Aivrs Apr

Attachment 1: Annual Performance Reporting Form Word Version

ANNUAL PERFORMANCE REPORTING FORM

WORD Version

For the American Indian Vocational Rehabilitation Services Program

OMB #: 1820-0655

Expiration Date:

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 11 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 (Section 121 of the Rehabilitation Act of 1973, as amended Public Law 113-128. 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 1820-0655. Note: Please do not return the completed APR to this address.

General Information

* Required fields

*Grantee Name:

     

*State:

     

*Grant Start Date:

     

*Grant End Date:

     

*Project Title:

     

*Project Director:

     

*Telephone:

     

*E-mail:

     

Grantee URL (if applicable):

     

Grantee/Project E-mail (if applicable):

     

Grantee 800 Number (if applicable):

     

Person responsible for completing this form (if other than the project director):

*Name:

     

*Title:

     

*Telephone:

     

Fax:

     

*E-mail:

     

Authorized representative (The individual that signed the grant application, usually the Chief, President, Chairperson, etc.):

*Name:

     

*Title:

     

*Telephone:

     

*E-mail:

     

Note: the ED 524B form is required to be submitted with an original signature from the Authorized Representative.

1. Budget and Narrative

1a. Enter the grant amount awarded by RSA for the entire fiscal year for this reporting period. Do not include carry-over funds.	$     
1b. Enter the match contribution for this reporting period (cash or in-kind, fairly valued).	$     
1c. The sum of 1a plus Line 1b equals the total cost of the project (This sum is automatically calculated).	$Auto-Calculated

2. Was an Order of Selection requested and approved by RSA for any time during this reporting period? An Order of Selection prioritizes, by category, the order eligible individuals will receive vocational rehabilitation (VR) services, in the event that fiscal or personnel resources are insufficient or unavailable to provide VR services to all eligible individuals who apply. Eligible individuals are assigned to a category based on the significance of their disability and individuals with the most significant disability are placed in the highest priority category.

Yes

No

3a. Did this reporting period start with any carry-over funds? Choose N/A for six-month and first year reports.(Carryover funds are grant funds that are unused during the fiscal year which are transferred to the following fiscal year.)

Yes

No

NA

3b. If yes, enter the dollar amount.

$     

3c. Were there carry-over funds at the end of this reporting period? Choose N/A for six-month reports.

Yes

No

N/A

3d. If yes, enter the dollar amount of carry-over funds. If the amount of carry-over funds is not yet available, estimate the amount of carry-over funds.
	$     

3e. Use the box below to explain why there are carry-over funds and the reason for not expending funds at the rate expected. (NOTE: Discuss the use of any carry-over funds with your assigned ED program contact.) If there are no carry-over funds, enter “None” in the box.

     

4a. Enter any program income generated for this reporting period. Enter 0 (zero) if none.

4b. Enter the total amount of cash funding in support of the

grant received during this reporting period from sources other than program income (4a), grant award (1a), or match

$

$

contribution (1b). Enter 0 (zero) if no other funding was provided.

4

c. List the full name of the source(s) of any other cash funding identified in 4b. If there are no other sources, enter “None” in the box.

5a. During this reporting period, were changes to the budget requested and approved due to programmatic changes? Examples of programmatic changes under 2 CFR 200.308 include changes in key personnel. If no, skip to Section 2, Project Goals and Objectives.			Yes				No
5b. Was the modification(s) approved by RSA? If yes, skip to Section 2, Project Goals and Objectives.		Yes				No

5c. If the answer is no, use this space to describe the modification(s) and the resulting budget changes.

     

2. Project Goals and Objectives

The Tribe’s approved grant application includes a response to the Selection Criteria “(c) Quality of the Project Design” that states ”the extent to which the goals, objectives, and outcomes to be achieved by the proposed project are clearly specified and measurable.”

