Annual Progress Reporting Form

ANNUAL PERFORMANCE REPORTING FORM

WORD Version

For the American Indian Vocational Rehabilitation Services Program

OMB #: 1820-0655

Expiration Date: xx/xx/xxxx

The U.S. Department of Education

Rehabilitation Services Administration (RSA)

Annual Reporting Form

For

American Indian Vocational Rehabilitation Services Program

OMB Number: 1820-0655

Expiration Date: xx/xx/xxxx

PR/Federal Award Number:

(Type in your PR/Award number exactly as it appears on your Grant Award Notification.)

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. Public reporting burden for this collection of information is estimated to average 13 hours per response, including the time for reviewing instructions, searching existing data resources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is required to obtain or retain benefit (34 CFR 75.118). Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Education, 400 Maryland Avenue, SW, Washington, DC, 20210-4537 or email ICDocketMgr@ed.gov and reference the OMB Control Number 1820-0655. Note: Please do not return the completed Annual Reporting Form for American Indian Vocational Rehabilitation Services to this address.

Table of Contents

Section Page

General Information 3

1. Budget and Narrative 5

2. Project Goals and Objectives 7

3. Serving American Indians With Disabilities 8

4. VR Services 9

5. Educational Goals and Employment Outcomes 12

6. Job Training Common Measures 15

7. Interaction with State VR Agency 17

8. Evaluation 20

9. Consumer Satisfaction 21

General Information

* Required fields

*Grantee Name:

     

*Grantee Address:	     

*City:

     

*State:

     

*Zip:

     

*Grant Start Date:

     

*Grant End Date:

     

*Project Title:

     

*Project Director:

     

*Telephone:

     

*E-mail:

     

Grantee URL (if applicable):

     

Grantee/Project E-mail (if applicable):

     

Grantee 800 Number (if applicable):

     

Person responsible for completing this form (if other than the project director/principal investigator):

Name:

     

Title:

     

Telephone:

     

Fax:

     

*E-mail:

     

Authorized representative:

*Name:

     

*Title:

     

*Telephone:

     

*E-mail:

     

Note: The ED 524B form with an original signature from the Authorized Representative is required to be submitted.

1. Budget and Narrative

1a. Enter the grant amount awarded by RSA for the reporting period. Do not include carry-over funds. If a six-month report is being submitted, enter the grant amount awarded for the entire fiscal year in 1a, and enter 0 (zero) in 1b.	$     
1b. Enter the match contribution for the reporting period. Enter 0 (zero) for six-month reports.	$     
1c. Add Line 1a plus Line 1b, which equals the total cost of the project.	$     

2. Was an Order of Selection in effect and approved by RSA for any time during the reporting period? An Order of Selection consists of priority categories that determine the order in which eligible individuals are provided vocational rehabilitation (VR) services, in the event that sufficient fiscal or personnel resources are unavailable to provide VR services to all eligible individuals who apply. Eligible individuals are assigned to priority categories based on the significance of their disability and individuals with the most significant disabilities are placed in the highest priority category.

Yes

No

3a. Did the reporting period start with any carry-over funds? Enter N/A for six-month and first year reports.

Yes

No

NA

3b. If yes, enter the dollar amount.

$     

3c. Were there carry-over funds at the end of the reporting period? Enter N/A for six-month reports.

Yes

No

N/A

3d. If yes, enter the dollar amount of carry-over funds. If the amount of carry-over funds is not yet available, estimate the amount of carry-over funds.
	$     

3e. Use the box below to explain why there are carry-over funds and the reason for not expending funds at the rate expected. If there are no carry-over funds, enter “None” in the box.

     

4a. Enter any program income generated for the reporting period. Enter 0 (zero) if none.

4b. Enter the total amount of cash funding in support of the

grant received during the reporting period from sources other than program income (4a), grant award (1a), or match

$

$

contribution (1b). Enter 0 (zero) if no other funding was provided.

4

c. List the full name of the source(s) of any other cash funding identified in 4b. If there are no other sources, enter “None” in the box.

5a. During the reporting period, were changes made to the budget due to programmatic changes? Examples of programmatic changes under 34 CFR 80.30 (d)(1)-(4) include revision of the scope or objectives of the project and changes in key personnel. If no, skip to Section 2, Project Goals and Objectives.			Yes				No
5b. Was the modification(s) approved by RSA? If yes, skip to Section 2, Project Goals and Objectives.		Yes				No

5c. If the answer is no, use this space to describe the modification(s) and the resulting budget changes.

