RSA Payback Form

Grantee Reporting Form -- RSA Scholars CURRENTLY Participating in Training Program								Page 1
Grantees are required to submit this form to RSA annually until all scholars have completed their work obligations. Report each year on each scholar supported under this grant. Do not use this form for more than one grant. Current Scholars are reported on page 1 while participating in your program. Scholars Who Have Exited your program are reported on page 3. Note: Column titles are defined in the “Instructions” on page 2. Failure to report scholars may result in a cost disallowance found through an audit and may affect your ability to receive future grants.
G rantee:			Project Director: Grant Number:
Address:			Phone: FY Grant Amount: $
			E-mail Address: Reporting Period (FY last completed)
Report on each scholar with whom you have entered into an agreement under this grant.
Name of RSA Scholar	1.Rehab. Field of Training	2.Academic Degree Sought	3.Scholarship Amount CURRENT Year	4. Total Support ALL Years to Date	5.Expected Date of Graduation	6. # Work Years Owed to Date	7. Date Work Must Be Completed (Include 2 years grace)
1.			$	$	$
2.			$	$	$
3.			$	$	$
4.			$	$	$
5.			$	$	$
6.			$	$	$
TOTAL NUMBER			$	$	$	#
COMMENTS:
Signature of Individual Submitting This Form:							Send Form To RSA
Title of Individual Submitting This Form: Date:

Grantee Reporting Form -- RSA Scholars CURRENTLY Participating in Training Program								Page 2
Below is an example of one Current Scholar’s date, followed by instructions for completing page 1.
Name of RSA Scholar	1.Rehab. Field of Training	2.Academic Degree Sought	3.Scholarship Amount CURRENT Year	4.Total Support ALL Years to Date	5.Expected Date of Graduation	6.# Work Years Owed to Date	7.Date Work Must Be Completed (Incl.2 years grace)
Scholar X	Rehab. Counselor	M.A.	$1,500	$4,800	5/00	4	6/06

Grantee, Address, Project Director, Phone, E-mail Address, Grant Number, Grant Amount, Reporting Period: Supply information for every line.

1. Rehabilitation Field of Training: Report training program in which the scholar is participating (e.g., Rehabilitation Counselor).

2. Academic Degree Sought: Report program’s academic degree level of study (e.g., M.A.).

3. Scholarship Amount CURRENT Year: Report the total actual $ amount of support/assistance each scholar received during this academic year, from this grant .

4. Total Support ALL Years to Date: Report the cumulative $ amount of support scholar has received to date under this grant. This must include all support from prior academic year(s). If no prior year support, the cumulative support equals the total of tuition, stipends, and other amounts for this academic year.

5. Expected Date of Graduation: Report the date the scholar is expected to exit your program. For example, if the scholar is in his/her first year of study and is expected to complete his/her training program after one more academic year, the exit date will be one year away.

6. # Work Years Owed to Date: Report the cumulative number of work years owed to date by scholar currently in training to fulfill his/her payback obligation. (Two years of work are required for every year of support. A year of support is defined as one academic year, as defined by the training institution.)

7. Date Work Must Be Completed: Report the date the scholar’s work must be completed in order for the scholar to fulfill his/her obligation under this grant within the statutorily required time frame: two years of work are required for every year of support, plus a grace period of two years.

(NOTE: If the scholar has been granted an academic “deferral” or “exception,” please note this in the COMMENTS section.)

TOTAL NUMBER: Report the total number of scholars, the aggregate $ amounts, and the aggregate number of work years owed.

NOTE: The total dollars ($) expended each year by the training institution to pay for student scholarships (tuition, stipends and other support) should equal 75% of the total federal training grant awarded to the training institution each year.

OMB Control #: 1820-0617 Expiration Date: 07/31/2010 RSA Web Site: http://rsadev.net/payback

Paperwork Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is 1820-0617. The time required to complete this information collection is estimated to average one hour per response, including the time to review instructions, search existing data resources gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Education, Washington, D.C. 20202-4651. If you have comments or concerns regarding the status of your individual submission of this form, write directly to: U.S. Department of Education, RSA, 550 12th Street, S.W., Washington, D.C. 20024.

