UNITED STATES DEPARTMENT OF EDUCATION

OFFICE OF SPECIAL EDUCATION AND REHABILITATIVE SERVICES

REHABILITATION SERVICES ADMINISTRATION

WASHINGTON, D.C. 20202-2531

POLICY DIRECTIVE

RSA-PD-01-04

DATE: March 27, 2001

ADDRESSEES: STATE VOCATIONAL REHABILITATION AGENCIES (GENERAL)

STATE VOCATIONAL REHABILITATION AGENCIES (BLIND)

CLIENT ASSISTANCE PROGRAMS

STATE REHABILITATION COUNCILS

AMERICAN INDIAN VOCATIONAL REHABILITATION SERVICE

PROGRAMS

RSA SENIOR MANAGEMENT TEAM

SUBJECT: Promulgation of Report Form RSA-227, Annual Client Assistance
Program (CAP) Report

POLICY

STATEMENT: The Office of Management and Budget (OMB) has approved a new
version of Form RSA-227, Annual Client Assistance Program (CAP) Report,
as a data collection instrument. OMB has approved the RSA-227 until
February 29, 2004, under the Paperwork Reduction Act of 1995. The OMB
number is 1820-0528.

RSA uses the form to meet specific data collection requirements of
Sections 13 and 112 of the Rehabilitation Act of 1973, as amended. We
have made minor revisions to the reporting form and instructions to
reflect mandates from the 1998 amendments and to clarify portions of the
previous form that were unclear.

We require that all CAPs report annually using Form RSA-227 (copy
attached). Information on transmittal of the form, including electronic
transmission, is found on pages 19-21 of the reporting instructions. The
form is due on or before December 30 of each year, which is 90 days
after the end of each fiscal year.

RSA has modified the annual reporting form in two specific ways.
Regarding the information being sought in Part II with respect to the
racial/ethnic background of those persons receiving services from the
CAPs, RSA has changed the wording of the categories. This modification
brings the annual reporting form into conformity with similar data
collection instruments used by RSA and other Federal agencies.

Again in Part II of the annual reporting form, in response to comments
received from the CAPs, RSA has eliminated the need to report
information concerning the reasons why persons are dissatisfied with the
services they have received from CAP. Both changes will enable the CAPs
to simplify their information collection procedures.

CITATIONS

IN LAW: Rehabilitation Act of 1973, as amended, Sections 13 and 112,
Paperwork Reduction Act of 1995

CITATIONS IN

REGULATIONS: 34 CFR Part 370

EFFECTIVE

DATE: Immediately upon issuance

AFFECTED

POLICIES: None

EXPIRATION

DATE: February 29,2004

INQUIRIES: RSA Regional Commissioners

Mark E.Shoob

> Deputy Commissioner

Rehabilitation Services Administration

ATTACHMENTS

**[Annual Client Assistance Program (CAP) Report (Form
RSA-227)]{.underline}**

**[Instructions]{.underline}**

1\. **[Heading]{.underline}**

**Fiscal Year:**

Enter the fiscal year covered by this report.

**Agency Information:**

Enter the name, address, telephone and fax numbers (including area
codes), and e-mail address of the agency designated to administer the
CAP. Be sure to include the same information for the operating CAP
agency, if different from the designated agency. Also include the name
of the CAP Director/Coordinator.

**Person to contact about this form:** Print/type the name and phone
number of the person RSA can contact if any problems with the form
arise.

2\. **[PART I. AGENCY WORKLOAD DATA]{.underline}**

**Definitional Guidelines for Completing this form:**

a\. **Information/referral service:** The Rehabilitation Act of 1973, as
amended (Act), and its implementing regulations authorize CAP to provide
information and referral services to any individual with disabilities in
the State or to Rehabilitation Act clients or client applicants who have
[not]{.underline} been defined as \"**individuals served**\" (see
defini­tion below) or to such individuals\' representatives.
Information/referral services include responses to individuals at
meetings, one-time telephone discussions, and follow-up mailings of
letters, brochures and/or pamphlets per an individual\'s request. These
individuals do not have case files (see definition below). These
services generally take less than one hour of service time. CAP usually
does not have personal identifying information about the individuals who
ask for and receive these services, except for perhaps the name, address
and phone number.

b\. **Individuals served:** An individual is considered an \"individual
served\" or a \"client\" of CAP if he/she meets three criteria:

1\) the individual is eligible for CAP services according to Section
112(a) of the Act;