     

2. Project Goals and Objectives

			Goal Start Date (Month/Year)		Goal End Date (Month/Year)
Goal #1:		     	Expected Date of Completion		Status of Objective for Current Year
			Month (mm)	Year (yyyy)	Status Options: Not Started, Dropped, In Progress, Met, Not Met
Obj.1.	     		     	     
2.	     		     	     
3.	     		     	     
4.	     		     	     
5.	     		     	     
6.	     		     	     
7.	     		     	     
8.	     		     	     
9.	     		     	     
10.	     		     	     

3. Serving American Indians with Disabilities

Questions 1 – 4 ask for details on individuals who were served during the reporting period.

Enter the total number of individuals the project proposed to serve under an Individualized Plan for Employment (IPE) during the reporting period.
Enter the actual number of individuals who received VR services under an IPE during the reporting period. 2a. Enter the number of individuals who received VR services under an IPE developed during this reporting period. 2b. Enter the number of individuals who received VR services under an IPE developed in a prior reporting period. For six-month and first year projects enter zero (0). 2c. Enter the number of individuals served under an IPE developed under a previous grant cycle that have been carried forward into the current grant.
Of the total number of individuals the project proposed to serve under an IPE, what percent actually received VR services under an IPE?
Compare the number the project proposed to serve (Question 1) with the number actually served (Question 2) using 4a or 4b below. For six-month reports, compare the number in Question 2 with one half of the number in Question 1. In the box below, please explain if: 4a. The number actually served is substantially fewer than the number proposed for this reporting period; or 4b. The number actually served substantially exceeds the number proposed for this reporting period.
	     

4. VR Services

• Indicate the VR services provided during the reporting period.

• “VR Services provided” means VR services provided by project staff, purchased with any type of project funds, or procured from another source, such as comparable/similar services.

• Choose “Yes” in the first set of columns if, during the reporting period, the VR service was provided. If the VR service was not provided, choose “No.”

• If the VR service was provided, choose “Yes” or “No” in the second set of columns to indicate whether the VR service was paid for in part or in full with funds other than AIVRS funds.

VR Service	Services provided during the reporting period?		If Yes, was service paid for in part or full with funds other than AIVRS funds?
1. Assessment for determining eligibility and VR needs	Yes	No	Yes		No
2. Counseling and guidance	Yes	No	Yes		No
3. Referral and other services to secure needed services	Yes	No	Yes		No
4. Job-related services, including job search and placement services, job retention services, follow-up services, and follow-along services	Yes	No	Yes		No
5. Vocational and other training services, including personal and vocational adjustment training services	Yes	No	Yes		No
6. Book, tools, and other training materials	Yes	No	Yes		No
7. Diagnosis and treatment of physical and mental impairments as included in Section 103 (a)(6)(A-F) of the Rehabilitation Act	Yes	No	Yes		No
VR Service	Services provided during the reporting period?		If Yes, was service paid for in part or full with funds other than AIVRS funds?
8. Maintenance	Yes	No	Yes		No
9. Transportation	Yes	No	Yes		No
10. On-the-job or other related personal assistance services provided while an individual is receiving other services.	Yes	No	Yes		No
11. Interpreter and reader services	Yes	No		Yes	No
12. Rehabilitation teaching services and orientation and mobility services for individuals who are blind	Yes	No		Yes	No
13. Occupational licenses, tools, equipment, and initial stocks and supplies	Yes	No		Yes	No
14. Technical assistance and other services to conduct market analyses, develop business plans, and other services to eligible individuals who are pursuing self-employment or telecommuting or establishing a small business operation as an employment outcome	Yes	No		Yes	No
15. Rehabilitation technology, including telecommunications, sensory, and other technological aids and devices	Yes	No		Yes	No
16. Transition services for students with disabilities that facilitate the achievement of the employment outcome identified in the IPE	Yes	No		Yes	No
17. Supported employment services	Yes	No		Yes	No
VR Service	Services provided during the reporting period?			If Yes, was service paid for in part or full with funds other than AIVRS funds?
18. Services to the family of an individual with a disability necessary to assist the individual to achieve an employment outcome	Yes	No		Yes	No
19. Specific post-employment services necessary to assist an individual with a disability to retain, regain, or advance in employment	Yes	No		Yes	No
20. Services traditionally used by Indian tribes, including native healing	Yes	No		Yes	No
21a. Other service(s) determined necessary for achievement of an employment outcome	Yes	No		Yes		No
21b.If yes, list other service(s).