In the box below, please list the goals and objectives as they were described in the approved grant application. If any of the goals or objectives were approved during this reporting period, please enter those (It may be easiest to copy and paste directly from the approved grant application).

In the box below, please describe the progress toward achieving the goals and objectives that specifically pertain to this reporting period (measurable outcomes),

3. Serving American Indians with Disabilities

Questions 1 – 4 ask for details on individuals who were served during the reporting period.

Enter the total number of individuals the project proposed to serve under an Individualized Plan for Employment (IPE) during this reporting period.
2a. Enter the number of individuals who received VR services under an original IPE developed during this reporting period (Please exclude amendments to the IPE). 2b. Enter the number of individuals who received VR services under an IPE developed prior to this reporting period (including a prior grant cycle). 2c. The actual number of individuals who received VR services under an IPE during this reporting period (this field is automatically calculated).
3. This is the percent based on the ratio of those individuals who the project had proposed to be served divided by the individuals who the project actually served. (This field is automatically calculated)
In the box below, please explain why: 4a. The number actually served is fewer than the number proposed for this reporting period; or 4b. The number actually served exceeded the number proposed for this reporting period.
	     

4. VR Services

• “VR Services provided” means VR services as described in Section 103 of the Rehabilitation Act, provided by project staff, purchased with any type of project funds, or procured from another source, such as comparable/similar services.

• After each VR service listed below, enter the number of consumers who 1) received services that were paid for in full using AIVRS (federal) funds, or 2) received services that were paid for in part or in full with funds other than AIVRS (federal) funds. If no services were provided for any of the VR services listed below, please enter 0 (zero).

• Note: due to the nature of this program, a consumer will receive more than one VR service.

VR Services	Services provided paid in full with AIVRS (federal) funds	Services provided paid for in part or in full with funds other than AIVRS (federal) funds.
Assessment for determining eligibility and VR needs.
Counseling and guidance.
Referral and other services to secure needed services.
Job-related services, including job search and placement assistance, job retention services, follow-up services, and follow-along services.
Vocational and other training services, including personal and vocational adjustment training services.
Books, tools, and other training materials.
Diagnosis and treatment of physical and mental impairments as included in Section 103(a)(6)(A-F) of the Rehabilitation Act.
Maintenance.
Transportation.
On-the-job or other related personal assistance services provided while an individual is receiving other services.
Interpreter and reader services.
Rehabilitation teaching services and orientation and mobility services for individuals who are blind.
Occupational license, tools, equipment, and initial stocks and supplies.
Technical assistance and other services to conduct market analyses, develop business plans, and otherwise provide resources to eligible individuals who are pursuing self-employment or telecommuting or establishing a small business operation as an employment outcome.
Rehabilitation technology, including telecommunications, sensory, and other technological aids and devices.
Transition services for students with disabilities that facilitates the achievement of the employment outcome identified in the IPE.
Supported employment services.
Customized employment.
Encouraging qualified individuals who are eligible to receive services under this title to pursue advanced training in a science, technology, engineering, or mathematics (including computer science) field, medicine, law, or business.
Services to the family of an individual with a disability necessary to assist then individual to achieve an employment outcome.
Specific post-employment services necessary to assist an individual with a disability to retain, regain, or advance in employment.
Services traditionally used by Indian tribes, including native healing.
Other service(s) determined necessary to assist an individual with a disability achieve an employment outcome.
If other service(s) were provided in #23, list the other service(s) that were provided and provide the number of individuals who received each of the other services according to 1) or 2) in the second bullet at the top of this section:

5. Educational Services

• Educational services are for the purpose of increasing the skills needed for achieving an employment outcome consistent with the IPE.

Enter the number of individuals who were enrolled in an educational program during this reporting period. Note: It is possible that a consumer was enrolled in more than one of the areas below.

1. E

   
   

   nter the number of individuals enrolled in a two-year

post-secondary education program.

2. E

   
   

   nter the number of individuals enrolled in a four-year

post-secondary education program.

