7-ob

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ED(RSA)-7-OB Form

OMB No. 1820-0608

Expiration Date:

UNITED STATES DEPARTMENT OF EDUCATION

OFFICE OF SPECIAL EDUCATION AND REHABILITATIVE SERVICES

REHABILITATION SERVICES ADMINISTRATION

Washington D.C. 20202

FISCAL YEAR _______

ANNUAL REPORT

INDEPENDENT LIVING SERVICES FOR

OLDER INDIVIDUALS WHO ARE BLIND (OIB) Program

Grantee
Grant No.

Title VII Chapter 2, of the Rehabilitation Act, as amended by Title IV of the Workforce Innovation and Opportunity Act (WIOA)

Sections 751(b) and 752(h)(2)(A) of the Rehabilitation Act, as amended by the Workforce Innovation and Opportunity Act (WIOA)

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 OMB control number for this collection is 1820-0608. Public reporting burden for this collection of information is estimated to average 360 minutes/6 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 benefits under Sec. 752(h)(2)(A) of the Rehabilitation Act of 1973, as amended by Title IV of the Workforce Innovation and Opportunity Act (WIOA). 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 1820-0608. If you have comments or concerns regarding the status of your individual submission of this form, write directly to: Roseann Ashby, U.S. Department of Education, 400 Maryland Ave, S.W., PCP Room 5151, Washington, D.C. 20202-5176.

TABLE OF CONTENTS

PART I: FUNDING SOURCES AND EXPENDITURES IN SUPPORT OF THE OIB PROGRAM 3

PART II: PROGRAM STAFFING 5

PART III: DATA ON INDIVIDUALS SERVED 6

PART IV: TYPES OF SERVICES PROVIDED AND FUNDS EXPENDED 9

PART V: PROGRAM PERFORMANCE MEASURES AND OUTCOME DATA 11

PART VI: TRAINING AND TECHNICAL ASSISTANCE NEEDS 14

Part VII: Narrative 15

PART VIII: SIGNATURE 16

PART I: FUNDING SOURCES AND EXPENDITURES IN SUPPORT OF THE OIB PROGRAM

1. Funding Sources and Amounts in Support of the OIB Program for the Reported Federal Fiscal Year (FFY)

1. Title VII-Chapter 2 Federal grant award for

reported FFY $ _______________

2. Title VII-Chapter 2 carryover from previous FFY $ _______________

3. Total Title VII-Chapter 2 Funds (A1 + A2) $ _______________

4. Title VII-Chapter 1, Part B Funds $ _______________

5. Other Federal funds available for expenditure in

the reported FFY $ _______________

6. TOTAL FEDERAL FUNDS (A3 + A4 + A5) $ _______________

7. State funds (excluding in-kind contributions) $ _______________

8. In-kind contributions $ _______________

9. Other non-Federal funds $ _______________

10. TOTAL NON-FEDERAL FUNDS (A7 + A8 + A9) $ _______________

11. TOTAL OF ALL FUNDS AVAILABLE FOR EXPENDITURE

IN THE REPORTED FFY (A6 + A7 + A9) $ _______________

B. OIB Program Expenditures in Reported FFY

1. Funds expended for administrative costs in the

reported FFY

1. Administrative expenditures from (1) Title

VII-Chapter 2 OIB Federal grant award funds

and (2) non-Federal sources used in meeting

the match requirement $ ______________

2. Administrative expenditures from all other

allowable sources as identified in Part IA

above $ ______________

3. Total administrative expenditures (Sum of

1A and 1B) $ ______________

2. Funds expended for direct program services

during the reported FFY

1. Direct service expenditures from (1) Title

VII-Chapter 2 OIB Federal grant award

and (2) funds from non-Federal sources

used in meeting the match requirement $ ______________

2. Direct service expenditures from all other

allowable sources as identified in Part IA

above $ ______________

3. Total direct service expenditures (Sum

of 2a and 2b) $ ______________

3. Total funds expended for the program during

the reported FFY (B1c + B2c) $ ______________

PART II: PROGRAM STAFFING

A. Full-time Equivalent (FTE) Program Staff

FTE (full time equivalent) is based on the number of hours per week considered full time for the position.

Type of staff	Administrative & Support (a)	Direct Service(b)	TOTAL (c)
1. FTE State Agency	(a)	(b)	(c)
2. FTE through contract/subgrant	(a)	(b)	(c)
3. TOTAL FTE (A1 + A2)	(a)	(b)	(c)

B. Employees with Disabilities

Employees with Disabilities (agency and contract/subgrant staff)	Number of Employees
1. Employees with Disabilities other than blindness or severe visual impairments
2. Employees with Blindness or Severe Visual Impairments who are Age 55 and Older
3. Employees with Blindness or Severe Visual Impairments who are under Age 55
4. TOTAL EMPLOYEES with Disabilities (B1 + B2 + B3)

PART III: DATA ON INDIVIDUALS SERVED

Provide data in each of the categories below on the number of individuals for whom one or more services were provided (program participants) during the reported FFY.