2\) CAP has opened a case file/service record by including at least the
name, address, age, race, disability, signed release of information form
(if appropriate), concern or complaint, and action taken in the service
record; and

3\) CAP provided at least one \"significant service,\" such as:

a\) At least one hour of case service time;

b\) A supervised referral that allows follow-up to assure that the
referral was appropriate and completed;

c\) The completion of a second telephone call to the client when the
time between telephone calls was used to obtain additional information
about appropriate programs; or

d\) The provision of any allowable service beyond information and
referral (as defined above).

c\. **Case file/service record:** This is the compilation of personal
identifying information about the individual, documents, letters,
complaints/issues raised, advocate\'s notes, etc., used in working with
an \"**individual served**\" (as defined above). It may contain many
issues at any one time. In fact, most individuals served will present
several issues to CAP during the course of the CAP/client relationship.
The case file/service record is opened at the time CAP determines that
it will provide at least one \"significant service\" (as defined above)
for the individual. New issues may arise while still working with the
individual. These new issues, if appropriate for CAP intervention,
should be added to the existing case file/service record.

[A.]{.underline} [Information/referral services]{.underline}:

Include in this category the number of times that CAP provided
information about:

1\) services available under the Act and Title I of the Americans with
Dis­abilities Act (ADA) of 1990;

2\) the rights and responsibilities of persons applying for or receiving
services under the Act;

3\) the routine activities of programs, projects and community
rehabilitation programs funded under the Act; and

4\) services available from CAP.

Information/referral services also include responses to individuals at
meetings, one-time telephone discussions, and follow-up mailings of
letters, brochures or pamphlets. With regard to follow-up mailings, be
sure to count only the number of individuals who actually requested the
information, [not]{.underline} the number of letters, brochures or
pamphlets sent. Do not include the number of brochures, pamphlets or
newsletters that are routinely distributed en masse or the number of
individuals who attend workshops or presentations given by CAP.
Summarize these activities in the narrative section of this report.

Estimated counts are not acceptable for this section. All CAPs should
maintain logs to respond accurately to this item. Such routine requests
should not require maintenance of client confidential information,
extensive research by CAP staff, or extended contact with the
individual. Do [not]{.underline} include in this section any
information/referral services provided to individuals that meet the
definition of \"individuals served.\" Services provided to those
individuals are recorded in a later section of this report.

**Line A1:** Enter the number of requests CAP responded to regarding
information about services and benefits available under the Act (e.g.,
address of the State vocational rehabilitation (VR) agency or the scope
of VR services).

**Line A2:** Enter the number of requests CAP responded to regarding
information about rights under Title I of the ADA.

**Line A3:** Enter the number of requests CAP responded to regarding
information on other issues (e.g., Medicaid/Medicare, Social Security,
assistive technology, etc.).

**Line A4:** Add lines A1+A2+A3 and enter the total number here. This
should reflect the total number of information/referral services
provided by CAP during the fiscal year.

**Line A5 (optional):** Enter the number of individuals who attended
training sessions (e.g., orientation sessions, self-advocacy training,
etc.) conducted by CAP staff.

[B.]{.underline} [Individuals served]{.underline}:

As stated in the definitional guidelines section above, an \"individual
served\" is someone who is eligible for CAP services under the Act; who
has a case file/service record with CAP; and who receives one or more
significant services from CAP. All concerns noted in the case
file/service record should have required some type of intervention (even
if it is only brief) with a program, project or community rehabilitation
program funded under the Act from CAP staff in the resolution of the
problem.

An \"individual served\" is counted only once during a fiscal year,
regardless of how many case files/service records were opened/closed for
that individual during the year. Estimated counts are not acceptable.
All CAPs should maintain logs to respond accurately to this item. Do
[not]{.underline} include in this section any information/referral
services provided to individuals who do not meet the definition of
\"individuals served.\" Information/referral services provided to those
individuals are recorded in an earlier section of this report.

**Line B1:** Enter the number of individuals who had open case
files/service records on hand at the beginning of the fiscal year, which
were carried over from the prior fiscal year.

**Line B2:** Enter the number of individuals who had new case
files/service records opened during this fiscal year.

**Line B3:** Add lines B1+B2 and enter the total number here. This is
the total number of individuals served this fiscal year. Remember, no
individual may be counted more than once in a fiscal year.

**Line B4:** Of the number of individuals accounted for on Line B3,
enter here the number of those individuals who had more than one case
file/service record opened/closed during the fiscal year. Please refer
to the definitional guidelines above in answering this item.