3. E

   
   

   nter the number of individuals enrolled in one or more training

programs.

Enter the number of individuals who completed an educational service consistent with their IPE. Include those who achieved one or more of the following educational services during this reporting period:

1

. Obtained a High School Diploma/Certificate/GED

2. Obtained a post-secondary degree (A.A., B.A., etc.)

3

. Obtained a post-secondary certificate (cosmetology, culinary, computer technology, etc.)

4. Completed on-the-job-training/apprenticeship

5

. Completed any other job-related training (truck driving, CPR food handling, etc.)

Describe the other job-related trainings from 5 above and provide the number of individuals who completed the other job-related training:

     

6. Employment Outcomes

Definition:

• Employment Outcome: The term "employment outcome" means, with respect to an individual‑‑ entering or retaining full‑time or, if appropriate, part-time competitive employment; satisfying the vocational outcome of supported employment; or satisfying any other vocational outcome the Secretary of Education may determine to be appropriate (including satisfying the vocational outcome of customized employment, self-employment, telecommuting, or business ownership), in a manner consistent with the Rehabilitation Act of 1973, as amended. An individual is considered to have achieved an employment outcome after the individual has ended participation in the program by maintaining the employment outcome for 90-days and no longer require VR services. Post-employment services are provided after the achievement of an employment outcome and are not considered an additional outcome.

• Self-employment and Business Ownership: The term “self-employment” means work for profit or fees including operating one’s own business, farm, shop, or office. The term “business ownership” means an individual having control over a business and being able to direct its functioning and operations.

1

. Enter the number of individuals the project proposed to achieve an

employment outcome during this reporting period.

2

. Enter the actual number of individuals who achieved an employment

outcome. If the answer is none, enter a zero (0) and go to item #3.

Of those individuals in #2 who achieved an employment outcome, enter the number:

2

a. Employed full-time for 32 or more hours per week at or above the applicable minimum wage:

2b. Employed part-time for 31 or fewer hours per week at or above the applicable minimum wage:

2

c. Achieved an employment outcome of self-employment

(including subsistence outcomes):

2d. Achieved an employment outcome of telecommuting:

2

e. Achieved an employment outcome of business ownership:

2

f. Achieved an employment outcome in supported

employment (supported employment defined in Section 7(38) of the Rehabilitation Act of 1973):

2g. Achieved any other type of employment outcome e.g., unpaid work on a family farm or business:

3. T

   
   

   his is the percent based on the ratio of those individuals who the project had proposed to achieve an employment outcome divided by the individuals who actually achieved an employment outcome during this reporting period (this field is automatically calculated).

3. E

   
   

   nter the number of individuals who received VR services under an IPE, whether the IPE was developed during this reporting period or in a previous reporting period, but ended participation in the program during this reporting period without achieving an employment outcome (formerly Status 28).

5

. Enter the number of individuals that were provided Post-employment services during this reporting period that resulted in maintaining, retaining, or advancing in their employment outcome.

6. In the box below, please explain if:

6a. The number of employment outcomes achieved is fewer than proposed for this reporting period; or

6b. The number of employment outcomes achieved exceeds the number proposed for this reporting period.

     

7 Interaction with State VR Agency or Agencies

1. During this reporting period, was a collaborative agreement entered into or participated in with the State VR Agency or Agencies?

Yes

No

2

. Of the number of individuals served under an IPE during this reporting

period, how many were jointly served with the State VR Agency or

Agencies?

List the interactions with only the State VR Agency or State VR Agencies during this reporting period. List the state name and agency (Combined/General/Blind; e.g., Utah Combined). Space is provided for each interaction. If additional State VR Agencies need to be added, please click the “Add an Agency” button at the bottom of this section. If additional space is needed, feel free to utilize space in the Executive Summary of the 524B form.

Note: The information provided in this section is for use by RSA’s AIVRS ED Program Staff and is held confidential.

