Form RSA-15 Report of Vending Facility

REPORT OF VENDING FACILITY PROGRAM

­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­STATE:
REPORTING PERIOD: October 1 to September 30

U.S. Department of Education

Rehabilitation Services Administration

Washington, D.C. 20202

Form RSA-15

OMB No. 1820-0009

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 23.5 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

1. EARNINGS AND EMPLOYMENT

1. Gross Sales $

2. Merchandise Purchases $

3. Gross Profit (subtract line 2 from line 1) $

4. Payroll Expenses $

5. Other Operating Expenses $

6. Total Expenses (add lines 4 and 5) $

7. Operating Profit (subtract line 6 from line 3) $

8. Vending Machine and Other Income $

9. Retirement/Other Benefits Paid to/for Vendors During the Operating Year $

10. Net Proceeds (add lines 7, 8, and 9) $

11. Levied Set Aside Funds $

12. Net Profit to Vendors (subtract line 11 from line 10) $

13. Fair Minimum Return to Vendors $

14. Vendor Earnings (add lines 12 and 13) $

15. Vendor Person Years of Employment $

16. Average Vendor Earnings (divide line 14 by line 15) $

17. The Median of Vendor Earnings in the State $

18. Number of Other Persons with Disabilities Employed $

19. Total Number Employed in the Program $ _______________

2. VENDING FACILITIES AND VENDORS

1. FACILITIES ON FEDERAL PROPERTY

1. Number at Beginning of the Year

2. Number Established During the Year

3. Number Closed During the Year

4. Number at End of the Year

2. VENDING FACILITIES LOCATED ON FEDERAL PROPERTY, END OF YEAR

1. General Services Administration

2. U.S. Postal Service

3. Department of Defense (Add 3a. and 3b.)

1. Military Dining Facility Contracts

2. Other Department of Defense Vending Facilities

4. Department of Homeland Security

5. Department of Health and Human Services

6. Veterans Administration

7. Department of the Interior

8. Vending Routes on Multiple Federal Locations

9. Other Federal Agencies (please identify): __________________________

10. Total (add lines 1 through 9)

3. CONTRACTS FOR OPERATION OF CAFETERIAS AND MILITARY DINING FACILITIES

   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
   				$
   				$
   				$
   				$

4. VENDORS ON FEDERAL PROPERTY

1. Number at Beginning of the Year

2. Number Entering During the Year

3. Number Leaving During the Year

4. Number at End of the Year

5. FACILITIES ON PUBLIC PROPERTY (State, County, Municipal)

1. Number at Beginning of the Year

2. Number Established During the Year

3. Number Closed During the Year

4. Number at End of the Year

1. Vending Facilities on State Property (end of year)

2. Vending Facilities on County Property (end of year)

3. Vending Facilities on Municipal Property (end of year)

6. VENDORS ON PUBLIC PROPERTY (State, County, Municipal)

1. Number at Beginning of the Year

2. Number Entering During the Year

3. Number Leaving During the Year

4. Number at End of the Year

7. FACILITIES ON PRIVATE PROPERTY

1. Number at Beginning of the Year

2. Number Established During the Year

3. Number Closed During the Year

4. Number at End of the Year

8. VENDORS ON PRIVATE PROPERTY

1. Number at Beginning of the Year

2. Number Entering During the Year

3. Number Leaving During the Year

4. Number at End of the Year

3. VENDING LOCATIONS UNDER THE INTERSTATE HIGHWAY PROGRAM (Transportation Equity Act for the 21st Century of June 1998)

   Item	Total Number (1)	Total Vending Machine Receipts (2)
   Total Number of Vending Locations
   Number of Locations Operated by Vendors		$
   Number of Locations Operated by Third-Party Contractors		$
   Number of Vendors Operating Locations in the Highway Program

4. PROGRAM EXPENDITURES BY SOURCE OF FUNDS

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

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

Item	Vending Machine Income Federal (1)	Vending Machine Income Non-Federal (2)	Levied Set-Aside (3)	Total (4)
1. Amount at Beginning of the Year	$	$	$	$
2. Funds Added During the Year	$	$	$	$
3. Total Funds Available (add lines 1 and 2)	$	$	$	$
4. Funds Distributed to Vendors	$	$	$	$
5. Other Funds Expended	$	$	$	$
6. Total Funds Distributed and Expended (add lines 4 and 5)	$	$	$	$
7. Amount at the End of the Year (subtract line 6 from line 3)	$	$	$	$

6. NUMBER OF SITES SURVEYED

Item	Federal Property Total (1)	Non-Federal Property (2)	Total (3)
1. Number of Sites Surveyed During the Reporting Year
2. Number of Sites Accepted by the SLA (add a., b., c., and d.)
Number of Accepted Sites Added to Existing Vending Facilities
Number of Accepted Sites Used to Create New Vending Facilities
Number of Accepted Sites Pending Assignment to a Blind Vendor
Number of Accepted Sites Contracted to a Third-Party
3. Number of Sites Not Accepted by the SLA (add a., b., and c.)
Due to Infeasibility of Site
Due to Lack of Available SLA Funds
Due to Lack of Qualified Vendors
4. Number of Sites Denied to the SLA by Property Management Officials
5. Number of Surveyed Sites with a Decision Pending

7. VENDOR TRAINING

1. Number of Individuals Completing Training in the Reporting Year

to Become Vendors: (add a through d)

1. Number Licensed and Placed as Vendors

2. Number Certified Awaiting Placement as Vendors

3. Number Placed as Employees in the Vending Facility Program

4. Number Employed in Allied Food Service Occupations

2. Total Number of Certified/Qualified Individuals Awaiting Placement as Vendors

3. Number of Vendors Provided In-Service Training (including on-line training)

4. Number of Vendors Provided Upward Mobility Training (including on-line 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

8. STATE AND NOMINEE AGENCY PERSONNEL

1. Agency Personnel

Type of Personnel	State Agency Personnel (1)	Nominee Agency Personnel (2)	Total (3)
Vending Facility Program Staff (FTE)
a. Number of Business Consultants/Counselors Staff (FTE)

2. Training

Type of Training	State Agency Personnel (1)	Nominee Agency Personnel (2)	Total (3)
Number Who Received Training Related to Blindness, Business Management, or Aspects of the Randolph-Sheppard Vending Facility Program
Number Who Participated in National Consumer-Driven Conferences
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.

Name of Authorized Official

Title

Date Certified

Contact Person

Telephone Number

Email Address

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