Form 7-OB

ED(RSA)-7-OB Form

OMB No. 1820-0608

Expiration Date: May 31, 2011

UNITED STATES DEPARTMENT OF EDUCATION

OFFICE OF SPECIAL EDUCATION AND REHABILITATIVE SERVICES

REHABILITATION SERVICES ADMINISTRATION

Washington D.C. 20202

FISCAL YEAR

ANNUAL REPORT

INDEPENDENT LIVING SERVICES FOR

OLDER INDIVIDUALS WHO ARE BLIND

Grantee
Grant No.

Title VII Chapter 2, of the Rehabilitation Act, as amended

Section 752(I)(2)(A) of the Rehabilitation Act, as amended

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 1820-0608. The time required to complete this information collection is estimated to average 8 hours (or minutes) 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: Elizabeth Akinola, U.S. Department of Education, 400 Maryland Ave, S.W., PCP Room 5031, Washington, D.C. 20202-2800.

TABLE OF CONTENTS

PART I: FUNDING SOURCES AND EXPENDITURES 1

PART II: STAFFING 1

PART III: DATA ON INDIVIDUALS SERVED 2

PART IV: TYPES OF SERVICES PROVIDED AND RESOURCES ALLOCATED 4

PART V: COMPARISON OF PRIOR YEAR ACTIVITIES TO CURRENT REPORTED YEAR 5

PART VI: PROGRAM OUTCOMES/PERFORMANCE MEASURES 5

PART VII: NARRATIVE 6

PART VIII: SIGNATURE 9

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222µ222222222222222PART I: FUNDING SOURCES AND EXPENDITURES

Title VII-Chapter 2 federal grant award for reported fiscal year		$
Title VII-Chapter 2 carryover from previous year		$
A. Funding Sources for Expenditures in Reported FY		Expended or encumbered
A1. Title VII-Chapter 2		$
A2. Total other federal (a)+(b)+(c)+(d)+(e)		$
(a) Title VII-Chapter 1-Part B	$
(b) SSA reimbursement	$
(c) Title XX - Social Security Act	$
(d) Older Americans Act	$
(e) Other	$
A3. State (excluding in-kind)		$
A4. Third party		$
A5. In-kind		$
A6. TOTAL MATCHING FUNDS (A3+A4+A5)		$
A7. TOTAL ALL FUNDS EXPENDED (A1+A2+A6)		$
B. Total expenditures and encumbrances allocated to administrative, support staff, and general overhead costs
		$
C. Total expenditures and encumbrances for direct program services (Line A7 minus Line B)
		$

PART II: STAFFING

FTE (full time equivalent) is based upon a 40-hour workweek or 2080 hours per year.

A. Full-time Equivalent (FTE) Program Staff	Administrative & Support	Direct Service	TOTAL
A1. FTE State Agency	a.	b.	c.
A2. FTE Contractors	a.	b.	c.
A3. TOTAL FTE (A1 + A2)	a.	b.	c.
B. Employed or advanced in employment		No. employed	FTE
B1. Employees with Disabilities		a.	b.
B2. Employees with Blindness Age 55 and Older		a.	b.
B3. Employees who are Racial/Ethnic Minorities		a.	b.
B4. Employees who are Women		a.	b.
B5. Employees Age 55 and Older		a.	b.
C. Volunteers
C1. FTE program volunteers (no. of volunteer hours ÷ 2080)

PART III: DATA ON INDIVIDUALS SERVED

Provide data in each of the categories below related to the number of individuals for whom one or more services were provided during the reported fiscal year.

A. INDIVIDUALS SERVED
A1. Number of individuals who began receiving services in the previous FY and continued to receive services in the reported FY
A2. Number of individuals who began receiving services in the reported FY
A3. TOTAL individuals served during the reported fiscal year (A1+ A2)
B. AGE
B1. 55-59
B2. 60-64
B3. 65-69
B4. 70-74
B5. 75-79
B6. 80-84
B7. 85-89
B8. 90-94
B9. 95-100
B10. 100 & over
B11. TOTAL (Add B1 through B10, must agree with A3)
C. GENDER
C1. Female
C2. Male
C3. TOTAL (Add C1 + C2, must agree with A3)
D. RACE/ETHNICITY
D1. American Indian or Alaska Native
D2. Asian
D3. Black or African American
D4. Native Hawaiian or Other Pacific Islander
D5. White
D6. Hispanic/Latino of any race or Hispanic/ Latino only
D7. Two or more races
D8. Race and ethnicity unknown (only if consumer refuses to identify)
D9. TOTAL (Add D1 through D8, must agree with A3)
E. DEGREE OF VISUAL IMPAIRMENT
E1. Totally Blind (LP only or NLP)
E2. Legally Blind (excluding totally blind)
E3. Severe Visual Impairment
E4. TOTAL (Add E1 through E3, must agree with A3)

