Sheet 1: Instructions

	
	

		
Social Service Report for Registered Services
	
	

		
Completion Instructions
	
	

		


	
	

		
The purpose of the Social Service Report for Registered Services is to record the number of individuals receiving registered services such as personal care, homemaker, and case management and demographic information that pertains to them.  The information is reported in the National Aging Program Information System - State Program Report which is submitted annually to the Administration on Aging and the state Social Services Block Grant Report. Social services reported on this form must correspond to services provided by the Area Agency on Aging or Tribe under the current contract with the Division of Aging and Adult Services.  Family Caregiver Support Program (Title III-E) results are reported on separate forms.  Non-registered services are reported on form AG-031-N.
	
	

		


	
	

		
1. Enter the name of the Area Agency on Aging or Tribe reporting the information.
	
	

		
2. Enter the month and year services were provided.
	
	

		


	
	

		
Part I – Service Data
	
	

		
The numbers entered in this section pertain to new individuals who have received services within the current state fiscal year. The state fiscal year begins July 1st and goes through June 30th.  An unduplicated count of individuals receiving the service is required.  An unduplicated count means that if an individual received a service during the fiscal year, then discontinued the service, and then received the service again in the same fiscal year, that individual should only be counted once for the entire year. 
	
	

		


	
	

		
3. Enter the name of the service being reported (only one service may be listed per page). Enter the total number of NEW individuals who have received services for the first time during the fiscal year. Enter the total number of individuals who have received the services year-to-date for the fiscal year. 
	
	

		


	
	

		
Part II - Demographic Data
	
	

		


	
	

		


	
	

		
Columns A and B:  The numbers entered in this section pertain to NEW individuals, under 60 or 60 years of age and older, who have received services for the first time during the fiscal year.
	
	

		


	
	

		
4 through 10 – Ethnicity: For each category, enter the number of new individuals served during the month in the appropriate column.  
	
	

		
11 - Total: The sum of lines 4 through 10 will calculate automatically.
	
	

		
12 through 14 - Age: Enter the number of new individuals served during the month by age category for Column B only.
	
	

		
15 and 16 – Gender: Enter the number of new individuals served during the month by gender.
	
	

		
17 - Frail/Disabled:  Enter the number of new individuals who are unable to perform at least two activities of daily living without maximum assistance.  
	
	

		
18 - Residents of Rural Areas: Enter the number of new individuals served during the month who reside in rural areas as defined by the U.S. Census Bureau.  Reservations are considered rural.
	
	

		
19 - Low-Income Non-Minority: Enter the number of new individuals served during the month who are white with an annual income at or below the Federally established poverty level. Current poverty guidelines are found on the DHHS website - http://aspe.hhs.gov/poverty/
	
	

		
20 - Low-Income Minority: Enter the number of new individuals served during the month who are American Indian/Alaska Native, Asian/Pacific Islander, Black, or Hispanic with an annual income at or below the Federally established poverty level. Current poverty guidelines are found on the DHHS website -http://aspe.hhs.gov/poverty/
	
	

		


	
	

		
Columns C and D:  The numbers entered in this section pertain to individuals who have received services in prior months and the current month during the fiscal year.
	
	

		


	
	

		
4 through 20: All entries made in this section should be the total number of individuals served, year-to-date during the fiscal year.
	
	

		


	
	

		
Ethnicity total (<60) = Gender total (<60)
	
	

		
Ethnicity total (60+) = Age total (60+) = Gender total (60+)
	
	

		


	
	

		
21. Enter the name of the individual who prepared the report.
	
	

		
22. Enter the date the report is submitted.
	
	

		
23. Enter the phone number of the person who prepared the report.
	
	

		
24. Enter the e-mail address of the person who prepared the report.
	
	

		


	
	

		
E-mail the report to your respective DAAS Contract Management Specialist.