NIRS Activity Form – FY 2015
*Response Required
*Program Type:UCEDD
*Fiscal Year:2015
*Core Function:Information Dissemination
*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.)
Product Dissemination (Must select “Add Product” or “Link an Existing Product” and complete the appropriate Product Form)
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Add a New Product
Link an Existing Product
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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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*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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*All Agencies Collaborating on the Work of the Activity (Select all that apply; name of agency/ies may be supplied in space provided)
Not Applicable/No Collaborating Agency State Title V 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) ______
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:______
*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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