F. MAJOR CAUSE OF VISUAL IMPAIRMENT
F1. Macular Degeneration
F2. Diabetic Retinopathy
F3. Glaucoma
F4. Cataracts
F5. Other
F6. TOTAL (Add F1 through F5, must agree with A3)
G. OTHER AGE-RELATED IMPAIRMENTS
G1. Hearing Impairment
G2. Diabetes
G3. Cardiovascular Disease and Strokes
G4. Cancer
G5. Bone, Muscle, Skin, Joint, and Movement Disorders
G6. Alzheimer’s Disease/Cognitive Impairment
G7. Depression/Mood Disorder
G8. Other Major Geriatric Concerns
H. TYPE OF LIVING ARRANGEMENT
H1. Lives alone
H2. Lives with others (family, spouse, caretaker, etc.)
H3. TOTAL (Add H1 + H2, must agree with A3)
I. TYPE OF RESIDENCE
I1. Private residence (house or apartment)
I2. Senior Living/Retirement Community
I3. Assisted Living Facility
I4. Nursing Home/Long-term Care facility
I5. TOTAL (Add I1 through I4, must agree with A3)
J. SOURCE OF REFERRAL
J1. Eye care provider (ophthalmologist, optometrist)
J2. Physician/medical provider
J3. State VR agency
J4. Government or Social Service Agency
J5. Senior Center
J6. Faith-based organization
J7. Independent Living center
J8. Family member or friend
J9. Self-referral
J10. Other
J11. TOTAL (Add J1 through J10, must agree with A3)

PART IV: TYPES OF SERVICES PROVIDED AND RESOURCES ALLOCATED

Provide data related to the number of older individuals who are blind receiving each type of service and resources committed to each type of service.

A. Clinical/functional vision assessments and services
A1. a. Total Cost from VII-2 funds b. Total Cost from Other funds			$		# Persons Served
			$
A2. Vision screening / vision examination / low vision evaluation
A3. Surgical or therapeutic treatment to prevent, correct, or modify disabling eye conditions
B. Assistive technology devices and services
B1. a. Total Cost from VII-2 funds b. Total Cost from Other funds			$		# Persons Served
			$
B2. Provision of assistive technology devices and aids
B3. Provision of assistive technology services
C. Independent living and adjustment training and services
C1. a. Total Cost from VII-2 funds b. Total Cost from Other funds			$		# Persons Served
			$
C2. Independent living and adjustment skills training
# Persons Served
C3. Orientation and Mobility training
C4. Communication skills
C5. Daily living skills
C6. Supportive services (reader services, transportation, personal attendant services, support service providers, interpreters, etc)
C7. Advocacy training and support networks
C8. Counseling (peer, individual and group)
C9. Information, referral and community integration
C10. Other IL services
D. Community Awareness Activities/ Information and Referral Services
D1. a. Total Cost from VII-2 funds b. Total Cost from other funds	$			# Events/ Activities	# Persons Served
	$
D2. Information and Referral
D3. Community Awareness: Events/Activities			a.		b.

PART V: COMPARISON OF PRIOR YEAR ACTIVITIES TO CURRENT REPORTED YEAR

	Prior FY	Reported FY	Change ( + / - )
A1. Program Cost (all sources)	a.	b.	c.
A2. No. Individuals Served	a.	b.	c.
A3. No. of Minority Individuals Served	a.	b.	c.
A4. No. of Community Awareness Activities	a.	b.	c.
A5. No. of Collaborating agencies and Organizations (other than sub-grantees)	a.	b.	c.
A6. No. of Sub-grantees	a.	b.	c.

PART VI: PROGRAM OUTCOMES/PERFORMANCE MEASURES

Provide the following data for each of the performance measures below. This will assist RSA in reporting results and outcomes related to the program.

VI. PROGRAM OUTCOMES/PERFORMANCE MEASURES		No. of Persons
A1.	Number of individuals who received orientation and mobility (O & M) services (refer to Part IV C3).
A2.	Of those receiving orientation and mobility (O & M) services, the number of individuals who experienced functional gains or maintained their ability to travel safely and independently in their residence and/or community environment as a result of services.
B1.	Number of individuals who received services or training in alternative non-visual or low vision techniques (refer to Part IV C2).
B2.	Number of individuals that experienced functional gains or successfully restored or maintained their functional ability to engage in their customary life activities as a result of services or training in alternative non-visual or low vision techniques.
C1.	Number of individuals receiving AT (assistive technology) services and training (refer to Part IV B2).
C2.	Number of individuals receiving AT (assistive technology) services and training who regained or improved functional abilities that were previously lost or diminished as a result of vision loss.
D1.	Number of individuals served who reported feeling that they are in greater control and are more confident in their ability to maintain their current living situation as a result of services they received.
D2.	Number of individuals served who reported feeling that they have less control and confidence in their ability to maintain their current living situation as a result of services they received.
D3.	Number of individuals served who reported no change in their feelings of control and confidence in their ability to maintain their current living situation as a result of services they received.

PART VII: NARRATIVE

A. Briefly describe the agency’s method of implementation for the Title VII-Chapter 2 program (i.e. in-house, through sub-grantees/contractors, or a combination) incorporating outreach efforts to reach underserved and/or unserved populations. Please list all sub-grantees/contractors.

B. Briefly describe any activities designed to expand or improve services including collaborative activities or community awareness; and efforts to incorporate new methods and approaches developed by the program into the State Plan for Independent Living (SPIL) under Section 704.

C. Briefly summarize results from any of the most recent evaluations or satisfaction surveys conducted for your program and attach a copy of applicable reports.

D. Briefly describe the impact of the Title VII-Chapter 2 program, citing examples from individual cases (without identifying information) in which services contributed significantly to increasing independence and quality of life for the individual(s).

E. Finally, note any problematic areas or concerns related to implementing the Title VII-Chapter 2 program in your state.

PART VIII: SIGNATURE

Please sign and print the name, title and telephone number of the IL-OIB Project Director below.

I certify that the data herein reported are statistically accurate to the best of my knowledge.

Name (Printed) Title Telephone Number

Name (Signature) Date