Aivrs Apr

Annual Reporting Form for American Indian Vocational Rehabilitation Services (AIVRS)

This form (OMB 1820-0655) has been approved for use by OMB through 01/31/2024.

Tribe Name: Click or tap here to enter text.

P/R Award Number: Click or tap here to enter text.

Reporting Period: Click or tap to enter a date. To Click or tap to enter a date.

Amount of Award: Click or tap here to enter text.

General Information

Grantee Name: Click or tap here to enter text.

State: Click or tap here to enter text.

Grant Start Date: Click or tap to enter a date.

Grant End Date: Click or tap to enter a date.

Project Title: Click or tap here to enter text.

Project Director: Click or tap here to enter text.

Telephone: Click or tap here to enter text.

Email: Click or tap here to enter text.

Grantee URL (if applicable): Click or tap here to enter text.

Grantee/Project Email (if Applicable): Click or tap here to enter text.

Grantee 800 Number (if applicable): Click or tap here to enter text.

Person responsible for completing this form

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

Name: Click or tap here to enter text.

Title: Click or tap here to enter text.

Telephone: Click or tap here to enter text.

Email: Click or tap here to enter text.

Authorized Representative

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

Name: Click or tap here to enter text.

Title: Click or tap here to enter text.

Telephone: Click or tap here to enter text.

Email:Click or tap here to enter text.

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

1. Budget and Narrative

1. Did this reporting period start with carry-over funds? Choose N/A for six-month and first year reports. (Carry-over funds are grant funds that are unobligated during a fiscal year which can be used for obligations the following fiscal year, as long as he grantee met its required match.)

2. If yes, enter the dollar amount.

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3. Did this reporting period end with unobligated funds? Choose N/A. for six-month reports.

4. Provide the reason why there are unobligated funds.

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5. Of the amount of unobligated funds, enter the carry-over amount for the net reporting period.

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6. Enter any program income generated for his reporting period. Enter 0 (zero) if none.

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7. Enter the total amount of cash funding, in support of the grant, received during this reporting period from sources other than program income (question 6), grant award, or match contribution. Enter 0 (zero) if no other funding was received.

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8. List the full name(s) of the cash-funding identified in question 7. If there are no sources, enter “None”.

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9. During this reporting period, were there any modifications to the budget? If no, skip to question 12.

10. Was the modification(s) approved by RSA? If yes, skip to question 12.

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

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12. 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 in which eligible individuals will receive vocational rehabilitation (VR) services, in the event 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.

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.”

List the goals and objectives, as they were described in the approved grant application, and the progress made towards achieving each of those goals and objectives that are specific to this reporting period. If there were any changes to any of the goals or objectives requested and approved during this reporting period, address those.

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3. Serving American Indians with Disabilities

Questions 1 to 4 ask for details on individuals who were served during this reporting period.

1. Enter the total number of individuals proposed to be served under an Individualized Plan for Employment (IPE) during this reporting period.

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2. Enter the number of individuals who received VR services under an IPE developed during this reporting period (Exclude amendments to the IPE).

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3. Enter the number of individuals who received VR services under an IPE developed prior to this reporting period (including a prior grant cycle).

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4. The total number of individuals who received VR services under an IPE during this reporting period (add the numbers entered for questions 2 and 3 for the result).

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5. This is the percent based on the ratio of those individuals who the project proposed to be served by the number of individuals who the project actually served (divide the number entered in question 4 by the number ended in question 1).

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6. Explain why the number served is fewer than the number proposed for this reporting period.

