Annual Vocational Rehabilitation Program/Cost Report

Form RSA‑2 OMB Num­ber: 1820-0017

Expires:

DEPARTMENT OF EDUCATION

OFFICE OF SPECIAL EDUCATION AND REHA­BILITATIVE SERVIC­ES

REHABILITATION SERVICES ADMINISTRATION

WASHINGTON, D.C. 20202

ANNUAL VOCATIONAL REHABILITATION PROGRAM/COST REPORT

State &

Agency:____________________________ ( ) General/Combined Fiscal Year____________

( ) Blind

SCHEDULE I. TOTAL EXPENDITURES AMOUNT

1. Administration $_____________

a. Admin. Costs Paid with Title VI B funds $____________

b. Indirect Costs ____________

2. Services to Individuals with Disabilities

A. Services Provided by State VR Agency Personnel

1. Employed at Agency Operated Community Rehabilitation Programs

a) Assessment, Counseling, Guidance, and Placement _____________

b) Other Services _____________

­ 2. Employed Elsewhere

a) Assessment, Counseling, Guidance, and Placement _____________

b) Other Services _____________

B. Services Purchased by State VR Agency From:

1. Public Community Rehabilitation Programs _____________

2. Private Community Rehabilitation Programs _____________

3. 3. Other Public Vendors _____________

4. 4 Other Private Vendors _____________

3. Services for Groups of Individuals with Disabilities

a) Establishment, Development or Improvement of

Community Rehabilitation Programs _____________

b) Construction of Facilities for Community Rehabilitation Programs _____________

c) Business Enterprise Program _____________

d) Other _____________

4. Total Expenditures ___

5. Innovation & Expansion Activities $____________

SCHEDULE II. Number of Individuals Served and Expenditures by Service Category

TYPE OF SERVICE NO. OF INDIVIDUALS - A M O U N T -

1. Assessment, Counseling, Guidance and Placement __

(Provided by State VR Agency Personnel)

2. Assessment (Purchased only) ____________ $____________

3. Diagnosis & Treatment of Physical and

Mental Impairments ____________ ____________

4. Training:

a. Postsecondary Institution of

Higher Education ____________ $____________

b. Job Readiness and Augmentative

Skills Training ____________ ____________

c. Vocational and Occupational

Skills Training ____________ ____________

d. All Other ____________ ____________

e. Total ____________ ____________

5. Maintenance ____________ ____________

6. Transportation ____________ ____________

7. Personal Assistance Services ____________ ____________

8. Placement (Purchased only) ____________ ____________

9. All Other ____________ ____________

10. Total No. of Individuals and Expenditures ____________ ____________

11. Post-Employment Services ____________ ____________

12. Rehabilitation Technology Services ____________ ____________

13. Small Business Enterprises ____________ ____________

14. Total Section 110 Funds Expended on Services ____________

15. Total Title VI-B Funds Expended on Services ____________

SCHEDULE III. PERSON YEARS -- Report Whole Years Only

(1) (2) (3)

110 TITLE

NO. OF YEARS ONLY VI B

1. Administrative Staff XXXXX XXXXX

2. Counselor Staff XXXXX XXXXX

3. Staff Supporting Counselor

Activities XXXXX XXXXX

4. Other Staff XXXXX XXXXX

5. Total _______ _______

SCHEDULE IV. Expenditures From Title VI B Funds and Other Rehabilitation Funds

1. Expenditures From Title VI B Funds $____________

2. Expenditures From Other Rehabilitation Funds ____________

SCHEDULE V. Carryover Funds

1. Amount of current Fiscal Year Section 110 Allotment carried over to next FY $____________

2. Amount of previous Fiscal Year Section 110 Allotment carried over and expended this FY ____________

3. Amount of current Fiscal Year Title VI B Allotment carried over to next FY ____________

4. Amount of previous Fiscal Year Title VI B Allotment carried over and expended this FY ____________

5. Amount of current Fiscal Year Program Income carried over to the next FY ____________

6. Amount of previous Fiscal Year Program Income carried over and expended this FY ____________

CERTIFICATION

This Report is Complete and Correct: Signed: ______________________________________

Date: ________________________________________

E-Mail Address: _______________________________

Agency Point of Contact for this Report: Name: _______________________________________

Phone: _______________________________________

E-Mail Address: _______________________________

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