**Example A:** An individual requests CAP assistance at the beginning of
the fiscal year. She raises several issues concerning her VR program.
CAP opens a case file/service record for her immediately. Three months
later, CAP has resolved all of the issues and there are no more
foreseeable problems. CAP closes the case file/service record. Near the
end of the fiscal year, the individual returns to CAP with new problems.
The issues she raises now may or may not be related to the issues CAP
assisted her with earlier in the year. CAP opens a new case file/service
record. This individual would be counted on Line B4 as having had
multiple case files/service records this year. If this were the only
individual who met this criteria, CAP should put a \"1\" on Line B4.

**Example B:** An individual requests CAP assistance sometime during the
fiscal year. The individual has raised several issues regarding her VR
program. CAP opens a case file/service record for this individual. While
CAP is working on resolving these initial issues and the case
file/service record is still open, the individual raises new issues that
are appropriate for CAP intervention. These new issues should be added
to those being worked on in the existing case file/service record. A new
case file should not be opened for this individual to address these new
issues. This individual would [not]{.underline} be counted on Line B4.
If none of the \"individuals served\" seems to match the criteria for
having multiple cases during the same year, CAP should put a \"0\" on
Line B4.

[C.]{.underline} [Individuals still being served as of September
30]{.underline}:

Enter here the number of individuals who still had open case
files/service records with CAP as of September 30. These are the
individuals who need CAP intervention to continue into the next fiscal
year (carryover) in order to resolve the problems/issues raised this
fiscal year. This number may not exceed the total of individuals served
listed on Line I.B3. This number will equal the \"number of individuals
with open case files/service records on hand as of October 1\" (Line
I.B1) on next fiscal year\'s annual report.

[D.]{.underline} [Reasons for closing individuals' case files/service
records]{.underline}:

Following is a list of the various reasons CAP might give for closing
the case file/service record of an \"individual served\". Please choose
**one** primary (most appropriate) reason for closing each case
file/service record (defined above). Do [not]{.underline} itemize a
reason for resolving each issue. This item asks you to choose one
overall reason for closing the entire case file/service record after CAP
has done all it can for the individual in terms of resolving the
issues/problems raised. The number of case files/service records may, in
some situations, be greater than the total number of individuals served
(Line I.B3) in order to account for those unusual situations, referred
to in Line I.B4, when an individual had multiple case files/service
records closed during the fiscal year. Estimated counts are not
acceptable. CAPs should maintain records to respond accurately to this
item.

**Line D1:** Enter the number of case files closed because all of the
issues requiring CAP intervention were resolved in favor of the
individual.

**Line D2:** Enter the number of case files closed which demonstrate
that at least some of the issues were resolved in the individual\'s
favor. This reason for closure is appropriate only if the individual has
raised multiple issues requiring CAP intervention during the time the
case file/service record was opened.

**Line D3:** Enter the number of case files closed because CAP
determined that the VR agency\'s decision or action is appropriate under
the Act and regulations and that there is nothing CAP can do at this
time.

**Line D4:** Enter the number of case files closed because CAP
determined, after exploring the facts and law, that the individual\'s
complaint lacked legal merit or that the individual\'s complaint was
outside the scope of CAP\'s authority.

**Line D5:** Enter the number of case files closed because the
individual decided not to pursue CAP representation, but instead
obtained representation elsewhere.

**Line D6:** Enter the number of case files closed because the
individual decided not to pursue resolution of the problem at this time.
In these situations, the individual wanted to \"forget it\".

**Line D7:** Enter the number of case files closed because the
individual had exhausted all available/appropriate appeal procedures and
did not prevail. The appeal procedures relevant to this item include
formal administrative hearings and legal remedies. For example, CAP may
choose to close a case for this reason if the individual served did not
prevail at the formal administrative hearing and the case lacks merit
for judicial review. CAP may also choose to close a case for this reason
if the individual served did not prevail at the formal administrative
hearing and judicial review is not allowed under the State\'s
Administrative Procedure\'s Act (APA). If a case file is closed at the
informal administrative review stage when the individual did not
prevail, one of the reasons given on Lines D2-6, 8-10 would be a more
appropriate reason for closing the case file/service record.

**Line D8:** Enter the number of case files closed because the
individual has died, or moved out of state, or for some reason is
unavailable for continued representation by CAP.

