Rsa-2

Form RSA‑2 OMB Number: 1820-0017

Expires: xx/xx/xxx

U.S. Department of Education

Office of Special Education and Rehabilitative Services

Rehabilitation Services Administration

ANNUAL VOCATIONAL REHABILITATION PROGRAM/COST REPORT (RSA-2)

State: ___________________________________ Fiscal Year: ___________________

Agency: ________________________________ [ ] Blind [ ] Combined [ ] General

	SCHEDULE I: Agency Expenditures
	Line Items				Amount
	1. Administration Expenditures
	Administration Personnel Costs				$
	Direct Administration Costs				$
	C. Indirect Costs				$
	D. Administration Expenditures for the SE Program Included in 1.A, 1.B and 1.C				$
	2. Service Expenditures
	A. Services Provided by Agency
	Services Provided by Agency Field Office Staff
	a. Assessment, Counseling, Guidance, and Placement Costs				$
	b. All other services, including Orientation, Mobility and Rehab Teaching/Training Services Costs				$
	Services Provided by Agency-Operated Community Rehabilitation Program (CRP) Staff
	a. Assessment, Counseling, Guidance, and Placement Costs				$
	b. All other services, including Orientation, Mobility and Rehab Teaching/Training Services Costs				$
	B. Services Purchased by Agency From:
	1. Public Community Rehabilitation Programs				$
	2. Private Community Rehabilitation Programs				$
	3. Other Public Vendors				$
	4. Other Private Vendors				$
	3. Services to Groups Expenditures
	A. Establishment, Development or Improvement of CRPs			$
	B. Construction of Facilities for CRPs			$
	C. Business Enterprise Program			$
	D. Transition Consultation and Technical Assistance			$
	E. All other services to groups			$
	4. Total Agency Expenditures
	Total SE Program Expenditures included in Sections 1, 2 and 3 above			$
	Total Innovation and Expansion Activity Costs included in 1, 2 and 3 above			$
	Form RSA‑2 OMB Number: 1820-0017
	SCHEDULE II: Labor Hours
	Staff Function Category			Labor Hours
	1. Administrative Staff
	2. Counselor Staff
	3. Staff Supporting Counselor Activities
	4. Other Staff
	5. Number of hours per week considered full time in state.
	SCHEDULE III: Number of Individuals Served and Purchased Service Expenditures by Service Category
	Service Category		Number of Individuals	Amount
	Assessment			$
	Diagnosis and Treatment of Impairments			$
	3. Vocational Rehabilitation Counseling and Guidance			$
	Graduate College or University Training			$
	5. Four-Year College or University Training			$
	6. Junior or Community College Training			$
	7. Occupational or Vocational Training			$
	8. On-the-job Training			$
	9. Apprenticeship Training			$
	10. Basic Academic Remedial or Literacy Training			$
	11. Job Readiness Training			$
	12. Disability Related Skills Training			$
	13. Miscellaneous Training			$
	14. Job Search Assistance			$
	15. Job Placement Assistance			$
	16. On-the-job Supports – Time-limited			$
	17. On-the-job Supports – Supported Employment			$
	18. Transportation			$
	19. Maintenance			$
	20. Rehabilitation Technology			$
	21. Reader			$
	22. Interpreter			$
	23. Personal Attendant			$
	24. Technical Assistance			$
	25. Information and Referral			$
	26. Benefits Counseling			$
	27. Customized Employment			$
	28. Other			$
Form RSA‑2 OMB Number: 1820-0017
SCHEDULE III: Number of Individuals Served and Purchased Service Expenditures by Service Category - Continued
29. Total Purchased Services Expenditures
Total SE Program Service Expenditures included in Schedule III above						$
30. Certification: By signing this report, I certify that it is true, complete, and accurate to the best of my knowledge. I am aware that any false, fictitious, or fraudulent information may subject me to criminal, civil, or administrative penalties. (U.S. Code, Title 18, Section 1001)
A. Typed or Printed Name and Title of Authorized Certifying Official		B. Telephone (Area code, number and extension):
		C. Email Address:
D. Signature of Authorized Certifying Official		E. Date Report Submitted (Month, Day, Year):
Public 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 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 (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 Form to this address.

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