information. The obligation to respond to this
collection is required to retain or maintain benefits the statutory authority 42 U.S. Code § 3057e. Information collected
is planned for use by ACL to: (1) monitor program achievement of performance objectives; (2) establish program policy
and direction; and (3) prepare responses to Congress, OMB, and public and private agencies as required by the Older
Americans Act (OAA) Title II sections 202(a)19 and 207. These data are also used to prepare data for the Federal
Interagency Task Force on Older Indians, established pursuant to section 134(d) of the 1987 Amendments to the OAA.
ACL uses information collected to monitor federal funds. Data will be kept private to the extent allowed by law. There
are no assurances of confidentiality.

ADMINISTRATION FOR COMMUNITY LIVING ADMINISTRATION ON AGING

TITLE VI PROGRAM PERFORMANCE REPORT
Report Period April 1, [year] – March 31, [year]
Title VI, Parts A/B and C

Title VI, Part A/B only

Grantee Name
Telephone

Email address

Part A/B Grant No.
Part C Grant No.
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TITLE VI, PART A/B REPORT
A. STAFFING INFORMATION
Enter the number of staff paid wholly or partly by Title VI, Part A/B funds.
Full-time staff
Full-time staff

Person(s)

Part-time staff
Part-time staff

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Person(s)

B. NUTRITION SERVICES
Congregate Meals
Unduplicated number of eligible persons who received one
or more Congregate Meal(s).
Total number of Congregate Meals served.

Person(s)
Meal(s)

Home-Delivered Meals
Unduplicated number of eligible persons who received one or
more Home-delivered Meal(s).
Total number of Home-delivered Meals provided.

Person(s)
Meal(s)

Other Nutrition Services
Total number of sessions of Nutrition Education.

Session(s)

Total number of persons who received Nutrition Counseling.

Person(s)

Total number of hours of Nutrition Counseling.

Hour(s)

C. SUPPORTIVE SERVICES
Access Services
Total number of contacts of Information/Assistance.
Total number of Outreach activities.
Unduplicated number of persons receiving Case
Management.
Total number of hours of Case Management.
Unduplicated number of persons receiving Transportation.
Total one-way trips of Transportation.

Contact(s)
Activities
Person(s)
Hour(s)
Person(s)
One-way
trip(s)

In-home Services
Unduplicated number of persons receiving Homemaker
Services.
Total number of hours of Homemaker Services.
Unduplicated number of persons receiving Personal
Care/Home Health Aid Services.
Total number of hours of Personal Care/Home Health Aid
Service.
Unduplicated number of persons receiving Chore Services.
Total number of hours spent on Chore Services.
Total number of contacts of Visiting.
Total number of contacts of Telephoning.

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Person(s)
Hour(s)
Person(s)
Hour(s)
Person(s)
Hour(s)
Contact(s)
Contact(s)

Other Supportive Services
Total number of Social Events held.
Total number of persons receiving Health Promotion and
Wellness activities.
Total number of visits to persons in nursing facilities/homes
or residential care communities.

Event(s)
Person(s)
Visit(s)

Optional space for other supportive services offered that are not listed above (1500 words or less):

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D. FINANCE
Part A/B Spending
Total amount of funds spent on Congregate and Homedelivered Meals.
Total amount of funds spent on Supportive Services
Programming.

Dollars
Dollars

Optional explanation of elements included in total amount of funds (1500 words or less):

What other sources of funds help you support your Title VI services:
Tribal funds
State funds
Title III funds
Other grants
Donations

Yes or No
Yes or No
Yes or No
Yes or No
Yes or No

This finance section will be an addendum to the 425. This will NOT be used for audits.

E. STORYTELLING
Please share an example of how your Title VI program has helped an individual or your community (1500
words or less):

**OFFICIAL SIGNATURE** - If only completing Title VI, Part A/B of this report go to page [insert
page] to sign and date.

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TITLE VI, PART C REPORT
A. STAFFING INFORMATION
Enter the number of staff paid wholly or partly by Title VI, Part C funds.
Full-time staff
Full-time staff

Person(s)

Part-time staff
Part-time staff

Person(s)

B. TOTAL CAREGIVERS SERVED
Caregivers served by the Title VI program are informal, unpaid providers of in-home and community
care. Caregivers may be family members, neighbors, friends, or others.
Unduplicated number of caregivers to Elders or
individuals of any age with Alzheimer’s disease and
Person(s)
related disorders.
Unduplicated number of Elder caregivers caring for
Person(s)
children under the age of 18.
Unduplicated number of Elder caregivers providing care
Person(s)
to adults 18-59 years old with disabilities.

C. CAREGIVER SUPPORT SERVICES
Services for Caregivers
Total number of activities of Information Services
provided.
Total number of contacts of Information and Assistance
provided.
Unduplicated number of caregivers receiving Counseling
(e.g. formal and/or informal counselors).
Total number of hours of Counseling.
Total number of sessions of Support Group.
Unduplicated number of caregivers served in Caregiver
Training.
Total number of hours of Caregiver Training.

Activities
Contact(s)
Person(s)
Hour(s)
Session(s)
Person(s)
Hour(s)

Supplemental Services: (report on units provided, unduplicated caregivers served, service category)
Service Category
Description of Service
Unduplicated Caregivers
There will be a dropdown menu of service categories: Home Modification/Repairs, Consumable Items,
Lending Closet, Homemaker/Chore/Personal Care Service, Financial Support, Other.

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Respite Care for Caregivers
Respite care is a service for informal caregivers, not Elders or children. Respite care refers to allowing
caregivers time away to do other activities by having an Elder, person with a disability, or child cared for
by someone else.
Unduplicated number of caregivers of Elders provided
Person(s)
Respite Care.
Total number of hours of Respite Care for caregivers of
Hour(s)
Elders.
Unduplicated number of caregivers of children under the
Person(s)
age of 18 provided Respite Care.
Total number of hours of Respite Care for caregivers of
Hour(s)
children under the age of 18.
Unduplicated number of caregivers of adults 18-59 years
Person(s)
old with disabilities provided Respite Care.
Total number of hours of Respite Care for caregivers of
Hour(s)
adults 18-59 years old with disabilities.

D. FINANCE
Part C Spending
This finance section will be an addendum to the 425. This will NOT be used for audits.
Total amount of funds spent on the Caregiver Program.
Total amount of funds spent on Respite Care.

Report Certified By
(Tribal Official or other authorized personnel)
Report Prepared by:
Telephone:

Date Submitted:

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Email address:

Dollars
Dollars