**Line D9:** Enter the number of case files closed because the
individual has made it impossible for CAP to continue effective
representation. Some of the reasons might have been that the individual
refused to:

> a\. give CAP access to necessary information in the individual\'s VR
> case file or past history;

b\. follow or accept CAP advice; or

c\. follow through with the individual\'s obligations.

**Line D10:** Enter the number of case files closed because CAP was
unable to represent the individual due to lack of CAP resources or
staff.

**Line D11:** Enter the number of case files closed for a reason not
listed above. RSA has attempted to list all of the possible reasons CAP
could cite for closing a case file/service record. However, we realize
there may be some unusual circumstances not encompassed in this listing.
This response should be reserved for rare instances. Be sure to attach a
separate explanation of the circumstances for the case closure if you
use this response.

[E.]{.underline} [Outcomes achieved]{.underline}:

\"Outcomes achieved\" should be recorded for each case file/service
record closed during the year. These are the outcomes that resulted from
CAP intervention on behalf of the individual served. Although services
rendered on behalf of an individual might have resulted in several
outcomes, choose **one** primary or most appropriate outcome for each
case file closed during the year ([not]{.underline} for each issue
addressed). Choose the outcome that reflects most of the services
rendered by CAP on behalf of the individual while the case file/service
record was opened. As stated in section D above, the number of case
files/service records may, in some situations, be greater than the total
number of individuals served (Line I.B3) in order to account for those
unusual situations, referred to in Line I.B4, when an individual had
multiple case files/service records closed during the fiscal year.
Estimated counts are not acceptable. CAPs should maintain records to
respond accurately to this item.

Enter the number of case files/service records closed in which the
following outcomes were achieved during the fiscal year:

**Line E1:** Enter the number of case files closed where the primary
outcome was that CAP explained the controlling law and/or policy to the
individual. For example, this outcome could be appropriate for those
case files closed because CAP determined that the VR agency\'s
decision/position was appropriate for the individual, or for those cases
closed because the individual\'s complaint lacked legal merit or was
beyond the scope of CAP\'s authority. This outcome also could be
appropriate for those times when the primary CAP service provided was
advice about the individual\'s rights under the ADA.

**Line E2:** Enter the number of case files closed where the primary
outcome was that the individual completed/submitted his application for
VR services.

**Line E3:** Enter the number of case files closed where the primary
outcome was that the eligibility determination process was expedited for
the individual.

**Line E4:** Enter the number of case files closed where the primary
outcome was that the individual was allowed to participate in an
extended evaluation process or other evaluation process.

**Line E5:** Enter the number of case files closed where the primary
outcome was the development or implementation of the IWRP for the
individual.

**Line E6:** Enter the number of case files closed where the primary
outcome was a compromise or a reversal of a decision by the other party.
The other party could be, among others, a VR agency, other community
rehabilitation program, or an employer on an issue involving Title I of
the ADA. This item could include those times when the compromise or
reversal of decision allowed the individual to exercise his/her right to
make informed choices.

**Line E7:** Enter the number of case files closed where the primary
outcome was that communication was re-established between the individual
and the other party. The other party could be, among others, a VR
agency, other community rehabilitation program, or an employer (for an
issue under Title I of the ADA). This item could include those times
when the re-establishment of communication enabled the individual to
exercise his/her right to make informed choices.

**Line E8:** Enter the number of case files closed where the primary
outcome was that the individual was assigned to a new counselor, office,
or program at the individual\'s request. This outcome would be most
appropriate for a case when the transfer itself basically resolved most
of the individual\'s issues/problems.

**Line E9:** Enter the number of case files closed where the primary
outcome was that CAP identified alternative resources for the individual
in order to resolve some or all of the issues raised.

**Line E10:** Enter the number of case files closed where the primary
outcome was that the individual filed an ADA/504/EEO/OCR complaint.

**Line E11:** Enter the number of case files closed where the primary
outcome was something other than listed above. RSA has attempted to list
all of the possible outcomes CAP could cite as having achieved. However,
we realize there may be others not encompassed in this listing. This
response should be reserved for rare instances. Be sure to attach a
separate explanation of the outcomes achieved if you use this response.

3\. **[PART II. PROGRAM DATA]{.underline}**

**[IMPORTANT NOTE]{.underline}:** The following items are based on
statistical information about the \"individuals served\" (defined
earlier in this report). Each individual may be counted only once during
a fiscal year. Estimated counts are not acceptable for these items. All
CAPs should maintain records to answer these items accurately.

