NIRS Activity Form – FY 2018
*Response Required
*Program Type:UCEDD
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*Fiscal Year:2018
*Core Function:Demonstration Services
*Title of Activity:______
Brief Activity Description (This field may be used to provide brief explanatory information (up to 50 words) on the activity being reported in this record) ____________
______
______
Staff Involvement______
(List the first and last name of all staff members who were involved in conducting this activity.)
Total number of consults, contacts, or services ______
Number of unduplicated individuals served______
Race of individuals served (Supplynumber for all thatapply)
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______White
______Black or African-American
______American Indian and Alaska Native
Tribe:______
______Asian (includes Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, and other Asian)
______Native Hawaiian and Other Pacific Islander (includes Native Hawaiian, Guamanian or Chamorro, Samoan, and other Pacific Islander)
______More than one race includes individuals who identify with two or more racial designations
______Unrecorded is included for individuals who are unable to identify with the categories
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Ethnicity of individuals served(Supply number for all that apply)
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______Hispanic
______Non Hispanic
______Unrecorded
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Ages of individuals served(Supply number for all that apply)
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______Pregnant Women (All Ages)
______Infants <1 year
______Children 1 to 12 years
______Adolescents 12-18 years
______Young Adults 18-25 years
______CSHCN Infants <1 year
______CSHCN Children and Youth 1 to 25 years
______Women 25+
______Men 25+
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*Type of Activity (Select one)
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Advocacy
Capacity Building
Systemic Change
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*Area of Emphasis (Check one)
Areas listed in the DD Act:
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Quality Assurance Activities
Child Care-Related Activities
Employment-Related Activities
Transportation-Related Activities
Education & Early Intervention
Health-Related Activities
Housing-Related Activities
Recreation-Related Activities
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Areas not listed in the DD Act:
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Quality of Life Activities
Other-Cultural Diversity
Other, Please Specify: ______
Other-Assistive Technology
Other-Leadership
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Customer Satisfaction
*Was the Center the lead on this activity?
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Yes (If Yes, please enter the survey results below.)
No
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Total number surveyed______Supply total number responding:
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Strongly Agree______
Agree______
Disagree______
Strongly Disagree______
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*All Agencies Collaborating on the Work of the Activity
(Must check all that apply)
(Name of agency/ies may be supplied in space provided)
Not Applicable/No Collaborating Agency
State Title V Agency ______
Other MCHB Funded or Related Program ______
State Health Dept. ______
Clinical Programs/Hospitals ______
State Adolescent Health ______
Other Health-Related Program ______
Health Insurance/Managed Care Organization ______
Medicaid ______
Development Disabilities Council ______
Protection & Advocacy Agency (P&A) ______
Another UCEDD ______
Childcare/Early Childhood/Part C Infants and Toddlers ______
Head Start/Early Head Start ______
State/Local Special Education (3-21) ______
State/Local General Education ______
Post Secondary Education (Community College-University) ______
Employment/Voc Rehab ______
State/Local MR/DD Agency or Provider ______
State/Local Social Services ______
Aging Organization ______
Health Agency - Public/Private ______
Mental Health/Substance Abuse Agency ______
Housing Agency/Provider ______
Recreation Agency ______
Transportation Agency ______
Provider Organization ______
Consumer/Advocacy Organization ______
State/Local Coalition ______
Legislative Body ______
Justice/Legal Organization ______
Community or Faith-Based Organization ______
National Association ______
Independent research or policy organization ______
Foundation ______
Other______
*Project Affiliation
Not Applicable/No Affiliated Project
Primary AffiliatedProject – List Title:______
Secondary Affiliated Project– List Title:______
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*Duration (Report to the nearest full hour): ______
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Not Applicable
Date of Activity______
(mm/dd/yyyy)
Recurring activity?
(For on-going activities, you may just enter thedate the activity began)
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