FORM RSA-113 OMB Approval No.: 1820-0013
Expiration Date: xx/xx/xxxx
QUARTERLY CUMULATIVE CASELOAD REPORT
Rehabilitation Services Administration
OSERS/US DEPARTMENT OF EDUCATION
Fiscal Year
Period Covered
[ ] Blind [ ] Oct-Dec [ ] Oct-Jun
State [ ] General/Combined [ ] Oct-Mar [ ] Oct-Sep
Operated Under Order Of Selection During Period? [ ] Yes [ ] No
CASELOAD ITEMS |
TOTAL NUMBER |
NUMBER WITH SIGNFICANT DISABILITY |
A. APPLICATIONS AND ELIGIBILITY |
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Applicants |
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1 Applicants On Hand October 1 |
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2 Applicants, New This FY |
|
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3 Applicants At End Of Period (A1+A2-A5-A8-A12-D7) |
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4 Applicants In Trial Work/EE On Hand, October 1 |
|
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5 Applicants In Trial Work/EE Referred This FY |
|
|
6 Applicants In Trial Work/EE At End Of Period (A4+A5-A9-A13-D6) |
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|
Eligible Individuals On Order Of Selection (OOS) Waiting List |
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7 Individuals On OOS Waiting List On Hand October 1 |
|
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8 Individuals On OOS Waiting List, New This FY From Application |
|
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9 Individuals On OOS Waiting List, New This FY From Trial Work/EE |
|
|
10 Individuals On OOS Waiting List At End Of Period (A7+A8+A9-A14-D5) |
|
|
Individuals Determined Eligible, Before Signed IPE |
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11 Eligible Individuals Before Signed IPE On Hand, October 1 |
|
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12 Eligible Individuals Before Signed IPE, New This FY From Application |
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13 Eligible Individuals Before Signed IPE, New This FY From Trial Work/EE |
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14 Eligible Individuals Before Signed IPE, New This FY From OOS Waiting List |
|
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15 Eligible Individuals Before Signed IPE At End Of Period (A11+A12+A13+A14-B2-D3) |
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B. DEVELOPMENT OF INDIVIDUALIZED PLAN FOR EMPLOYMENT (IPE) |
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1 Individuals With Signed IPE, Before Receiving Services, On Hand October 1 |
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2 Individuals With Signed IPE, Before Receiving Services, This FY |
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3 Individuals With Signed IPE, Before Receiving Services, At End Of Period (B1+B2-C2-D4) |
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|
C. SERVICE IMPLEMENTATION |
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1 Individuals Receiving Services, On Hand October 1 |
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2 Individuals Receiving Services, Beginning This FY |
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3 Individuals Receiving Services At End Of Period (C1+C2-D1-D2) |
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D. OUTCOMES FOR INDIVIDUALS EXITING THE PROGRAM |
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1 Individuals Exiting With Employment Outcomes |
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2 Individuals Exiting Without Employment, After Receiving Services |
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3 Individuals Exiting Without Employment, After Eligibility, Before Signed IPE |
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4 Individuals Exiting Without Employment, After Signed IPE, Before Receiving Services |
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5 Individuals Exiting From OOS Waiting List |
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6 Individuals Exiting From Trial Work/EE |
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7 Individuals Exiting As Applicants |
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8 Total Number Of Individuals Exiting The Program (D1+D2+D3+D4+D5+D6+D7) |
|
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Contact Person (Please Print) Phone Number _______
E-mail address ____________
Date Authorized Signature
Paperwork Reduction Act 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 1.0 hour 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 benefits (Rehabilitation Act of 1973, as amended). 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 1820-0013. Note: Please do not return the completed RSA-113 form to this address.
| File Type | application/msword |
| File Title | FORM RSA-113 OMB Approval No |
| Author | DoED User |
| Last Modified By | Authorised User |
| File Modified | 2011-09-16 |
| File Created | 2008-09-24 |