Independent Living Organizational Survey for COMPENDIUM

CIL Information
Does your center receive Title VII funds from the federal government?
     YES           NO     
     Part B      YES           NO     
     Part C      YES           NO     
Chapter 2 Elder Blind      YES           NO     
Name of Executive Director      First      Last     
CIL Name    
Street     
City         State       Zip
Phone ie: (XXX)XXX-XXXX     
TTY / TDD     
Fax     
E-Mail     
Website     
Are you a satellite or branch of a Main CIL?      YES         NO   
  If Yes, what is the name of the larger CIL?
    
Year your Center was established   
Number of consumers served by your center annually   
Organizational Structure of CIL
Please enter the number of each of the following you have at your CIL:
Management / Supervisors   
Support Staff (administrative / office staff)   
Direct Services Staff (totals)   
Number of Full Time Staff   
Number of Part Time Staff   
Number of Volunteer Staff   
Other Organization Information
Do you offer any of the following employee benefits?
         Health Care   Yes    No
         If Yes, please name your plan provider  
Dental Care    Yes    No
Life Insurance    Yes    No
Retirement Plan    Yes    No
Other   
Training / Staff Development
Please check the in-service training programs your center offers to staff.
(We mean structured training with handouts and learning objectives offered in-house.)
      Staff Orientation
      ADA and Related Regulations
      Computer Skills
      Systems Change Advocacy
      Self-Advocacy
      Cultural Diversity
      IL Philosophy / History
      Peer Counseling Skills
      Communication Skills
      Benefits Consultation
      Time Management Skills
   Other  
Program Information
Indicate those services offered by your CIL within the past year.
We know you are already providing the core services (peer counseling,
advocacy, IL skills and information and referral).
      Assistive Technology Training
      Audio Recording
      Brailing
      Case Management
      Community Education (disability awareness)
      Consumer Directed Personal Assistance Services
      Elderly Disabled Programs
      Literacy Programs
      Employment Assistance
      Family Support Services
      In Home Health Care
Mental Health Services
          Peer Run Support
          Out Patient Treatment
          Club House or Social Club
      Mobility Training (Blind / Low Vision)
      Rehabilitation Counseling
      Rehabilitation Teaching (Blind)
      Respite Care
      Sign Language Interpreting
      Transportation Service
      Youth Transition Service
      Youth Transition Services Ages (Leave blank for no services offered)
   Other   
Policies and Procedures
Please indicate the policies / procedures in use at your center:
      Board By-Laws
      Employee Orientation Manual
      Job Descriptions
      Office Protocols / Procedures
      Organizational Procedures
      Organizational Structure or Organizational Chart
      Personnel Policy Manual
      Program Descriptions
      Service Delivery Procedures / Standards
      Strategic Plan
      Vision / Mission Statements
Other   
Staffing and Salaries
In the space to the right of each position listed below,
please provide the following information:
Bullet Point The total number of staff in that position
Bullet Point The total number of Full Time Equivalent staff (4 full time and 1 half time = 4.5 FTE)
Bullet Point The starting salary paid to a full time staff person in that position

Example: Peer Counselor 6 total 5 FTE $ 19,500
Positions Number
of Staff		 #FTE Starting Salary
Executive Director or CEO
Department Heads
Supervisors / Managers
Peer Counselors
Advocates
Independent Living Specialists
Information Referral Specialists
Architectural Consultants
Case Managers
Assistive Technology Instructors
Teachers of the Blind
Employment Specialists
Benefits Consultants
Community Education Instructors
Peer/Support Group Coordinators
Deaf Services Coordinators
Intake Managers
Secretaries
Administrative Assistants
Sign Language Interpreters
Foreign Language Interpreters
Drivers
Personal Care Aides (to assist staff)
Personal Care Attendants (CD-PAS program)
Sanitation/Janitorial (only those on staff)
Readers
Accountants / Bookkeepers
Computer Systems Technicians
Fundraisers / Grant Writers
Public Relations
Community Outreach Coordinators
Revenue and Funding Sources
Total Annual Budget $
(Auto Calculated by amounts input below)
Please identify the amounts and sources of your total annual funding and place the amount of funding next to the appropriate source.
Skip sources that provide no funding.
Use the "Other" boxes to write in sources that we have not listed. For each "Other" that you check, please specify the source of funds. Example: Federal Sources, Other Federal - $2000 HUD Funds
Federal Sources
$   Dept. of Education
$   Dept. of Health
$   Dept. of Labor
$   Human Services
$   Social Security
$   Other
     Explain Other
State Sources
$   State Dept. of Education
$   State Dept. Mental Health
$   State MR / DD
$   State Blind Voc. Rehab
$   State Other Voc. Rehab
$   State Social Services
$   State Other
      Explain State Other
Local Sources
$   County
$   City/Local
$   United Way
$   Foundations
$   Fund Raising Events
$   Memberships
$   Local Other
      Explain Local Other  
$   Fee for Service Revenue
$   State VR Programs
$   CD-PAS Programs
$   Transportation
$   Medicaid Service Coordination
$   Sign Language
$   Private VR
$   Endowments
$   For-Profit Business Revenues
       What kind of for-profit business do you run?
      
$   Other
   Explain Other