Annual Progress Reporting Form

APPENDIX A

ANNUAL PROGRESS REPORTING FORM

WORD Version

For the American Indian Vocational Rehabilitation Services Program

Note: The word version is identical to the online version with the exception

Of available text boxes for answers to each question.

The U.S. Department of Education

Rehabilitation Services Administration (RSA)

Annual Reporting Form

For

American Indian Vocational Rehabilitation Services (AIVRS) Grant Program

OMB Number: 1820-0655

Expiration Date: 07/31/2008

PR/Federal Award Number:

(Type in your federal grant number exactly as it appears on your award contract.)

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 1820-0655. The time required to complete this form is estimated to average 16 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collected. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to the U.S. Department of Education, Washington, DC, 20202-4651. If you have comments or concerns regarding the status of your individual submission of this form, write directly to the Office of the Chief Financial Officer, U.S. Department of Education, 600 Independence Avenue, SW, Washington, DC, 20202-4248.

PURPOSE OF THE REPORT: The completion of this report satisfies the Annual Reporting requirements under 34 CFR 75.118 and 80.40(b)(2)(i-iii) for determining whether your grant has made substantial progress for continuation of the award. RSA will also use the reported information to prepare the Annual Report to Congress and other documents related to administering the AIVRS program.

Table of Contents

General Information Section

Section 1 – Budget Narrative

Section 2 – Project Goals and Objectives

Section 3 – Serving American Indians with Disabilities

Section 4 – VR Services

Section 5 – Educational Goals and Employment Outcome

Section 6 – Common Measures

Section 7 – Interaction with State VR Agency

Section 8 – Evaluation

Section 9 – Consumer Satisfaction

General Information
* Required fields
*	Grantee Name:
*	Grantee Address
*	City:
*	State:
*	Zip:
*	Grant Start Date:
*	Grant End Date:
*	Project Title:
	Tribal Agency with Fiscal Responsibility for the Grant:
*	Project Director:
*	Telephone ###-###-####
	E-Mail: (If no e-mail enter N/A)
	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:
*	Signed?
*	Signature Date:
	Note: If the report is not being submitted via the MIS, please print this General Information section, have it signed by the authorized representative, and mail the printed copy with the original signature of the authorized representative, to: Dr. Thomas Finch Rehabilitation Services Administration U.S. Department of Education 550 12th Street, SW, Room 5014 Washington, D.C. 20202-800   Federal Express or any other mail service: U.S. Department of Education Attn: Dr. Thomas Finch Mail Stop 2800 7100 Old Landover Road Landover, MD 20785-1506

1.	Budget and Narrative
*	Required fields
*	1a.	Indicate the grant amount awarded by RSA for the current 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.	Indicate the match contribution for the current reporting period. Enter 0 (zero) for 6-month reports.
	1c.	Add Line 1a plus Line 1b, which equals total project funding. This field is automatically calculated in the online reporting form.
*	2.	Was an Order of Selection in effect at any time during the current reporting period? An Order of Selection consists of priority categories that determine the order in which eligible American Indians with disabilities are provided services, in the event that an AIVRS project does not have sufficient fiscal or personnel resources to provide services to all eligible American Indians with disabilities who apply. Eligible individuals are assigned to priority categories based on the significance of their disability and American Indians with the most significant disabilities are placed in the highest priority category.
*	3a.	Was the current reporting period started with any carry-over funds? Enter N/A for 6-month reports.
	3b.	If yes, report the dollar amount with which the current reporting period started. Enter 0 (zero) for 6-month reports.
	3c.	Were there carry-over funds at the end of the current reporting period? Enter N/A for 6-month reports.
	3d.	If yes, report the dollar amount at the end of the current reporting period. If the amount of carry-over funds is not yet available, estimate the carry-over funds. Enter 0 (zero) for 6-month reports.
	3e.	Use this space 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.	Indicate any program income generated for the current reporting period. Enter 0 (zero) if no.
	4b.	Indicate the total amount of cash funding in support of the AIVRS grant received during the current 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.
	4c.	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 current reporting period, were changes made to the budget due to programmatic changes? Examples of programmatic changes under 34 CFR 80.30 (d)(1)-(4) includes revision of the scope or objectives of the project and changes in key personnel. If no, skip to Section 2, Project Goals and Objectives.
	5b.	Was the modification(s) approved by RSA? If yes, skip to Section 2, Project Goals and Objectives.
	5c.	If the answer is no, use this space to describe the modification(s) and the resulting budget changes.
Notes:

2. Project Goals and Objectives
Goal #1	Goal Description	Goal Start Date (mm/dd/yyyy)		Goal End Date (mm/dd/yyyy)
	Objective	Expected Date of Completion		Status of Objective for Current Year
Objective 1
Objective 2
Objective 3
Objective 4
Objective 5
Objective 6
Objective 7
Objective 8
Objective 9
Objective 10

An “Add Another Goal” button will be placed after each Goal and Objective chart.

 

3.	Serving American Indians with Disabilities
Questions 1 - 4 ask for details on individuals who were served under your grant for the current reporting period.
	1.	Enter the total number of individuals proposed to serve under an Individualized Plan for Employment (IPE) during the current reporting period.
	2.	Enter the actual number of eligible individuals who received services under an IPE during the current reporting period. The sum of 2a, 2b, and 2c should equal the number in 2.
		2a. Enter the number of individuals who received services under an IPE developed in a prior reporting period. For 6-months and first year reports enter zero (0).
		2b. Enter the number of individuals who received services under an IPE developed during this reporting period.
		2c. Enter the number of individuals served under an IPE developed under a previous grant cycle. Enter one of the following: 1) the number of individuals served under an IPE developed under a prior grant that have been carried forward into the current grant and that are not being served under a no-cost extension; or 2) the number of individuals served under an IPE developed under a prior grant, that are being served under that prior grant's no-cost extension.
	3.	Of the total number of individuals proposed to receive services under an IPE, what percent actually received services under an IPE? This field is automatically calculated in the online reporting form.
	4.	Compare the number proposed to serve (item 1) with the number actually served (item 2). For 6-month reports, compare the number in item 2 with one half of the number in item 1. Please explain below if:
		4a. The number actually served is substantially fewer than the number proposed for this current reporting period; or
		4b. The number actually served substantially exceeds the number proposed for this current reporting period.
	Notes

 

4. VR Services
Indicate the vocational rehabilitation (VR) services provided to American Indians with disabilities during the current reporting period. "Services provided" means the service was provided by project staff, purchased with any type of project funds, or procured from another source, such as comparable benefits. Check "Yes" in the first set of columns if, during the current reporting period, the listed service was provided. If the service was not provided during the current reporting period, check "No." If the service was provided, check "Yes" or "No" in the second set of columns to indicate whether the service was paid for in part or in full with funds other than federal AIVRS funds.
	VR Service	Services provided during current reporting period?	If Yes, was service paid for in part or full with funds other than federal AIVRS funds?
1.	Assessment for determining eligibility and VR needs
2.	Counseling and guidance
3.	Referral and other services to secure needed services
4.	Job-related services, including job search and placement services, job retention services, follow-up services, and follow-along services
5.	Vocational and other training services, including personal and vocational adjustment training services
6.	Book, tools and other training materials
7.	Diagnosis and treatment of physical and mental impairments as included in Section 103 (a)(6)(A-F) of the Rehabilitation Act
8.	Maintenance
9.	Transportation
10.	On-the-job or other related personal assistance services provided while an individual is receiving other services
11.	Interpreter and reader services
12.	Rehabilitation teaching services and orientation and mobility services for individuals who are blind
13.	Occupational licenses, tools, equipment, and initial stocks and supplies
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
15.	Rehabilitation technology, including telecommunications, sensory, and other technological aids and devices
16.	Transition services for students with disabilities that facilitate the achievement of the employment outcome identified in the IPE
17.	Supported employment services
18.	Services to the family of an individual with a disability necessary to assist the individual to achieve an employment outcome
19.	Specific post-employment services necessary to assist an individual with a disability to retain, regain, or advance in employment
20.	Services traditionally used by Indian tribes, including native healing
21a.	Other service(s) determined necessary for achievement of an employment outcome
21b.	If yes, list other service(s).
Provide the following details about training services
22.	Total number of eligible individuals enrolled in a two-year post-secondary education program during the current reporting period.
23.	Total number of eligible individuals enrolled in a four-year post-secondary education program during the current reporting period.
24.	Total number of eligible individuals enrolled in one or more training programs during the current reporting period.
Notes