For each agency listed:

1. Describe or give examples of interactions including, but not limited to, training/cross training; working jointly with an eligible individual; referrals; or having a VR representative on the project’s Advisory Board or State Rehabilitation Counsel.

2. Describe or give examples of concerns or issues such as a lack of a cooperative agreement or non-representation on the State Council. If no concerns exist, enter “None.”

3. Rate the overall satisfaction of interactions with the agency.

Agency Name	Discussion
Agency:      
A. Types of Interactions:	     
B. Successes/Concerns/Issues with Collaboration or Service Provision:	     
C. On a scale of 1 to 5, rate the level of satisfaction of interactions with this agency: 1 Very Dissatisfied 2 Somewhat Dissatisfied 3 Neutral 4 Somewhat Satisfied 5 Very Satisfied	     

Add an Agency

8. Evaluation

A. Briefly describe the self-evaluation efforts, as described in the approved grant application, and the results of those efforts for this reporting period.

     

B. Briefly describe any other independent evaluation effort and results for this reporting period. If none were conducted, enter “None.”

     

C. List future evaluation plans as described in your approved grant application. If none were planned, enter “None.”

     

D. Describe the most effective activities and services provided in meeting project goals and why they were effective. Examples may include, but are not limited to, developing new approaches for service provision, native healing, outreach, collaboration with a particular state rehabilitation counselor or administrator, or being involved with the one-stop program.

     

9. Consumer Satisfaction

Note: The information provided in this section is for use by RSA’s AIVRS ED Program Staff and is held confidential.

1. Did the grant application describe consumer satisfaction activities that would be conducted during this reporting period?

Yes

No

2. Were consumer satisfaction activities conducted during this reporting period? If yes, describe the types of consumer satisfaction activities conducted during this reporting period.		Yes		No
     

If no, but the application stated that consumer satisfaction activities would be conducted during this reporting period, explain why activities were not conducted.

     

10. Training and Technical Assistance Needs

Section 121(c) of the Rehabilitation Act as amended by Workforce Innovation and Opportunity Act (WIOA), P.L. 113-128

Survey

This survey is designed to identify the training and technical assistance needs of the AIVRS programs. Your answers in this survey will guide the priorities set by RSA for the Training and Technical Assistance project (84.250Z).

Instructions

Of all the items listed below, please choose no more than ten (10) items that reflect the training and technical assistance needs of your AIVRS project. Please prioritize each of the 10 items you choose with 1 being the highest priority. To delete an entry, click on the space above the “1-most important” option on the drop down menu. If you cannot complete the survey in one sitting, you may close out and resume where you left off when you reopen the form. Please provide any additional comments in the text box provided.

Applicable Laws

General overview and promulgation of various disability laws

Workforce Innovation and Opportunity Act (WIOA)

Medicaid/Medicare/PAS/waivers/long-term care

Rehabilitation Act of 1973, as amended

Social Security Act

Workforce Investment Act of 1998

Ticket to Work and Work Incentives Improvement Act of 1999

Government Performance Results Act of 1993

Assistive Technologies

General Overview

Data Collecting and Reporting

AIVRS Annual Performance Report

Performance Measures contained in AIVRS Report

Employment Outcomes

Financial: Grant Management

Federal Regulations

Budget Management

Fund Accounting

Financial: Resource Development

Community Partners

Program Planning

Conflict Management

Client Assistance Program/Due Process

Confidentiality

Collaboration in Shared Cases

Case Management and Case Record Documentation

Eligibility Determination and Individualized Plan for Employment

Assessment

Informed Choice

Vocational Rehabilitation Services (Sec. 103)

Staff Development in Current Issues in Physical and Mental Disabilities

Outreach to Unserved/Underserved Populations

Understanding Disabilities

Institutionalized Potential Consumers

Veterans

Other Areas and/or Comments (write-in)

Working with consumers that have criminal histories, felonies

Working with consumers that have drug and alcohol use disorders

A-1