5. Educational Goals and Employment Outcomes

Part A. Educational Goals

Report the number of persons who were enrolled in an educational program for the purpose of increasing the skills needed for employment.

1. T

   
   

   otal number of individuals enrolled in a two-year

post-secondary education program during the reporting period.

2. T

   
   

   otal number of individuals enrolled in a four-year

post-secondary education program during the reporting period.

3. T

   
   

   otal number of individuals enrolled in one or more training

programs during the reporting period.

Report the number of persons who achieved an intermediate educational goal for the purpose of increasing the skills needed for employment. Include all persons who achieved each of the following educational goals during the reporting period, regardless of whether or not they ended their participation in the program.

4. Total achieving an intermediate educational goal

Of the total number reported in Question 4, how many:

4a. obtained a GED

4b. obtained a post-secondary degree

4c. obtained a post-secondary certificate

4d. completed on-the-job-training/apprenticeship

4e. completed any other job-related training.

Describe:

     

Part B. Employment Outcomes

Definition:

• Employment Outcome: The term "employment outcome" means, with respect to an individual‑‑ entering or retaining full‑time or, if appropriate, part-time competitive employment in the integrated labor market; satisfying the vocational outcome of supported employment; or satisfying any other vocational outcome the Secretary may determine to be appropriate (including satisfying the vocational outcome of self-employment, telecommuting, or business ownership), in a manner consistent with the Rehabilitation Act of 1973, as amended. An individual is considered to have achieved an employment outcome after the individual has ended participation in the program by maintaining the employment for 90 days and no longer needing vocational rehabilitation services. Post-employment services are provided subsequent to achievement of an employment outcome and are not considered an additional outcome.

1

. Enter the number of individuals the project proposed to achieve an

employment outcome during the reporting period.

2

. Enter the actual number of individuals who achieved an employment

outcome. If the answer is none, enter a zero (0) in the box.

The number:

2a. Employed full-time in the integrated labor market at or above the applicable minimum wage for 32 or more hours per week.

2b. Employed part-time in the integrated labor market at or above the applicable minimum wage for 31 or fewer hours per week.

2c. Achieved an employment outcome of self-employment

2

d. Achieved an employment outcome of extended employment in

a community rehabilitation program (extended employment defined in Section 7(13) of the Rehabilitation Act of 1973).

2

e. Achieved an employment outcome in supported

employment (supported employment defined in Section 7(35) of the Rehabilitation Act of 1973).

2

f. Achieved any other type of employment outcome e.g., homemaking, subsistence activities, unpaid work on a family farm or business.

3. O

   
   

   f the total number of individuals proposed to achieve an employment

outcome, what percent actually achieved an employment outcome?

3. N

   
   

   umber of individuals who received VR services under an IPE but ended

participation in the program during the reporting period without achieving an employment outcome (formerly Status 28).

3. Compare the number of employment outcomes the project proposed (Question 1)

with the number actually achieved (Question 2) using 5a or 5b. For six-month reports, compare the number in Question 2 with one half of the number in Question 1.

In the box below, please explain if:

5a. The number of employment outcomes achieved is substantially fewer than proposed for this reporting period; or

5b. The number of employment outcomes achieved substantially exceeds the number proposed for this reporting period.

     

6. Job Training Common Measures

Data entered in this section is used to provide supplemental information for reporting on the Job Training Common Measures.

Goal: To improve employment outcomes of American Indians with disabilities who live on or near reservations by providing effective VR services.

Objective: To ensure that eligible American Indians with disabilities receive VR services and achieve employment outcomes consistent with their individual strengths, resources, abilities, capabilities, priorities, concerns, and informed choice.

Definition:

• Earnings: The amount of money earned in a typical week, including cash earnings and profits derived by self-employed individuals. In certain cases, earnings may be based on payment of commissions and reimbursement of business expenses that may or may not occur on a regular or weekly basis. In these cases, calculate the weekly average income over a representative time period, such as one month.

Please enter the appropriate number for each question. For questions that ask for a dollar amount, enter whole dollars only (i.e., round the amount to the nearest dollar and do not enter cents).

1. Enter the number of individuals whose employment outcomes resulted in

earnings.

2

$

. Enter the average weekly earnings of those individuals whose

employment outcome resulted in earnings.

3. Enter the number of individuals who had earnings at the time of

eligibility determination.

3

$

a. Enter the average weekly earnings at the time of eligibility

determination.

3

$

b. Enter the average weekly earnings at the time of achieving an

employment outcome.