A. Individuals Served

1. Number of individuals who began receiving

services in the previous FFY and continued

to receive services in the reported FFY _____________

2. Number of individuals who began receiving

services in the reported FFY _____________

3. TOTAL individuals served during the reported

FFY (Sum of A1 + A2)

B. Age at Application

1. 55-64 _____________

2. 65-74 _____________

3. 75-84 _____________

4. 85 & over _____________

5. TOTAL – Sum of B1 + B2 + B3 + B4, total must agree with A3

C. Gender

1. Individual self-identifies as female _____________

2. Individual self-identifies as male _____________

3. Individuals who did not self-identify gender _____________

4. TOTAL – Sum of C1 + C2 + C3, total must agree with A3

D. Race

1. American Indian or Alaska Native _____________

2. Asian _____________

3. Black or African-American _____________

4. Native Hawaiian or Other Pacific Islander _____________

5. White _____________

6. Individual Did Not Self-Identify Race _____________

7. Two or More Races _____________

8. TOTAL – Sum of D1 + D2 + D3 + D4 + D5 + D6 + D7, total must agree with A3

E. Ethnicity

1. Hispanic or Latino _____________

F. Degree of Visual Impairment

1. Totally Blind (Light perception only or no

light perception) _____________

2. Legally Blind (excluding totally blind) _____________

3. Severe Visual Impairment _____________

4. TOTAL – Sum of F1 + F2 + F3, total must agree with A3

G. Major Cause of Visual Impairment

1. Macular Degeneration _____________

2. Diabetic Retinopathy _____________

3. Glaucoma _____________

4. Cataracts _____________

5. Other Cause of Visual Impairment _____________

6. TOTAL – Sum of G1 + G2 + G3 + G4 + G5, total must agree with A3

H. Other Age-Related Impairments

1. Hearing Impairment _____________

2. Mobility Impairment _____________

3. Communication Impairment _____________

4. Cognitive or Intellectual Impairment _____________

5. Mental Health Impairments _____________

6. TOTAL – Sum of H1 + H2 + H3 + H4 + H5, total must agree with A3

I. Type of Residence

1. Private Residence (house or apartment) _____________

2. Senior Independent Living Facility _____________

3. Assisted Living Facility _____________

4. Nursing Home/Long-term Care Facility _____________

5. Homeless _____________

6. TOTAL – Sum of I1 + I2 + I3 + I4 + I5, total must agree with A3

J. Source of Referral

1. Eye care provider (ophthalmologist, optometrist) _____________

2. Physician/medical provider _____________

3. State VR agency _____________

4. Government/Public or Private Social Service

agency not listed elsewhere _____________

5. Veterans Administration _____________

6. Senior Program _____________

7. Assisted Living Facility _____________

8. Nursing Home/Long-term Care Facility _____________

9. Independent Living Center _____________

10. Family Member or Friend _____________

11. Self-referral _____________

12. Other Sources _____________

13. TOTAL – Sum of J1 through J12, total must agree with A3

PART IV: TYPES OF SERVICES PROVIDED AND FUNDS EXPENDED

Provide data related to the number of older individuals who are blind receiving each type of service and funds expended for each type of service.

A. Clinical/functional vision assessments and services

1. Total expenditures from all sources of program

funding $ ___________

2. Persons Served – Vision screening/vision

examination/low vision evaluation ___________

3. Persons Served – Surgical or therapeutic

treatments to prevent, correct, or modify

disabling eye conditions ___________

B. Assistive Technology devices and services

1. Total expenditures from all sources of program

funding $ ___________

2. Total unduplicated count of persons served –

Provision of assistive technology devices

and/or services ___________

C. Independent living and adjustment training services

1. Total expenditures from all sources of program

funding $ ___________

2. Total unduplicated count of persons receiving

independent living and adjustment training

services ___________

3. Number of persons receiving the following

services:

1. Orientation and mobility training __________

2. Communication skills training __________

3. Daily living skills training __________

4. Advocacy training __________

5. Adjustment counseling and/or peer support

services (individual or group) __________

6. Information and referral services __________

7. Other independent living services __________

D. Supportive services

1. Total expenditures from all sources of program

funding $ _________

2. Total unduplicated count of persons served –

Supportive services (reader services,

transportation, personal attendant

services, support service providers,

interpreters, etc.) __________

E. Community Awareness Activities and Information and Referral

1. Total expenditure from all sources of program

funding __________

F. TOTAL DIRECT EXPENDITURES – Sum of A1 + B1

+ C1 + D1 + E1, total must agree with the

direct service expenditures reported in

Part 1, B2 __________

PART V: PROGRAM PERFORMANCE MEASURES AND OUTCOME DATA

Program Measures

Objective: To restore, improve, or maintain the independence of older individuals whose functional capabilities have been lost or diminished as a result of vision loss or blindness.

A. Assistive Technology Devices and Services

Measure A: The percentage of individuals receiving assistive technology devices and services who demonstrated improvement in one or more functional capabilities during the reported FFY consistent with the objectives for receiving such devices and services.

