Form RSA - 15 RSA - 15 REPORT OF VENDING FACILITY PROGRAM

REPORT OF VENDING FACILITY PROGRAM

­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­STATE:
REPORTING PERIOD: October 1, to September 30,

U.S. Department of Education Form RSA-15

Rehabilitation Services Administration OMB No. 1820-0009

Washington, D.C. 20202 Exp. Date: xx/xx/xxxx

REPORT OF VENDING FACILITY PROGRAM

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 13.5 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 (20 U.S.C. 107a(6)(a) and 107b(4))). 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 1820-0009. Note: Please do not return the completed RSA-15: Report of Vending Facility Program to this address.

STATE:	AGENCY:
REPORTING PERIOD: October 1, to September 30,

I. EARNINGS AND EMPLOYMENT

1. Gross Sales
2. Merchandise Purchases
3. Gross Profit (Line 1 minus Line 2)
4. Payroll Expenses
5. Other Operating Expenses
6. Total Expenses (Lines 4+5)
7. Operating Profit (Line 3 minus Line 6)
8. Vending Machine and Other Income
9. Retirement and Other Benefits Paid
10. Net Proceeds (Lines 7+8+9)
11. Levied Set Aside Funds
12. Net Profit to Vendors (Line 10 minus Line 11)
13. Fair Minimum Return to Vendors
14. Vendor Earnings (Lines 12+13)
15. Vendor Person Years of Employment
16. Average Vendor Earnings (Line 14 divided by Line 15)
17. The Median of Net Vendor Earnings in the State
18. Number of Other Persons with Visual Disabilities Employed
19. Number of Other Persons with Disabilities Employed
20. Number of Persons Having No Disability Employed
21. Total Number Employed in the Program (Lines 18+19+20)

II. VENDING FACILITIES AND VENDORS

A. FACILITIES ON FEDERAL PROPERTY
1. Number at Beginning of Year
2. Number Established During Year
3. Number Closed During Year
4. Number at End of Year
B. B. VENDING FACILITIES LOCATED ON FEDERAL PROPERTY, END OF YEAR
1. General Services Administration
2. U.S. Postal Service
3. Department of Defense (3a. + 3b.)
a) Military Dining Facility Contracts
b) Other Department of Defense Vending Facilities
4. Department of Homeland Security
5. Health and Human Services
6. Vending Routes on Multiple Federal Locations
7. All Other Federal Agencies (Identify):
8. Total (Lines 1 through 7)

c. Contracts for Operation of Cafeterias AND Military Dining FACILITIES (For each contracted cafeteria and military dining hall operation funded using federally appropriated funds, please submit the information requested below.)
Agency or Branch of Military Awarding Contract	Name of Military Installation (if applicable)	Beginning Date of Contract	Anticipated Termination of Contract	Gross Sales (Value) of Contract for the Most Recently Completed Option Year
D. VENDORS ON FEDERAL PROPERTY
1. Number at Beginning of Year
2. Number Entering During Year
3. Number Leaving During Year
4. Number at End of Year
E. FACILITIES ON PUBLIC PROPERTY (State, County, Municipal)
1. Number at Beginning of Year
2. Number Established during Year
3. Number Closed during Year
4. Number at End of Year
Vending Facilities on State Property (end of year)
Vending Facilities on County Property (end of year)
Vending Facilities on Municipal Property (end of year)
F. VENDORS ON PUBLIC PROPERTY (State, County, Municipal)
1. Number at Beginning of Year
2. Number Entering During Year
3. Number Leaving During Year
4. Number at End of Year

G. FACILITIES ON PRIVATE PROPERTY
1. Number at Beginning of Year
2. Number Established During Year
3. Number Closed During Year
4. Number at End of Year
H. VENDORS ON PRIVATE PROPERTY
1. Number at Beginning of Year
2. Number Entering During Year
3. Number Leaving During Year
4. Number at End of Year

