Form 7OB

ED(RSA)-7-OB Form

OMB No. 1820-0608

Expiration Date: xx-xx-xxxx

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 OMB control number for this collection is 1820-0608. Public reporting burden for this collection of information is estimated to average 360 minutes/6 hours per response, including time for reviewing instructions, searching existing data sources, 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 Sec. 752(i)(2)(A) of the Rehabilitation Act of 1973, as amended; Sec. 410, Pub. L. 105-220, Workforce Investment Act of 1998. 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 Ave., SW, Washington, DC 20210-4537 or email [email protected] and reference the OMB Control Number 1820-0608. Note: Please do not return the completed ED RSA 7-OB application to this address. 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 5068, Washington, D.C. 20202-2800.

TABLE OF CONTENTS

PART I: FUNDING SOURCES FOR EXPENDITURES AND ENCUMBRANCES 1

PART II: STAFFING 2

PART III: DATA ON INDIVIDUALS SERVED 3

PART IV: TYPES OF SERVICES PROVIDED AND RESOURCES ALLOCATED 5

PART V: COMPARISON OF PRIOR YEAR ACTIVITIES TO CURRENT REPORTED YEAR 6

PART VI: PROGRAM OUTCOMES/PERFORMANCE MEASURES 7

PART VII: NARRATIVE 9

PART VIII: SIGNATURE 11

PART I: FUNDING SOURCES FOR EXPENDITURES AND ENCUMBRANCES

Title VII-Chapter 2 federal grant award for reported fiscal year		$
Other federal grant award for reported fiscal year		Will be entered
Title VII-Chapter 2 carryover from previous year		$
Other federal grant carryover from previous year		Will be entered
A. Funding Sources for Expenditures and encumbrances 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 (include blind and visually impaired not 55 or older)		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 (not blind and visually impaired)		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. 95-99
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. Hispanic/Latino of any race or Hispanic/ Latino only
D2. American Indian or Alaska Native, not Hispanic/Latino
D3. Asian, not Hispanic/Latino
D4. Black or African American, not Hispanic/Latino
D5. Native Hawaiian or Other Pacific Islander, not Hispanic/Latino
D6. White, not Hispanic/Latino
D7. Two or more races, not Hispanic/Latino
D8. Race and ethnicity unknown, not Hispanic/Latino (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 RESIDENCE
H1. Private residence (house or apartment)
H2. Senior Living/Retirement Community
H3. Assisted Living Facility
H4. Nursing Home/Long-term Care facility
H5. Homeless
H6 TOTAL (Add H1 through H5, must agree with A3)
I. SOURCE OF REFERRAL
I1. Eye care provider (ophthalmologist, optometrist)
I2. Physician/medical provider
I3. State VR agency
I4. Government or Social Service Agency
I5. Veterans Administration
I6. Senior Program
I7. Assisted Living Facility
I8. Nursing Home/Long-term Care facility
I9 Faith-based organization
I10 Independent Living center
I11. Family member or friend
I12 Self-referral
I13. Other
I14. TOTAL (Add I1 through I13, 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	Cost	Persons Served
A1a	Total Cost from VII-2 funds
A1b	Total Cost from Other funds
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, aids, services and training	Cost	Persons Served
B1a	Total Cost from VII-2 funds
B1b	Total Cost from Other funds
B2	Provision of assistive technology devices and aids
B3	Provision of assistive technology services and training .

C	Independent Living And Adjustment training And Services	Cost	Persons Served
C1a	Total Cost from VII-2 funds
C1b	Total Cost from Other funds
C2	Orientation and Mobility training
C3	Communication skills
C4	Daily living skills
C5	Supportive services (reader services, transportation, personal attendant services, support service providers, interpreters, etc)
C6	Advocacy training and support networks
C7	Counseling (peer, individual and group)
C8	Information, referral and community integration
C9	Other IL services

D	Community Awareness Activities/Information and Referral	Cost	Events / Activities	Persons Served
D1a	Total Cost from VII-2 funds
D1b	Total Cost from Other funds
D2	Information and Referral (optional)
D3	Community Awareness: Events/Activities

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. Number of Individuals Served	a.	b.	c.
A3. Number of Minority Individuals Served	a.	b.	c.
A4. Number of Community Awareness Activities	a.	b.	c.
A5. Number of Collaborating agencies and Organizations (other than sub-grantees)	a.	b.	c.
A6. Number 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		Number of Persons	Percent of Persons
A1.	Number of individuals receiving AT (assistive technology) services and training (must be same as Part IV B3).	Computed	computed
A2.	Number of individuals receiving AT (assistive technology) services and training who maintained or improved functional abilities that were previously lost or diminished as a result of vision loss. (closed/inactive cases only)		computed
A3.	Number of individuals for whom functional gains have not yet been determined at the close of the reporting period.		computed
B1.	Number of individuals who received orientation and mobility (O & M) services (must be same as Part IV C2).	Computed	computed
B2.	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. (closed/inactive cases only)		computed
B3.	Number of individuals for whom functional gains have not yet been determined at the close of the reporting period.		computed
C1	Number of individuals who received communication skills training. (must be same as Part IV C3)	Computed	Computed
C2	Of those receiving communication skills training, the number of individuals who gained or maintained their functional abilities as a result of services they received. (Closed/inactive cases only)		computed
C3	Number of individuals for whom functional gains have not yet been determined at the close of the reporting period.		computed

D1	Number of individuals who received daily living skills training (must be same as Part IV C4).	Computed	computed
D2.	Number of individuals that experienced functional gains or successfully restored or maintained their functional ability to engage in their customary daily life activities as a result of services or training in personal management and daily living skills. (closed/inactive cases only)		computed
D3.	Number of individuals for whom functional gains have not yet been determined at the close of the reporting period.		computed
E1.	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. (closed/inactive cases only)		computed
E2.	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. (closed/inactive cases only)		Computed
E3.	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. (closed/inactive cases only)		Computed
E4.	Number of individuals served who experienced changes in lifestyle for reasons unrelated to vision loss. (closed/inactive cases only)		Computed
E5.	Number of individuals served who died before achieving functional gain or experiencing changes in lifestyle as a result of services they received. (closed/inactive cases only)		computed

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 Program 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