RSA-2 RSA Annual Vocational Rehabilitation Program Cost Report

Form RSA‑2 OMB Num­ber: 1820-0017

Expires: xx/xx/xxxx

DEPARTMENT OF EDUCATION

OFFICE OF SPECIAL EDUCATION AND REHA­BILITATIVE SERVIC­ES

REHABILITATION SERVICES ADMINISTRATION

WASHINGTON, D.C. 20202

ANNUAL VOCATIONAL REHABILITATION PROGRAM/COST REPORT

State &

Agency:____________________________ ( ) General/Combined Fiscal Year____________

( ) Blind

SCHEDULE I. TOTAL EXPENDITURES AMOUNT

1. Administration $_____________

a. Admin. Costs Paid with Title VI B funds $____________

b. Indirect Costs ____________

2. Services to Individuals with Disabilities

A. Services Provided by State VR Agency Personnel

1. Employed at Agency Operated Community Rehabilitation Programs

a) Assessment, Counseling, Guidance, and Placement _____________

b) Other Services _____________

­ 2. Employed Elsewhere

a) Assessment, Counseling, Guidance, and Placement _____________

b) Other Services _____________

B. Services Purchased by State VR Agency From:

1. Public Community Rehabilitation Programs _____________

2. Private Community Rehabilitation Programs _____________

3. 3. Other Public Vendors _____________

4. 4 Other Private Vendors _____________

3. Services for Groups of Individuals with Disabilities

a) Establishment, Development or Improvement of

Community Rehabilitation Programs _____________

b) Construction of Facilities for Community Rehabilitation Programs _____________

c) Business Enterprise Program _____________

d) Other _____________

4. Total Expenditures ___

5. Innovation & Expansion Activities $____________

SCHEDULE II. Number of Individuals Served and Expenditures by Service Category

TYPE OF SERVICE NO. OF INDIVIDUALS - A M O U N T -

1. Assessment, Counseling, Guidance and Placement __

(Provided by State VR Agency Personnel)

2. Assessment (Purchased only) ____________ $____________

3. Diagnosis & Treatment of Physical and

Mental Impairments ____________ ____________

4. Training:

a. Postsecondary Institution of

Higher Education ____________ $____________

b. Job Readiness and Augmentative

Skills Training ____________ ____________

c. Vocational and Occupational

Skills Training ____________ ____________

d. All Other ____________ ____________

e. Total ____________ ____________

5. Maintenance ____________ ____________

6. Transportation ____________ ____________

7. Personal Assistance Services ____________ ____________

8. Placement (Purchased only) ____________ ____________

9. All Other ____________ ____________

10. Total No. of Individuals and Expenditures ____________ ____________

11. Post-Employment Services ____________ ____________

12. Rehabilitation Technology Services ____________ ____________

13. Small Business Enterprises ____________ ____________

14. Total Section 110 Funds Expended on Services ____________

15. Total Title VI-B Funds Expended on Services ____________

SCHEDULE III. PERSON YEARS -- Report Whole Years Only

(1) (2) (3)

110 TITLE

NO. OF YEARS ONLY VI B

1. Administrative Staff XXXXX XXXXX

2. Counselor Staff XXXXX XXXXX

3. Staff Supporting Counselor

Activities XXXXX XXXXX

4. Other Staff XXXXX XXXXX

5. Total _______ _______

SCHEDULE IV. Expenditures From Title VI B Funds and Other Rehabilitation Funds

1. Expenditures From Title VI B Funds $____________

2. Expenditures From Other Rehabilitation Funds ____________

SCHEDULE V. Carryover Funds

1. Amount of current Fiscal Year Section 110 Allotment carried over to next FY $____________

2. Amount of previous Fiscal Year Section 110 Allotment carried over and expended this FY ____________

3. Amount of current Fiscal Year Title VI B Allotment carried over to next FY ____________

4. Amount of previous Fiscal Year Title VI B Allotment carried over and expended this FY ____________

5. Amount of current Fiscal Year Program Income carried over to the next FY ____________

6. Amount of previous Fiscal Year Program Income carried over and expended this FY ____________

CERTIFICATION

This Report is Complete and Correct: Signed: ______________________________________

Date: ________________________________________

E-Mail Address: _______________________________

Agency Point of Contact for this Report: Name: _______________________________________

Phone: _______________________________________

E-Mail Address: _______________________________

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 4.7 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 a benefit as required by the 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 1820-0017. Note: Please do not return the completed RSA-2 to this address.

06.1X-FINAL.doc

4