 

5. Educational Goals and Employment Outcomes:
Part A. Educational Goals
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 current reporting period, regardless of whether they exited the program or not.
1.	Total achieving an intermediate educational goal
	Of the total number reported in Item 1 above, how many:
	1a.	Obtained a GED
	1b.	Obtained a post-secondary degree
	1c.	Obtained a post-secondary certificate
	1d.	Completed on-the-job-training/apprenticeship
	1e.	Completed any other job-related training
	Describe:
Part B. Employment Outcomes
Definitions:
Employment Outcome:
Entering or retaining full-time or, if appropriate, part-time competitive employment in the integrated labor market, the practice of a profession, self-employment, homemaking, farm or family work (including work for which payment is in kind rather than cash), extended employment in a community rehabilitation program, supported employment, or other gainful work.
Exited the AIVRS Program:
Exiting the AIVRS program means that the AIVRS project has closed the individual’s record of VR service.
1.	Enter the total number of individuals who exited the AIVRS program after achieving an employment outcome. If the answer is none, enter a "0" in the box.
	Of the total number reported above, how many are:
	1a.	Employed full-time in the integrated labor market at or above minimum wage, 32 or more hours per week?
	1b.	Employed part-time in the integrated labor market at or above minimum wage, 31 or fewer hours per week?
	1c.	Achieved a vocational outcome of self-employment
	1d.	Achieved a vocational outcome of extended employment in a community rehabilitation program.
	1e.	Achieved a vocational outcome in supported employment
	1f.	Achieved any other type of employment outcome e.g., homemaking, subsistence activities, unpaid work on a family farm or business.
2.	Enter the proposed number of individuals who were expected to obtain an employment outcome during the current reporting period.
3.	Of the total number of individuals proposed to obtain an employment outcome during the current reporting period, what percent actually obtained an employment outcome? Please compute this figure by dividing the number in item 1 by the number in item 2 and multiply by 100. This field is automatically calculated in the online reporting form.
4.	Number of eligible individuals who exited the AIVRS program during the current reporting period after receiving services under an IPE and who did not achieve an employment outcome during the current reporting period (formerly “Status 28”).
5.	Compare the number of employment outcomes proposed (item 2) with the number actually achieved (item 1). For 6-month reports, compare the number in item 1 with one half of the number in item 2. Please explain below if:
	5a.	The number of employment outcomes is substantially fewer than proposed for this current reporting period; or
	5b.	The number of employment outcomes achieved substantially exceeds the number proposed for this current reporting period.
	Notes

 