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4. VR Services

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

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

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

VR Services	Services provided paid in full with AIVRS (grant) funds	Services provided paid for in part or in full with funds other than AIVRS (grant) funds
1. Assessment for determining eligibility and VR needs.	Click or tap here to enter text.	Click or tap here to enter text.
2. Counseling and guidance.	Click or tap here to enter text.	Click or tap here to enter text.
3. Referral and other services to secure needed services.	Click or tap here to enter text.	Click or tap here to enter text.
4. Job-related services, including job search and placement assistance, job retention services, follow-up services, and follow-along services.	Click or tap here to enter text.	Click or tap here to enter text.
5. Vocational and other training services, including personal and vocational adjustment training services.	Click or tap here to enter text.	Click or tap here to enter text.
6. Books, tools, and other training materials	Click or tap here to enter text.	Click or tap here to enter text.
7. Diagnosis treatment of physical and mental impairments as included in Section 103(a)(6)(A-F) of the Rehabilitation Act.	Click or tap here to enter text.	Click or tap here to enter text.
8. Maintenance.	Click or tap here to enter text.	Click or tap here to enter text.
9. Transportation.	Click or tap here to enter text.	Click or tap here to enter text.
10. On-the-job or other related personal assistance services provided while an individual is receiving other services.	Click or tap here to enter text.	Click or tap here to enter text.
11. Interpreter and reader services.	Click or tap here to enter text.	Click or tap here to enter text.
12. Rehabilitation teaching services and orientation and mobility services for individuals who are blind.	Click or tap here to enter text.	Click or tap here to enter text.
13. Occupational license, tools, equipment, and initial stocks and supplies.	Click or tap here to enter text.	Click or tap here to enter text.
14. Technical assistance and other services to conduct market analysis, 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.	Click or tap here to enter text.	Click or tap here to enter text.
15. Rehabilitation technology, including telecommunications, sensory, and other technological aids and devices.	Click or tap here to enter text.	Click or tap here to enter text.
16. Transition services for students with disabilities that facilitates the achievement of the employment outcome identified in the IPE.	Click or tap here to enter text.	Click or tap here to enter text.
17. Supported employment services.	Click or tap here to enter text.	Click or tap here to enter text.
18. Customized employment	Click or tap here to enter text.	Click or tap here to enter text.
19. 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.	Click or tap here to enter text.	Click or tap here to enter text.
20. Services to the family of an individual with a disability necessary to assist the individual to achieve an employment outcome.	Click or tap here to enter text.	Click or tap here to enter text.
21. Specific post-employment services necessary to assist an individual with a disability to retain, or advance in employment.	Click or tap here to enter text.	Click or tap here to enter text.
22. Services traditionally used by Indian Tribes, including native healing.	Click or tap here to enter text.	Click or tap here to enter text.
23. Other service(s) determined necessary to assist an individual with a disability achieve an employment outcome.	Click or tap here to enter text.	Click or tap here to enter text.

If other service(s) were provided for #23, including culturally appropriate VR services, list the service(s) and provide the number of individuals who received each of the other services in column 1) or 2) according to the instructions in the second bullet at the top of this section.

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5. Employment/Educational Outcomes

• 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,a s 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 requiring 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.

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

1. Enter the number of individuals the project proposed to achieve an employment outcome during this reporting period.

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2. Enter the actual number of individuals who achieved an employment outcome. If the answer is none, enter 0 (zero) and go to Item #11.

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

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

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

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5. Achieved an employment outcome of self-employment (including subsistence outcomes):

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6. Achieved an employment outcome of telecommuting:

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7. Achieved an employment outcome of business ownership:

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8. Achieved an employment outcome in supported employment (supported employment defined in Section 7(38) of the Rehabilitation Act of 1973):

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9. Achieved any other type of employment outcome (e.g., unpaid work on family farm or business):

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10. This 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.

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11. Enter 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).

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12. 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.

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13. Explain if the number of employment outcomes achieved is substantially fewer than proposed for this reporting period.

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14. Enter the number of individuals enrolled in a post-secondary program or in one or more training programs.

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15. Enter the number of individuals who completed an educational program consistent with their IPE.

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6. Interaction with State VR Agency

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

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?

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List the interaction with the State VR Agency or 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 space is needed to add a State VR Agency, feel free to use space in the Executive Summary of the ED 524B form.

For each agency listed:

1. Describe or provide examples of interactions including, but not limited to, training/cross training, working jointly with eligible individuals, referrals, or having a VR representative on the State Rehabilitation Council.

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

3. Rate the overall satisfaction of the interactions with the agency (1 being least satisfied, 5 being most satisfied).

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

Agency 1

Agency:Click or tap here to enter text.

1. Type of Interactions: Click or tap here to enter text.

2. Concerns/Issues with Collaboration or Service Provision: Click or tap here to enter text.

3. On a scale of 1 to 5, rate the level of satisfaction of interactions with this agency.

Agency 2

Agency: Click or tap here to enter text.

1. Type of Interactions: Click or tap here to enter text.

2. Concerns/Issues with Collaboration or Service Provision: Click or tap here to enter text.

3. On a scale of 1 to 5, rate the level of satisfaction of interactions with this agency.

Agency 3

Agency: Click or tap here to enter text.

1. Type of Interactions: Click or tap here to enter text.

2. Concerns/Issues with Collaboration or Service Provision: Click or tap here to enter text.

3. On a scale of 1 to 5, rate the level of satisfaction of interactions with this agency.

Agency 4

Agency: Click or tap here to enter text.

1. Type of Interactions: Click or tap here to enter text.

2. Concerns/Issues with Collaboration or Service Provision: Click or tap here to enter text.

3. On a scale of 1 to 5, rate the level of satisfaction of interactions with this agency.

Agency 5

Agency: Click or tap here to enter text.

