RSA Payback Grantee Form

RSA Payback Grantee Form: Sample Instrument

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 1 hour report, 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. 20202-4537. If you have comments or concerns regarding the status of your individual submission of this form, write directly to: Office of Special Education and Rehabilitative Services, U.S. Department of Education, 400 Maryland Avenue, S.W., Room 5027 PCP, Washington, D.C. 20202.

The RSA Payback form is submitted electronically using the RSA MIS system. This sample form provides an overview of the information grantees are required to submit each fiscal year until every scholar under a specific grant successfully fulfills their payback obligation. Detailed instructions for grantees are included in the Payback MIS User Guide and Instructions manual. Cells that are shaded gray indicate the information either rolls over from a previous screen or the information can not be input by grantees because the data self populates based on information entered into other areas of the form.

Screen 1: General Information
Grantee:		Project Director:		Grant Number:
Address:		Phone:		FY Grant Amount
Rehab Field of Training		Email:		Reporting Period (last Fiscal Year completed)
If “other” please specify

The data fields are self explanatory for this screen. Grantees will type in the information requested. The Rehab Field of Training field displays a drop down box that asks grantees to select the correct field of training the grant they are reporting on supports. If none of the choices fit the grant’s training objective the grantee can enter the specific field of training in the “if other, please specify” data field which is a text box.

Screen 2: Add/Edit Scholars
Name of RSA Scholar	Status	Scholar start date	Total support all years	Payback agreement signed and on file?	Current address on file?
Text field	Drop down box	Text field	Text field	Yes/No checkbox	Yes/No checkbox

The second screen of the RSA payback form asks for information about the students receiving aid under the grant. Grantees type in or choose the correct from drop down menu or checkbox for the information requested. Under “status” the grantee will note whether the student is currently enrolled in the program or has exited. The last two fields on Screen 2 require grantees to check a box certifying that the required payback agreement has been signed and is on file and that the scholar’s address information is up to date.

Screen 3: RSA Current Scholars
Name of RSA Scholar	Academic degree sought	Student Status	Scholarship amount for current year
Text field	Drop down box	Drop down box	Text field

Screen three asks for information on scholars currently enrolled in the grantee’s academic program. This information will carry over year to year until the student’s status is changed from current to exited on screen 2.

Screen 4: RSA Exited Scholars
Name of RSA Scholar	Why did this scholar exit the program?	Date exited the program	Date work must begin (including 2 years grace)	Date by which work must be completed (including 2 years grace)
Text field	Drop down box	Text field	Text field	Text field

Screen four collects information on scholars who have graduated or otherwise exited the grantee’s program and are now in payback status. Grantees need to specify why a scholar exited the program and provide the applicable dates so the payback obligation completion date can be calculated.

Screen 5: RSA Exited Scholars (continued)
Name of RSA Scholar	Employment Status	If deferment or waiver or non qualifying employment, explain	Number of work years owed	Work years completed to date	Payback complete?
Text field	Drop down box	Text field	Text field	Text field	Automatically populates: no data entry required

Screen five collects additional information on RSA exited scholars, specifically information about employment. Grantees are required to update the information each year until each scholar fulfills their payback obligation. When the fields in number of work years owed equals work years completed to date the system will automatically default to “Yes” in the payback complete field and the scholars’ information will not appear of future payback forms. Grantees cannot manually change the payback complete field.

Screen 6: Summary and Signatures
Total support all years to date
Total scholarship amount current year
Average number of work years owed
Total number of scholars on this report
Total number of current scholars
Total number of full time scholars
Total number of part time scholars
Total number of graduated scholars
Total number who exited without graduating
Total for whom payback is complete
Total for whom payback is not complete
Total number of scholars in unqualified employment
Total number of deferments (table in guide says temporary deferments)
Total number of waivers
Name of individual submitting this form	Text field
Title of individual submitting this form	Text field
Date	Text field

The last screen provides a summary of grantee activity based on data entered into the prior five screens. Grantees must fill out the last three text boxes on this form: the name of the individual submitting the current form, their title and the date. RSA will use all of the grantee summary screens for analysis. Any fields that with questionable data will be noted by RSA project officers who will then contact the grantees for additional information or to provide technical assistance.

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