4

. Enter the number of individuals who did not receive any VR services for 90 consecutive calendar days, but whose case record was still open during the reporting period (exclude individuals whose VR services were temporarily interrupted due to reasons such as the receipt of medical treatment or institutionalization).

5

. Enter the number of individuals who during this reporting period, were still employed three months after achieving an employment outcome (formerly ‘Status 26’).

6

. Enter the number of individuals who during this reporting period, were still employed six months after achieving an employment outcome (formerly ‘Status 26’).

7

. Enter the number of individuals who achieved an employment outcome

during the current or prior reporting period and who have received post-

employment services in the current reporting period.

8

. Enter the number of individuals who achieved an employment outcome

during the current or prior reporting period (excludes prior grant cycles), but have reapplied, were determined eligible, and received VR services in the current reporting period.

7 Interaction with State VR Agency or Agencies

1. During the reporting period, was a collaborative agreement entered into or participated in with the State VR Agency or Agencies?

Yes

No

2

. Of the number of individuals served under an IPE during this reporting

period, how many were jointly served with the State VR Agency or

Agencies?

List the interactions with the State VR Agency or Agencies during the reporting period in boxes Agency 1 through Agency 4 below, as appropriate. List the state name and agency (Combined/General/Blind; e.g, Utah Combined). Space is provided for interactions with up to four Agencies. If additional space is needed, please feel free to utilize space in the Executive Summary of the 524B form.

For each agency listed:

1. Describe or give examples of interactions including, but not limited to, training/cross training; serving on the State Rehabilitation Council; working jointly with the same individual; referrals; or having a VR representative on the project Advisory Board.

2. Describe or give examples of concerns or issues such as a lack of a cooperative agreement or non-representation on the State Council. If no concerns exist, enter “None”.

3. Rate the overall satisfaction of interactions with the agency.

This information is for use by RSA and is held confidential.

Agency Name	Discussion
Agency 1:      
A. Types of Interactions:	     
B. Concerns/Issues with Collaboration or Service Provision:	     
C. Rate the level of satisfaction of interactions with this agency using the following scale: 1 Very Dissatisfied 2 Somewhat Dissatisfied 3 Neutral 4 Somewhat Satisfied 5 Very Satisfied	     

Agency Name	Discussion
Agency 2:      
A. Types of Interactions:	     
B. Concerns/Issues with Collaboration or Service Provision:	     
C. Rate the level of satisfaction of interactions with this agency using the following scale: 1 Very Dissatisfied 2 Somewhat Dissatisfied 3 Neutral 4 Somewhat Satisfied 5 Very Satisfied	     

Agency Name	Discussion
Agency 3:      
A. Types of Interactions:	     
B. Concerns/Issues with Collaboration or Service Provision:	     
C. Rate the level of satisfaction of interactions with this agency using the following scale: 1 Very Dissatisfied 2 Somewhat Dissatisfied 3 Neutral 4 Somewhat Satisfied 5 Very Satisfied	     

Agency Name	Discussion
Agency 4:      
A. Types of Interactions:	     
B. Concerns/Issues with Collaboration or Service Provision:	     
C. Rate the level of satisfaction of interactions with this agency using the following scale: 1 Very Dissatisfied 2 Somewhat Dissatisfied 3 Neutral 4 Somewhat Satisfied 5 Very Satisfied	     

8. Evaluation

A. Briefly describe self-evaluation efforts and the results of those efforts for the reporting period. Include, at a minimum, the specific evaluations described in the approved Grant Application.

     

B. Briefly describe any other independent evaluation effort and results for the reporting period. If none were conducted, enter “none.”

     

C. Please list any future evaluation plans. If none were planned, enter “none.”

     

D. Please describe the most effective activities and services provided in meeting project goals and tell why they were effective. Examples might include developing new approaches for service provision, native healing, advisory board activities, outreach, collaboration with a particular state rehabilitation counselor or administrator, or being involved with the one-stop program.

     

9. Consumer Satisfaction

This section refers to activities conducted for the purpose of determining consumer satisfaction with project services.

1. Did the grant application say that consumer satisfaction activities would be conducted during the reporting period?

Yes

No

2. Were any consumer satisfaction activities conducted during the reporting period? (The information provided in this section is for use by RSA and is held confidential.) If yes, describe in the box below the types of consumer satisfaction activities conducted during the reporting period.		Yes		No
     

If no, but the application stated that consumer satisfaction activities would be conducted in the reporting period, explain in the box why activities were not conducted.

     

A-1