[A.]{.underline} [Age]{.underline}:

Enter the number of individuals served in each of the age categories
listed. Record the individual\'s age as of the beginning of the fiscal
year. No individual can be counted more than once. The total recorded on
Line II.A5 must equal the total recorded on Line I.B3.

[B.]{.underline} [Gender]{.underline}:

Enter the number of individuals served according to their gender. Do not
count an individual more than once. The total recorded on Line II.B3
must equal the total recorded on Line I.B3.

[C.]{.underline} [Race/ethnicity]{.underline}:

Enter the number of individuals served according to their stated racial
or ethnic origin. An individual **may** be counted more than once, for
purposes of reporting his/her race/ethnicity on this form, in order to
account for those individuals who consider themselves
multicultural/racial.

**Line C1:** Enter the number of individuals served who consider
themselves to be an American Indian or Alaskan Native.

**Line C2:** Enter the number of individuals served who consider
themselves to be Asian. These individuals have origins in the Far East,
Southeast Asia, or the Indian subcontinent.

**Line C3:** Enter the number of individuals served who consider
themselves to be a Native Hawaiian or other Pacific Islander.

**Line C4:** Enter the number of individuals served who consider
themselves to be Black or African American. These individuals may be
African-American, African, Jamaican, etc.

**Line C5:** Enter the number of individuals served who consider
themselves to be Latino or Hispanic.

**Line C6:** Enter the number of individuals served who consider
themselves to be White or Caucasian.

**Line C7:** Enter the number of individuals served whose race or
ethnicity is unknown. This line should rarely be used.

[D.]{.underline} [Primary disabling condition of individuals
served]{.underline}:

Enter the number of individuals served according to the individual\'s
primary/major disabling condition. This is the physical or mental
condition, impairment or disease most responsible for the individual\'s
work or activity limitations. Consult the case file/service record or
the VR counselor to determine the major disabling condition. Persons
with multiple disabili­ties should be counted in the category that is
determined to be the primary disabling condition. Listed below is a
summary of the disabling conditions used by RSA in the VR classification
system. An individual may not be counted more than once during a fiscal
year. The total on Line II.D22 must equal the total on Line I.B3.

**Line D1:** Enter the number of individuals served who are blind in
both eyes. These individuals qualify as legally blind in both eyes.

**Line D2:** Enter the number of individuals served who are blind in
only one eye or who have other visual impairments that do not result in
blindness in both eyes.

**Line D3:** Enter the number of individuals served who are deaf, i.e.,
depend primarily on visual or tactile means to communicate.

**Line D4:** Enter the number of individuals served who are not deaf but
who are hard-of-hearing.

**Line D5:** Enter the number of individuals served who are deaf-blind.
These individuals meet the criteria for both blindness and deafness.

**Line D6:** Enter the number of individuals served who have orthopedic
deformities, paralysis or other functional impairments (except
amputations) involving the limbs, digits, trunk, back or spine.

**Line D7:** Enter the number of individuals served who are missing
major or minor extremities.

**Line D8:** Enter the number of individuals served with mental illness.

**Line D9:** Enter the number of individuals served with alcohol or drug
addictions.

**Line D10:** Enter the number of individuals served with all degrees of
mental retardation (mild, moderate and severe/profound).

**Line D11:** Enter the number of individuals served with any specific
developmental disorders that result in learning disabilities.

**Line D12:** Enter the number of individuals served who have epilepsy
or other disorders of the nervous system, not elsewhere classified.

**Line D13:** Enter the number of individuals served who are disabled
from respiratory system conditions including tuberculosis, emphysema and
chronic bronchitis.

**Line D14:** Enter the number of individuals served who are disabled
from cardiac and other circulatory system conditions.

**Line D15:** Enter the number of individuals served who are disabled
from digestive system conditions of the teeth and supporting structures,
ulcers, hernias and colostomies.

**Line D16:** Enter the number of individuals served with end-stage
renal failure or other genitourinary conditions.

**Line D17:** Enter the number of individuals served with speech
impairments, such as cleft palate and harelip with speech imperfections,
stam­mering and stuttering, laryngectomies, and aphasia resulting from
strokes.

**Line D18:** Enter the number of individuals served who are infected
with the human immunodeficiency virus (HIV), whether symptomatic or
asymptomatic.

**Line D19:** Enter the number of individuals served whose disabling
condition or functional limitation is caused by traumatic brain injuries
(TBI).

**Line D20:** Enter the number of individuals served who have other
impairments or disabling diseases and conditions not mentioned above.

