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* 1. Date Entered

Date

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* 2. Contact/Phone

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* 3. What CIL do you represent?

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* 4. How many active support groups do you have as of the end of the previous federal fiscal year? Please do not include youth focused groups.

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* 5. How many consumers do you have participating with these groups at the end of the fiscal year?

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* 6. How do these groups meet?

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* 7. How many active support groups (not included in number 1) are youth focused as of the end of the fiscal year?

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* 8. How many consumers do you have participating with these groups?

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* 9. How do these groups meet?

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* 10. Do you have any staff members participating with any MO SILC committee?

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* 11. If yes to the previous question, which committee?

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* 12. How many transportation resources were handed out to consumers in this fiscal year?

T