Form RSA-227 ANNUAL CLIENT ASSISTANCE PROGRAM REPORT

FORM RSA-227 OMB NO. 1820- 0528 EXPIRES:

ANNUAL CLIENT ASSISTANCE PROGRAM (CAP) REPORT

Fiscal Year

DESIGNATED AGENCY IDENTIFICATION
Name:
Address:
E-mail Address (if applicable):
Website Address (if applicable):
Phone: ( )	TTY: ( )
Toll-free Phone: ( )	Toll-free TTY: ( )
Fax: ( )
OPERATING AGENCY (IF DIFERENT FROM DESIGNATED AGENCY)
Name:
Address:
E-mail Address (if applicable):
Website Address (if applicable):
Phone: ( )	TTY: ( )
Toll-free Phone: ( )	Toll-free TTY: ( )
Fax: ( )
Name of CAP Director/Coordinator:
Person to contact regarding report:
Contact Person's phone: ( )
PART I. AGENCY WORKLOAD DATA
A. Information and Referral Services (I&R): (Multiple responses are not permitted.)
1. Information regarding the Rehabilitation Act
2. Information regarding Title I of the ADA
3. Other information provided
4. Total I&R services provided (Lines A1+A2+A3)
5. Individuals attending trainings by CAP staff (approximate)
B. Individuals served (An individual is counted only once during a fiscal year. Multiple counts are not permitted for Lines B1-B3.)
1. Individuals who are still being served as of October 1 (carryover from prior year)
2. Additional individuals who were served during the year
3. Total individuals served (Lines B1+B2)
4. Individuals (from Line B3) who had multiple case files opened/closed this year. (In unusual situations, an individual may have more than one case file opened/closed during a fiscal year. This number is not added to the total in Line B3 above.)
PART I. AGENCY WORKLOAD DATA (continued)
C. Individual still being served as of September 30 (Carryover to next year) (This total may not exceed Line I.B3.)
D. Reasons for closing individuals’ case files (Choose one primary reason for closing each case file. There may be more case files than the total number of individuals served to account for those unusual situations, referred to in Line I.B4, when an individual had multiple case files closed during the year.)
1. All issues resolved in individual’s favor
2. Some issues resolved in individual’s favor (when there are multiple issues)
3. CAP determines VR agency position/decision was appropriate for the individual
4. Individual’s case lacks legal merit; (inappropriate for CAP intervention)
5. Individual chose alternative representation
6. Individual decided not to pursue resolution
7. Appeals were unsuccessful
8. CAP services not needed due to individual’s death, relocation, etc.
9. Individual refused to cooperate with CAP
10. CAP unable to take case due to lack of resources
11. Other (Please explain on separate sheet)
E. Results achieved for individuals (Choose one primary outcome for each closed case file. As stated in Section D, there may be more case files than the total number of individuals served.)
1. Controlling law/policy explained to individual
2. Application for services complet­ed
3. Eligibility determination expedited
4. Individual participated in evaluation
5. IPE developed/implemented
6. Communication re-established between individual and other party
7. Individual assigned to new counselor/office
8. Alternative resources identified for individual
9. ADA/504/EEO/OCR complaint made
10. Other (Please explain on separate sheet)
PART II. PROGRAM DATA
A. Age (As of the beginning of the fiscal year.) (Multiple responses not permitted.)
1. 21 and under
2. 22 – 40
3. 41 – 64
4. 65 and over
5. Total (Sum of Lines A1 through A4. Total must equal Line I. B3.)
B. Gender (Multiple responses not permitted.)
1. Females
2. Males
3. Total (Lines B1+B2. Total must equal Line I.B3.)
PART II. Program Data (continued)
C. Race/ethnicity (Multiple responses are permitted.)
1. American Indian or Alaskan Native
2. Asian
3. Native Hawaiian or Other Pacific Islander
4. Black or African American
5. Hispanic or Latino
6. White
7. Race/ethnicity unknown
D. Primary disabling condition of individuals served (Multiple responses not permitted.)
1. Blindness (both eyes)
2. Other visual impairments
3. Deafness
4. Hard of hearing
5. Deaf-blind
6. Orthopedic impairments
7. Absence of extremities
8. Mental illness
9. Substance abuse (alcohol or drugs)
10. Mental retardation
11. Specific learning disabilities (SLD)
12. Neurological disorders
13. Respiratory disorders
14. Heart and other circulatory conditions
15. Digestive disorders
16. Genitourinary conditions
17. Speech impairments
18. AIDS/HIV positive
19. Traumatic brain injury (TBI)
20. All other disabilities
21. Disabilities not known
22. Total (Sum of Lines D1 through D21. Total must equal Line I. B3.)
E. Types of individuals served (Multiple responses permitted.)
1. Applicants of VR Program
2. Clients of VR Program
3. Applicants or clients of IL Program
4. Applicants or clients of other programs and projects funded under the Act
F. Source of individual’s concern (Multiple responses permitted.)
1. VR agency only
2. Other Rehabilitation Act sources only
3. Both VR agency and other Rehabilitation Act sources
4. Employer
PART II. PROGRAM DATA (continued)
G. Problem areas (Multiple responses permitted.)
1. Individual requests information
2. Communication problems between individual and counselor
3. Conflict about services to be provided
4. Related to application/eligibility process
5. Related to IPE development/implementation
6. Other Rehabilitation Act-related problems
7. Non-Rehabilitation Act related
8. Related to Title I of the ADA
H. Types of CAP services provided (Choose one primary service CAP provided for each closed case file. As stated above, there may be more case files than actual individuals served.)
1. Information/referral
2. Advisory/interpretational
3. Negotiation
4. Administrative/informal review
5. Alternative dispute resolution
6. Formal appeal/fair hearing
7. Legal remedy
8. Transportation
PART III. NARRATIVE (Attach separate sheet(s).) Refer to pages 16-19 of the instructions for guidelines on the contents of the narrative.

Reports are to be submitted to RSA within 90 days after the end of the fiscal year covered by this report. Please be reminded that you can enter data directly into RSA’s Management Information System (MIS) via the Internet. Information on transmittal of the form, including electronic transmission, is found on pages 19 and 20 of the reporting instructions.

Signature and title of designated agency official Date

Paperwork Burden Statement:

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 16 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 (34 CFR 370.44). 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 1820-0528. Note: Please do not return the completed Annual Client Assistance Program (CAP) Report to this address.