NIRS Activity Form – FY 2015
*Response Required
*Program Type:
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UCEDD
LEND
LEAH
PPC
DBP
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*Fiscal Year:2015
*Core Function:Technical Assistance
*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.)
*The primary target audience is (select one):
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Local
State
Tribal
Another State
Regional
National
International
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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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*Intensity of TA (Select one)
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One time brief (single)
One time extended (multi-day contact provided one time)
On-going Infrequent (3 or less contacts per year)
On-going frequent (more than 3 contacts per year)
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*Types and Numbers of Participants (Supply number for all that apply)
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Trainees Total______
Other Classroom Students______
Professionals & Para-Professionals______
Family Members/Caregivers______
Adults with Disabilities______
Children/Adolescents with Disabilities/SHCN______
Legislators/Policymakers______
General Public/Community Members______
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Customer Satisfaction
*Is the Center the lead on this activity?
Yes (If Yes, please enter the survey results below.)
No
Total number surveyed______Supply total number responding:
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Strongly Agree______
Agree______
Disagree______
Strongly Disagree______
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*Initial Outcome Measure
For TA recipients with a sustained relationship with the UCEDD, percent reporting an increase in any of the identified or requested item(s) below:
- Enhanced resources
- Enhanced services
- Strengthened networking of public and private entities across communities
- Increased awareness of evidence based practices
- Enhanced capacity to assess current practices in relation to evidence-based approaches
- Identification of policy changes needed within the area of emphasis
Total number surveyed______
Supply total number responding:
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Strongly Agree______
Agree______
Disagree______
Strongly Disagree______
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Not Applicable
*Primary Recipient of TA/Collaborator(Select one)
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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)
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
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*All Agencies Receiving TA/Collaborating on the Activity(Select all that apply; name of agency/ies may be supplied in space provided)
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) ______
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 ______
*Topic of Technical Assistance
*List A (select one)
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Clinical care related (including medical home)
Cultural Competence Related
Data, Research, Evaluation Methods (Knowledge Translation)
Family Involvement
Interdisciplinary Teaming
Healthcare Workforce Leadership
Policy
Prevention
Systems Development/ Improvement
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*List B (select all that apply)
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Women’s /Reproductive/ Perinatal Health
Early Childhood Health/ Development (birth to school age)
School Age Children
Adolescent
CSHCN/Developmental Disabilities
Autism
Emergency Preparedness
Health Information Technology
Mental Health
Nutrition
Oral Health
Patient Safety
Respiratory Disease
Vulnerable Populations
Racial and Ethnic Diversity or Disparities
Other, please specify: ______
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*Project Affiliation
Not Applicable/No Affiliated Project
Primary AffiliatedProject – List Title:______
Secondary Affiliated Project– List Title:______
*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 the date the activity began)
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