**Line D21:** Enter the number of individuals served whose major
disabling condition could not be determined. This line should be marked
in only rare circumstances.

**Line D22:** Add Lines D1 through D21 and enter the total here. This
sum also must equal the total recorded on Line I.B3.

[E.]{.underline} [Types of individuals served]{.underline}:

Enter the number of individuals served according to their relationships
with the various programs or projects providing them with services under
the Act. For purposes of CAP, \"services under the Act\" does not
include activities carried out under the Protection and Advocacy of
Individual Rights (PAIR) program. An individual may be counted more than
once during a fiscal year. However, the total on any line cannot exceed
the total on Line I.B3.

**Line E1:** Enter the number of individuals served who have applied for
or who have attempted to apply for services from the State VR agency and
one of the following situations has occurred:

a\) the application was not processed;

b\) no final determination of eligibility has been made; or

c\) the individual has been determined ineligible to receive services.

**Line E2:** Enter the number of individuals served who have been
determined eligible for VR services. It does not matter whether the
individual\'s IWRP has been developed or implemented. In addition, be
sure to include here any individual with severe disabilities who has
supported employment identified as his/her rehabilitation objective
(i.e., recipients of supported employment services). It does not matter
whether the supported employment activity is funded from Title I or
Title VI, Part C of the Act.

**Line E3:** Enter the number of individuals served who have either
applied for or are receiving Independent Living services under Title VII
of the Act.

**Line E4:** Enter the number of individuals served who have either
applied for or are receiving services from other programs funded under
the Act (e.g., community rehabilitation programs, Projects with
Industry, migratory farm workers, Supported Employment projects, VR
projects for American Indians, Recreation, and Interpreter Services).

[F.]{.underline} [Source of person\'s concern]{.underline}:

Enter the number of individuals served according to the source of the
individual\'s problems or concerns. Although multiple responses are
permitted, a problem area cannot be attributed to a particular
individual served more than once during a fiscal year. No line may
exceed the total on Line I.B3.

**Line F1:** Enter the number of individuals served who are only
experiencing problems with the State VR agency. It does not matter
whether the individual is receiving Title I or Title VI, Part C
services. All that matters is that the individual\'s complaint only
involves the State VR agency.

**Line F2:** Enter the number of individuals served who are experiencing
problems only with programs and projects, other than the State VR
agency, that provide services under the Act. In other words, the
individual\'s complaint is [not]{.underline} with the State VR program,
but instead is with another project or program funded under the Act.

**Line F3:** Enter the number of individuals served who are having
problems with both the State VR agency [and]{.underline} another program
or project that provides services under the Act.

**Line F4:** Enter the number of individuals served who had problems
with their employers regarding their rights under Title I of the ADA.

[G.]{.underline} [Problem areas]{.underline}:

Enter the number of individuals served according to the problem area
identified by the individual. An individual may have issues that fall
into more than one problem area; therefore, multiple responses are
permitted. However, a problem area cannot be attributed to a particular
individual served more than once during a fiscal year. The amount on any
line may not exceed the total on Line I.B3.

**Line G1:** Enter the number of individuals served who requested
information about any of the services, programs, and projects authorized
under the Act or about rights under Title I of the ADA.

**Line G2:** Enter the number of individuals served who need help in
resolving a communication problem. For example, the individual may ask
CAP to:

a\) clarify the individual\'s rights and obligations under the Act;

b\) clarify the policy/procedures of programs under the Act; or

> c\) help re-establish contact with the VR agency following an
> inadvertent breakdown in the communication process. An inadvertent
> breakdown in the communication process can occur when the staff member
> cannot locate the individual because he or she has moved or when the
> individual is not assigned to a new staff mem­ber after the former
> staff member has left the agency.

Do not include on this line communication problems that are due to a
conflict between the individual and the agency staff member. These
should be included on Line II.G3.

**Line G3:** Enter the number of individuals served who had a conflict
with their VR counselor or any staff member of one of the programs
authorized under the Act. In a sense, client-staff conflict
problems/concerns might be regarded as the underlying cause of most
other problem areas for individuals. Client/counselor conflicts can
occur when the client:

a\) dis­agrees with the deci­sion/action of the staff member;

b\) desires a change of a counselor or staff member; or

c\) has a personality conflict with the staff member.

Also include on this line the number of individuals served who request
CAP assistance in resolving problems that involve the quantity, quality,
and/or expediency of the services received under the Act. However, if
the basic cause of such delays or denials is a problem of the
individual\'s eligibility, this problem should be recorded on line
II.G4. Individuals served who had conflicts related to employment goals
or informed choice should be included on Line II.G5.

