| Person with Dementia |
Age of Person with Dementia |
|
|
| Under 60 |
60+ |
Totals |
|
| Gender |
|
|
|
|
| Female |
|
|
0 |
|
| Male |
|
|
0 |
|
| Gender Missing |
|
|
0 |
|
| Geographic Location |
|
|
|
|
| Urban |
|
|
0 |
|
| Rural |
|
|
0 |
|
| Geographic Location Missing |
|
|
0 |
|
| Relationship to Caregiver |
|
|
|
|
| Spouse |
|
|
0 |
|
| Unmarried Partner |
|
|
0 |
|
| Parent |
|
|
0 |
|
| Child |
|
|
0 |
|
| Other relative |
|
|
0 |
|
| Non-relative |
|
|
0 |
|
| Relationship Missing |
|
|
0 |
|
| Person with Dementia by Ethnicity |
|
|
|
|
| Hispanic or Latino |
|
|
0 |
|
| Not Hispanic or Latino |
|
|
0 |
|
| Ethnicity Missing |
|
|
0 |
|
| Person with Dementia by Race |
|
|
|
|
| White - Non-Hispanic |
|
|
0 |
|
| White - Hispanic |
|
|
|
|
| American Indian or Alaska Native |
|
|
0 |
|
| Asian |
|
|
0 |
|
| Black or African-American |
|
|
0 |
|
| Native Hawaiian or Other Pacific Islander |
|
|
0 |
|
| Persons Reporting Some Other Race |
|
|
0 |
|
| Persons Reporting 2 or More Races |
|
|
0 |
|
| Race Missing |
|
|
0 |
|
| Veteran Status |
|
|
|
|
| Veteran Status |
|
|
0 |
|
| Non-Veteran |
|
|
0 |
|
| Veteran Status Missing |
|
|
0 |
|
| Gray boxes are not to be filled out. |
|
|
|
|
| Caregiver |
Age of Primary Caregiver |
|
|
| Under 60 |
60+ |
Totals |
|
| Gender |
|
|
| Female |
|
|
0 |
|
| Male |
|
|
0 |
|
| Gender Missing |
|
|
0 |
|
| Geographic Location |
|
|
| Urban |
|
|
0 |
|
| Rural |
|
|
0 |
|
| Geographic Location Missing |
|
|
0 |
|
| Relationship to Person with Dementia |
|
|
| Spouse |
|
|
0 |
|
| Unmarried Partner |
|
|
0 |
|
| Child |
|
|
0 |
|
| Parent |
|
|
0 |
|
| Other relative |
|
|
0 |
|
| Non-relative |
|
|
0 |
|
| Relationship Missing |
|
|
0 |
|
| Primary Caregiver by Ethnicity |
|
|
|
|
| Hispanic or Latino |
|
|
0 |
|
| Not Hispanic or Latino |
|
|
0 |
|
| Ethnicity Missing |
|
|
0 |
|
| Primary Caregiver by Race |
|
|
| White - Non-Hispanic |
|
|
0 |
|
| White - Hispanic |
|
|
0 |
|
| American Indian or Alaska Native |
|
|
0 |
|
| Asian |
|
|
0 |
|
| Black or African-American |
|
|
0 |
|
| Native Hawaiian or Other Pacific Islander |
|
|
0 |
|
| Persons Reporting Some Other Race |
|
|
0 |
|
| Persons Reporting 2 or More Races |
|
|
0 |
|
| Race Missing |
|
|
0 |
|
| Veteran Status |
|
|
|
|
| Veteran |
|
|
0 |
|
| Non-Veteran |
|
|
0 |
|
| Veteran Status Missing |
|
|
0 |
|
|
|
|
|
|
| Gray boxes are not to be filled out. |
|
|
|
|
| Services & Expenditures |
Total Units of Direct Service Delivered |
Total ADSSP Expenditures |
Total Federal Funds Spent on Direct Services |
Total Federal Funds Spent on Administrative Services |
Percentage of Federal Funds Spent on Direct Service Expenses |
Percentage of Federal Funds Spent on Administrative Expenses |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Narrative |
|
|
|
|
|
|
| It is a statutory requirement for the Alzheimer’s Disease Supportive Services Program that at least 50% of federal grant funds spent be spent on direct service costs and that no more than 10% of federal funds be spent on administrative costs. If your project has not met these requirements by the end of this reporting period (reflected in the numbers above), please describe -- in the box to the right -- why the project has not met these requirements and confirm that the project will meet these requirements by the end of the grant. |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Participation* |
Program Entrants |
Program Completers |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| *Only complete for Evidence-Based Projects |
|
|
|
|
|
|