6.	Job Training Common Measures
	Data reported in this section will be 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 reservations by providing effective tribal 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.
	Definitions:
	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. Exiting The AIVRS Program: Exiting the AIVRS program means that the AIVRS project has closed the individual’s record of VR service.
	Please type in 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.	Number of individuals whose employment outcomes resulted in earnings.
	2.	Of the group specified in question 1, indicate the average weekly earnings of the individuals whose employment outcomes resulted in earnings. To calculate, add the weekly earnings of ALL individuals reported in Item 1 and divide by the number reported in Item 1. Enter whole dollars only; i.e. round the amount to the nearest dollar and do not enter cents.
	3.	Of the individuals reported in Item 1, specify the number of individuals who had earnings at the time of their entry into the AIVRS program.
	3a.	Of the number specified in Item 3, indicate the average weekly earnings at entry in the AIVRS program. To calculate, add the weekly earnings of ALL individuals reported in Item 3 and divide by the number reported in Item 3. Enter whole dollars only; i.e., round the amount to the nearest dollar and do not enter cents.
	3b.	Of the number specified in Item 3, indicate the average weekly earnings at the time of exit from the AIVRS program. To calculate, add the weekly earnings at the time of exit for all individuals reported in Item 3 and divide by the number reported in Item 3. Enter whole dollars only; i.e., round the amount to the nearest dollar and do not enter cents.
	4.	Number of individuals whose case record has not been closed, but have not received a project service for 90 consecutive calendar days. The following services are excluded: follow-up services or regular contact with the participant or employer to obtain information regarding the individual’s employment status or need for additional services after the individual has achieved an employment outcome.
	5.	Of the number in Item 1, indicate the number of eligible individuals who were employed 3 months after achieving the employment outcome; the number who were employed 3 months after achieving an employment outcome (formerly “Status 26”).
	6.	Of the number in Item 1, indicate the number of eligible individuals who were employed 6 months after achieving an employment outcome; the number who were employed 6 months after achieving an employment outcome (formerly “Status 26”).
	7.	Of the number in Item 1, indicate the number of individuals who exited after achieving an employment outcome during the current or prior reporting period, and who have received post-employment services in the current reporting period.
	8.	Of the number in Item 1, indicate the number of individuals who exited after achieving an employment outcome during the current or prior reporting period, but have reapplied and received vocational rehabilitation services in the current reporting period.
	Notes

 

7.	Interaction with State VR Agency(ies)
List the State VR Agency or Agencies you interacted with during the current 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. Use only the ones that you need starting with "Agency 1." For each agency listed:
A.	Describe or give examples of interactions. Examples of interactions might include 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.
B.	Describe or give examples of concerns or issues. Examples of concerns or issues might include lack of a cooperative agreement or non-representation on the State Council. If no concerns exist, enter "None".
C.	Fill out the satisfaction rating scale. For the rating scale, rate the overall satisfaction with interactions with the agency, taking into consideration all interactions.
The information provided in this section is for use by your project officer and is confidential.
Agency 1:
Types of Interactions:
Concerns/Issues with Collaboration or Service Provision:
Rate the level of satisfaction of interactions with this agency using the following 1 to 5 scale.
Agency 2:
Types of Interactions:
Concerns/Issues with Collaboration or Service Provision:
Rate the level of satisfaction of interactions with this agency using the following 1 to 5 scale.
Agency 3:
Types of Interactions:
Concerns/Issues with Collaboration or Service Provision:
Rate the level of satisfaction of interactions with this agency using the following 1 to 5 scale.
Agency 4:
Types of Interactions:
Concerns/Issues with Collaboration or Service Provision:
Rate the level of satisfaction of interactions with this agency using the following 1 to 5 scale.
Notes

 

8.	Evaluation
A.	Briefly describe the self-evaluation efforts, and the results of those efforts, for the current 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 current reporting period. If none were conducted, enter "none".
C.	List any future evaluation plans. If none were planned, enter "none".
D.	Describe the most effective activities and services provided in meeting the project goals and why they are 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.
	Notes

 

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 current reporting period? If "no," review entered data before clicking on “Save” and “Mark as Complete and Submit to RSA.”
	2.	Were any consumer satisfaction activities conducted during the current reporting period?
	If yes, describe in the box below the type(s) of consumer activities conducted during the current reporting period.
	If no, but the grant application stated that consumer satisfaction evaluations would be conducted in the current reporting period, explain in the box why the activities were not conducted.
	Notes:

 

 

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