B. Independent Living and Adjustment Training Services

Measure B: The percentage of individuals receiving one or more independent living and adjustment training services who demonstrated improvement in functional capabilities during the reported FFY.

C. Independence in the home and community

Measure C1: The percentage of individuals completing a plan of services who reported feeling that they are more confident in their ability to maintain their current living situation.

Measure C2: The percentage of individuals completing a plan of services who reported an increased ability to engage in their customary daily life activities in the home and community.

D. Efficiency Measure (To be calculated by RSA MIS from data reported in PARTS I and III)

Objective: To provide cost effective supports and services to increase the independence of older individuals who are blind so that they may remain in the community and to prevent or delay the need for an increasing level of care, particularly for those individuals who are at risk of entering institutions.

Measure: The average annual cost per individual served through the program during the reported FFY.

Provide the following data for each of the performance measures below. This will assist RSA in reporting results and outcomes related to the program.

PROGRAM PERFORMANCE DATA	Number of Persons	Percent of Persons
A. Assistive Technology Devices and Services
A1. Enter the unduplicated number of individuals receiving assistive technology devices and services for whom change in functional capabilities was assessed, during the reported FFY (Denominator).
A2. Enter the number of individuals receiving assistive technology devices and services who demonstrated improvement in one or more functional capabilities, during the reported FFY. (Numerator) Note: An individual who maintained but did not improve their capabilities may be reported here if the individual’s goal was to prevent further decline in their capabilities.
A3. The percentage of individuals receiving assistive technology devices and services who demonstrated improvement in one or more functional capabilities during the reported FFY consistent with the objectives for receiving such devices and services. (A2 divided by A1)	N/A	computed
B. Independent Living and Adjustment Training Services
B1. Enter the unduplicated number of individuals receiving independent living and adjustment training services for whom change in functional capabilities was assessed during the reported FFY (Denominator).
B2. Enter the unduplicated number of individuals receiving independent living and adjustment training services who demonstrated improvement in one or more functional capabilities. (Numerator) Note: An individual who maintained but did not improve their capabilities may be reported here if the individual’s goal was to prevent further decline in their capabilities.
B3. The percentage of individuals receiving one or more independent living and adjustment training services who demonstrated improvement in functional capabilities during the reported FFY.		computed
C. Independence in the Home and Community
C1. Enter the total number of individuals completing a plan of services during the reported FFY (Denominator).
C2. Enter the number of individuals completing a plan of services during the reported FFY that reported an increased ability to engage in their customary daily life activities in the home and community (Numerator).
C3. The percentage of individuals completing a plan of services who reported an increased ability to engage in their customary daily life activities in the home and community.		computed
C4. Enter the number of individuals completing a plan of services who reported feeling that they are more confident in their ability to maintain their current living situation as a result of services they received (Numerator).
C5. The percentage of individuals completing a plan of services who reported feeling that they are more confident in their ability to maintain their current living situation.		computed
D. Efficiency Measure (To be calculated by RSA from data reported in PARTS I and III)
D1.Total funds expended for direct program services during the reported FFY (as reported in PART I B2)	computed
D2. Number of individuals receiving services during the reported FFY (as reported in PART III A3)	computed
D3. The average annual cost per individual served through the program during the reported FFY.			computed

PART VI: TRAINING AND TECHNICAL ASSISTANCE NEEDS

Enter a brief description of training and technical assistance needs that you may have to assist in the implementation and improvement of the performance of your OIB program in your state.

Part VII: Narrative

A. Briefly describe the agency’s method of implementation for the OIB program (i.e. service delivery provided in-house, through sub-grantees/contractors, or a combination) incorporating outreach efforts to reach underserved and/or unserved populations. List all sub-grantees/contractors.

B. Briefly summarize results from your recent evaluations or satisfaction surveys conducted for your program.

C. Briefly describe the impact of the OIB program, citing examples from individual cases (without identifying information) in which services contributed significantly to increasing independence and quality of life for the individual(s).

D. Briefly describe the community awareness/outreach efforts and information and referral activities conducted with Title VII-Chapter 2 funds and other funds and the outcome of those activities.

E. Briefly describe capacity-building activities, including collaboration with other agencies and organizations (other than with sub-grantees) and the outcome of these activities on the program.

PART VIII: SIGNATURE

Sign and print the name, title and telephone number of the IL-OIB Program Director below.

I certify that the data herein reported are statistically accurate to the best of my knowledge.

Name (Printed)

Title

Telephone Number

Email

Date

Name (Signature)

Note: The report must be signed by a certifying official who is authorized to legally bind the non-Federal entity. By signing the report electronically, the grantee’s certifying official certifies the following statement: “By signing this report, I certify to the best of my knowledge and belief that the report is true, complete, and accurate, and the expenditures, disbursements and cash receipts are for the purposes and objectives set forth in the terms and conditions of the Federal award. I am aware that any false, fictitious, or fraudulent information, or the omission of any material fact, may subject me to criminal, civil or administrative penalties for fraud, false statements, false claims or otherwise.” (2 C.F.R. § 200.415 and U.S. Code, Title 18, Section 1001).