1. Type of Interactions: Click or tap here to enter text.

2. Concerns/Issues with Collaboration or Service Provision: Click or tap here to enter text.

3. On a scale of 1 to 5, rate the level of satisfaction of interactions with this agency.

Agency 6

Agency: Click or tap here to enter text.

1. Type of Interactions: Click or tap here to enter text.

2. Concerns/Issues with Collaboration or Service Provision: Click or tap here to enter text.

3. On a scale of 1 to 5, rate the level of satisfaction of interactions with this agency.

7. Evaluation

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

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2. Describe any other independent evaluation effort and its results for this reporting period. If none were conducted, enter "None".

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3. List future evaluation plans as described in your approved grant application. If none were planned, enter "None".

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4. 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, traditional healing, outreach, collaboration with a particular state rehabilitation counselor or administrator, or conducting a consumer satisfaction survey, etc.

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

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6. Were consumer satisfaction activities conducted during this reporting period? If yes, describe the types of consumer satisfaction activities conducted during this reporting period. If no, but the approved grant application stated that consumer satisfaction activities would be conducted during this reporting period, explain why activities were not conducted.

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8. Special Application Requirements

Provide examples of how the Special Application Requirements were met during this reporting period.

By completing this section, you are providing evidence that the data reported is true, complete, correct, and verifiable.

371.21(a): Effort will be made to provide a broad scope of vocational rehabilitation services in a manner and at a level of quality at least comparable to those services provided by the designated State unit.

Tribe’s Example: Click or tap here to enter text.

371.21(b): All decisions affecting eligibility for vocational rehabilitation services, the nature and scope of available vocational rehabilitation services and the provision of such services, will be made by a representative of the Tribal vocational rehabilitation program funded through this grant and such decisions will not be delegated to another agency or individual.

Tribe’s Example: Click or tap here to enter text.

371.21(c) Priority in the delivery of vocational rehabilitation services will be given to those American Indians with disabilities who are the most significantly disabled.

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371.21(d): An order of selection of individuals with disabilities to be served under the program will be specified if services cannot be provided to all eligible American Indians with disabilities who apply.

Tribe’s Example: Click or tap here to enter text.

371.21(e): All vocational rehabilitation services will be provided according to an individualized plan of employment which has been developed jointly by the representative of the Tribal vocational rehabilitation program and each American Indian with disabilities being served.

Tribe’s Example: Click or tap here to enter text.

371.21(f): American Indians with disabilities living on or near Federal or State reservations where Tribal vocational rehabilitation service programs are being carried out under this part will have an opportunity to participate in matters of general policy development and implementation affecting vocational rehabilitation service delivery by the Tribal vocational rehabilitation program.

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371.21(g): Cooperative working arrangements will be developed with the DSU, or DSUs, as appropriate, which are providing vocational rehabilitation services to other individuals with disabilities who reside in the State or States being served.

Tribe’s Example: Click or tap here to enter text.

371.21(h): Any comparable services and benefits available to American Indians with disabilities under any other program, which might meet in whole or in part the cost of any vocational rehabilitation service, will be fully considered in the provision of vocational rehabilitation services.

Tribe’s Example: Click or tap here to enter text.

371.21(i): Any American Indian with disabilities who is an applicant or recipient of services, and who is dissatisfied with a determination made by a representative of the Tribal vocational rehabilitation program and files a request for a review, will be afforded a review under procedures developed by the grantee comparable to those under the provisions of section 102(c)(1)-(5) and (7) of the Act.

Tribe’s Example: Click or tap here to enter text.

371.21(j): The Tribal vocational rehabilitation program funded under this part must assure that any facility used in connection with the delivery of vocational rehabilitation services meets facility and program accessibility requirements consistent with the requirements, as applicable, of the Architectural Barriers Act of 1968, the American with Disabilities Act of 1990, section 504 of the Act, and the regulations implementing these laws.

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371.21(k): The Tribal vocational rehabilitation program funded under this part must ensure that providers of vocational rehabilitation services are able to communicate in the native language of, or by using an appropriate mode of communication with, applicants and eligible individuals who have limited English proficiency, unless it is clearly not feasible to do so.

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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.  The valid OMB control number for this information collection is 1820-0655.  Public reporting burden for this collection of information is estimated to average 9.0 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 under EDGAR 75.118 and 75.590.  If you have any comments concerning the accuracy of the time estimate, suggestions for improving this individual collection, or if you have comments or concerns regarding the status of your individual form, application, or survey, please contact August Martin, Rehabilitation Services Administration, 550 12th St SW, Washington, DC 20202-2800 / [email protected], directly.