**Line G4:** Enter the number of individuals served who have concerns
involving such issues as the application process, ineligibility
determinations, delays in eligibility determinations, or reapplication
procedures.

**Line G5:** Enter the number of individuals served who have concerns
involving the development or implementation of their IWRP. Include on
this line those individuals who had problems related to employment goals
or informed choice issues.

**Line G6:** Enter the number of individuals served who have problems or
concerns with a program or project funded under the Act but that cannot
be included appropriately in one of the preceding categories.

**Line G7:** Enter the number of individuals served who had problems or
concerns with issues that are not related to their rehabilitation
program, such as AFDC, SSI/SSDI, or housing. An individual served may be
recorded here **only if** the individual served also is recorded in one
of the other problem areas above. The issues related to this problem
area are beyond the immediate domain of services provided under the Act.
However, sometimes these issues affect the individual\'s relationship
with the rehabilitation program or project.

**Line G8:** Enter the number of individuals served who had problems or
concerns related to their rights under Title I of the ADA. Do not
include on this line the number of individuals served who merely asked
for information about their rights under Title I of the ADA. Those
individuals served should be accounted for on line II.G1 above.

[H.]{.underline} [Types of services]{.underline}:

Following is a listing of the categories of services CAP can provide an
individual served. It is expected that CAP often will provide more than
one type of service during the course of the CAP/client relationship.
However, choose **one** primary CAP service provided to the individual
before the case file/service record was closed. Choose the CAP service
provided that best reflects the assistance and representation CAP
provided to the individual while the case file/service record was open.
Generally, this will mean that CAP should mark the highest level of
service CAP provided on behalf of the individual while the case
file/service record was open.

As stated in earlier sections of these instructions, the number of case
files/service records may, in some situations, be greater than the total
number of individuals served (Line I.B3) in order to account for those
unusual situations, referred to in Line I.B4, when an individual had
multiple case files/service records closed during the fiscal year.
However, no line may exceed the total on Line I.B3. Estimated counts are
not acceptable. CAPs should maintain records to respond to this item
accurately.

**Example 1:** An individual may have benefited from CAP\'s negotiation
assistance and been represented at an informal review and a fair
hearing. CAP provided the individual all of these services during the
course of one case file/service record. This individual should be
counted in the category for formal appeal procedures.

**Example 2:** An individual may have had two case files/service records
opened/closed during the same fiscal year. During the course of working
with the individual in the first case file/service record, CAP provided
information and negotiation assistance. During the course of working
with the individual in the second case file/service record, CAP provided
information and negotiation assistance and represented the individual at
an informal review proceeding. CAP should account for this individual in
the negotiation (first case file) and the informal review proceeding
(second case file) categories.

A description of advoca­cy services provid­ed to more than one individual
(systemic advocacy) should be provid­ed in the narrative section of this
report. See the instructions for completing the narrative section.

**Line H1:** Enter the number case files/service records closed in which
the highest level CAP service provided to the individual served was
information/referral (I&R) services. This category of services must be
[in addition]{.underline} to another service; therefore, this response
will be rarely marked. I&R services can include a telephone
conversation, letter, or face-to-face contact that provided information
to individuals served about rights and benefits available under the Act
and how to obtain such benefits, as well as rights provided under Title
I of the ADA, or resulted in a referral to another source for services.

**Line H2:** Enter the number of case files/service records closed in
which the highest level of CAP services provided to the individual
served fits into one of the following categories: reviewed the problem
or concern expressed; consulted with the individual on various courses
of action; researched possible solutions; developed strategies; and
provided advice. Also, include here the number of closed case
files/service records for individuals served that reflects CAP\'s
coaching and assistance with self-advocacy. The problems identified by
these individuals could fall under the Act or Title I of the ADA.

**Line H3:** Enter the number of case files/service records closed in
which the highest level of CAP services provided to the individual
served was that CAP engaged in negotiation in order to effect a
settlement or compromise with a representative of a program, project or
facility funded under the Act or with an employer to reconcile
differences.

**Line H4:** Enter the number of case files/service records closed in
which the highest level of CAP services provided to the individual
served was that CAP assisted the individual in requesting, preparing
for, or participating in an informal review with the rehabilitation
program or project funded under the Act. This assistance is more than
merely advising the individual of the administrative review process;
that kind of activity should be recorded on Line H1 above.