Grantee Reporting Form -- RSA Scholars Who Have Exited (Graduated or Withdrawn) from Training Program										Page 3
Grantees are required to submit this form to their RSA annually until all scholars have completed their work obligations. Report each year on each scholar supported under this grant. Do not use this form for more than one grant. Current Scholars are reported on page 1 while participating in your program. Scholars Who Have Exited your program are reported on page 3. Note: column titles are defined in the “Instructions” on page 4. Failure to report scholars may result in a cost disallowance found through an audit and may affect your ability to receive future grants.
Grantee:			Project Director:			Grant Number:
A ddress:			Phone: E-mail Address:			FY Grant Amount: $ Reporting Period (FY last completed)
Report on each scholar with whom you have entered into an agreement under this grant.
Name of RSA Scholar	1.Rehab. Field of Training	2.Graduation or Program Termination Date	3.Total Support ALL years	4.# Work Years Owed (total)	5.Date Work Must Begin (Including 2 years grace)		6.Date Work Must Be Completed (Including 2 years grace)	7. Is Current Address On File?	8.Type of Qualifying EmploymentFac./Agency	9. Work Years Completed To Date
1.			$
2.			$
3.			$
4.			$
5.			$
6.			$
TOTAL NUMBER			$	#
COMMENTS:
Signature of Individual Submitting This Form:									Send Form To RSA
Title of Individual Submitting This Form: Date:

Grantee Reporting Form -- RSA Scholars Who Have Exited (Graduated or Withdrawn) from Training Program									Page 4
Below is an example of one Exited Scholar’s data, followed by instructions for completing page 3.
Name of RSA Scholar	1. Rehab. Field of Training	2. Graduation or Program Termination Date	3. Total Support All Years	4. # Work Years Owed (Total)	5. Date Work Must Begin (Including 2 years grace)	6. Date Work Must Be Completed (Including 2 years grace)	7. Is Current Address On File?	8. Type of Qualifying Employment Fac./Agency		9. Work Years Completed To Date
Scholar Y	Rehab Med	6/99	$45,000	4	6/01	6/05	Y	State Agency		3 mos.

Grantee, Address, Project Director, Phone, E-mail Address, Grant Number, Grant Amount, Reporting Period: Supply information for every line.

1. Rehabilitation Field of Training: Report training program in which the scholar participated (e.g., PT/OT).

2. Graduation or Program Termination Date: Report the date the scholar exited his/her training (through graduation or withdrawal).

3. Total Support All Years: Report the cumulative $ support the scholar received under this grant. This must include all support from prior academic year(s). (Cumulative Support amount equals the total of tuition, stipends, and other amounts received under this grant during all academic years.)

4. # Work Years Owed: Report the cumulative amount of time in years the scholar is responsible for working to meet his/her payback obligation. (Two years of work are required for every year of support. A year of support is defined as one academic year, as defined by the training institution.

5. Date Work Must Begin: Report the date by which the scholar must begin work in order to fulfill his/her payback obligation within the statutorily required time frame. (Two years of work are required for every year of support, with a grace period of two years to begin work.)

6. Date Work Must Be Completed: Report the date by which the scholar’s work must be completed in order for the scholar to fulfill his/her obligation under this grant within the statutorily required time frame. Two years of work are required for every year of support, with a grace period of two years. (NOTE: If scholar has been granted an academic “deferral” or “exception,” please note this in the COMMENTS section.)

7. Current Address On File: Report whether (YES or NO) you have the current address for each scholar. (You may be asked to provide the address.) If NO, you are required to report your actions to gain such information.

8. Type of Qualifying Employment: Report the acceptable place of employment as a State agency, non-profit service provider, practice group, etc. If place of employment is not acceptable

( e.g. the place of employment does not meet payback requirements) then enter N/A.

9. Work Years Completed To Date: Report the cumulative time (in years and months) of acceptable work to date for each scholar funded under this grant.

TOTAL NUMBER: Report the total number of scholars, the aggregate $ amounts, and the aggregate # work years owed.

OMB Control #: 1820-0617 Expiration Date: 07/31/2010 RSA Web Site: http://rsadev.net/payback

Paperwork Burden Statement

A ccording to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is 1820-0617. The time required to complete this information collection is estimated to average one hour per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Education, Washington, D.C. 20202-4651. If you have comments or concerns regarding the status of your individual submission of this form, write directly to: U.S. Department of Education, RSA, 550 12th Street, S.W., Washington, D.C. 20024.