III. VENDING LOCATIONS UNDER THE INTERSTATE HIGHWAY

PROGRAM (Transportation Equity Act for the 21st Century of June 1998)

	Total Number (1)	Total Vending Machine Receipts (2)
1. Total Vending Locations
2. Locations Operated by Vendors
3. Locations Operated by Third-Party Contractors
4. Vendors Employed in Highway Program

IV. PROGRAM EXPENDITURES BY SOURCE OF FUNDS

	Total (1)	Vending Machine Income		Set-Aside (4)	State Appro-priated Fund (5)	Federal Funds (6)	Other (7)
		Federal (2)	Non-Federal (3)
1. Purchase of New Equipment
2. Maintenance of Equipment
3. Replacement of Equipment
4. Refurbishment of Facilities
5. Management Services
6. Fair Minimum Return
7. Retirement/Pension Programs
8. Health Insurance Programs
9. Paid Sick Leave/Vacation Time
10. Initial Stock and Supplies
11. All Other Expenditures
12. TOTAL (Sum Lines 1-11)

V. DISTRIBUTION AND EXPENDITURE OF PROGRAM FUNDS FROM VENDING MACHINE INCOME AND LEVIED SET-ASIDE

	Total (1)	Vending Machine Income		Levied Set-Aside (4)
Federal (2)	Non-Federal (3)
1. Amount at Beginning of Year
2. Funds Added During Year
3. Total Funds Available (Lines 1+2)
4. Funds Distributed to Vendors
5. Other Funds Expended
6. Total Funds Distributed and Expended (Lines 4+5)
7. Amount at the End of the Year (Line 3 minus Line 6)

VI. NUMBER OF SITES SURVEYED

	Total (1)	Federal Property (2)	Non-Federal Property (3)
1. Total (Sum of Lines 2 through 7)
2. Accepted for Vending Facility Site
3. Not Accepted Due to Infeasibility of Site
4. Not Accepted Due to Lack of Funds by State
5. Denied by Property Management Official
6. Not Accepted Due to Lack of Qualified Vendors
7. Decision Pending

VII. VENDOR TRAINING

1. Individuals Provided Initial Training: (Lines a+b+c+d)
a) Number Licensed and Placed as Vendors
b) Number Certified Awaiting Placement as Vendors
c) Number Placed as Employees in the Vending Facility Program
d) Number Employed in Allied Food Service Occupations
2. Total Number of Individuals Who Are Certified and Awaiting Placement as Vendors
3. Number of Vendors Provided In-Service Training
4. Number of Vendors Provided Upward Mobility Training
5. Number of Vendors Participating in National Consumer-Driven Conferences
6. Number of Vendors Who Received Certification or Re-Certification in Food Safety Through a Nationally Recognized or State Recognized Program

VIII. STATE AND NOMINEE AGENCY PERSONNEL

A. AGENCY PERSONNEL	State Agency Personnel (1)	Nominee Agency Personnel (2)	Total (3)
1. Vending Facility Program Budgeted FTE
2. Vending Facility Program Actual FTE
B. Training	State Agency Personnel (1)	Nominee Agency Personnel (2)	Total (3)
1. Number Who Received In-Service Training Related to Blindness, Business Management, or Aspects of the Randolph-Sheppard Vending Facility Program
2. Number Who Received Training through an External Source Related to Blindness, Business Management, or Aspects of the Randolph-Sheppard Vending Facility Program
3. Number Who Participated in National Consumer-Driven Conferences
4. The Number Who Received Certification or Re-Certification in Food Safety Through a Nationally Recognized or State Recognized Program

Notes or Explanations:

CERTIFICATION: I do hereby certify that, to the best of my knowledge, the information given in this report is complete and accurate.

________________________________________________________________________________

Print Name and Title of Authorized Official

_______________________________________________ _____________________________

Signature of Authorized Official Date

_________________________ ______________________ ______________________________

Contact Person Telephone Number Email Address

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