Disabilities Initiative Report

PDF Version - Fill & Print (97 Kb, 2 Pages)

Form Instructions

DCI# 471949 (2014-2015)

Privacy Act Statement

The information you provide in this document is collected under the authority of the Department of Indian Affairs and Northern Development Act for the purpose of assessing performance, allocating funds, and in determining, if applicable, eligibility for reimbursement. Information on individuals is used by Aboriginal Affairs and Northern Development Canada's Assisted Living Program employees who need to know the information in order to respond to your request and/or the program requirements. As a general rule, we do not share personal information with other federal government departments. However, in exceptional circumstances, case specific information may be discussed with Health Canada and/or the province/territory under whose jurisdiction the recipient may fall. The personal information will be kept for a period of five years after which it will be sent to archives. Individuals have the right to the protection of and access to their personal information under the Privacy Act. The information collected is described under the Treasury Board Personal Information Bank INA SEP 502 which is detailed at InfoSource.

Section A: Contact Information

Recipient Name

Recipient Number

Region

Reporting Period (YYYYMMDD)

From

To

Section B: Financial Summary

Total funding from AANDC's Disabilities Initiative

Have other sources contributed to funding?

  • Yes
  • No

If Yes, list other contributions sources and amounts received.

Source

Amount ($)

Total Funding From Other Sources

Section C: Project Context

Project Summary (no more than 200 words)

Project Results and Outcomes (no more than 200 words)

Objective(s) of the project:

Select the activity area(s) reached and indicate the actual amount of AANDC Disability Initiative funds spent for each.

Information Services
Public Education and Awareness
Information Sharing Events
Other (Specify)

Total AANDC Funds Spent

How many individuals were actually reached?

Population Group(s):

Select the group(s) reached and indicate the total (estimated) percentage of individuals who participated in the project by population group.

Women
Men
Children
Youth
Elders
Caregivers
Professionals (e.g. Counselors, Doctors, Academics, etc.)
Persons With Disabilities
Other (Specify)

The information provided is accurate to the best of my knowledge.

Given Name

Family Name

Title

Date (YYYYMMDD)