**Line H5:** Enter the number of case files/service records closed in
which the highest level of CAP services provided to the individual
served was that CAP engaged in alternative dispute resolution (ADR)
procedures to resolve the dispute between the individual and the
rehabilitation program or project funded under the Act or between the
individual and an employer. ADR can include mediation which involves a
mediator, intermediary, or conciliator to settle disputes between
parties. Mediation may involve the use of a professional mediator, other
independent third party mutually agreed to by the parties in the
dispute, or a CAP employee who: 1) is not involved with representing or
assigned to represent the individual; and 2) has not previously
represented or been involved with representing the individual. See
related section later in the \"narrative\" portion of these
instructions.

**Line H6:** Enter the number of case files/service records closed in
which the highest level of CAP services provided to the individual
served was that CAP assisted the individual in requesting, preparing
for, or participating in formal review proceedings conducted by
impartial hearing officers and State Directors/Fair Hearing Boards. Do
not include any legal services provided on this line.

**Line H7:** Enter the number of case files/service records closed in
which the highest level of CAP services provided to the individual
served was that CAP assisted the individual in pursuing legal recourse
in the judicial system to resolve the individual\'s problem or concern.

**Line H8:** Enter the number of case files/service records closed in
which CAP provided the individual served with transportation services in
connection with other CAP services. An individual also is deemed to have
received transportation services if his/her attendant was transported on
his/her behalf.

[I.]{.underline} [Satisfaction of individuals served:]{.underline}

The Government Performance and Results Act (GPRA) requires Federal
agencies to focus on outcomes and results regarding the programs they
fund. In light of these GPRA standards, RSA identified client
satisfaction as one indicator it will examine when analyzing the
effectiveness of CAP.

RSA is requiring that all CAP agencies send each \"individual served\"
(as defined earlier in these instructions) a \"satisfaction survey\" at
the time of closing the case. CAPs should encourage individuals served
to respond to these surveys. RSA suggests that the survey be made
intentionally short and simple and that the respondents be kept
anonymous in order to encourage a large percentage of responses. RSA
also encourages CAP agencies to use these survey results for their own
program improvement.

**Line I1:** Enter the number of surveys mailed. CAP should send a
satisfaction survey to each \"individual served\" (as defined earlier)
at the time of case closure. The number entered here cannot exceed the
total number of individuals served reported on Line I.B3 of this form.

**Line I2:** Enter the number of surveys returned to CAP. This is the
number on which the rest of the questions in this section will be based.

**Line I3:** Enter the number of surveys according to how the respondent
indicated his/her overall satisfaction with the CAP. The total number of
responses for the three categories of \"not satisfied\", \"satisfied\",
and \"very satisfied\" cannot exceed the number of surveys CAP actually
received and entered on line I2 above.

**Line I4:** Enter the number of surveys returned according to whether
the individual served would use CAP services again. The total for this
entire question cannot exceed the total number of surveys returned to
the CAP as indicated on line I2 above.

4\. **[PART III. NARRATIVE (Attach separate sheets.)]{.underline}**

According to Education Department General Administrative Regulations
(EDGAR) at 34 CFR Part 80, each CAP agency shall submit a written
performance report that includes, but is not limited to, the following
information. Be sure to include any other information, not otherwise
collected on this reporting form that would be helpful in describing the
extent of CAP activities this fiscal year. Please limit the narrative
report, including attachments, to 20 pages or less.

a\. **Type of agency used to administer CAP:** Identify the type of
agency used to administer the CAP and type of agency operating the CAP,
if different. Types of agencies used to administer the CAP include, but
are not limited to:

1\) external \-- P&A;

2\) exter­nal \-- other public agency;

3\) external \-- nonprofit agency;

4\) internal to State VR agency (not sub-contracted); and

5\) internal to State VR agency (sub-contracted).

b\. **Sources of funds expended:** Specify the total expenditure of
funds used in providing services to CAP-eligible individuals according
to the source of funding. Provide this information even if the agency\'s
only source of funding is the Federal formula grant. The following chart
is recommended:

  ------------------------- ---------------------------------------------
  Source of funding         Total expenditures spent on individuals

  Federal funds             

  State funds               

  All other funds           

  Total from all sources    
  ------------------------- ---------------------------------------------

The \"all other\" category is broad and includes funds from local
governments, earned income (e.g., legal fees), charitable contributions,
and other grants or contracts. This category does not include in-kind
donations. However, it is hoped that CAP agencies will collect this
information separately if appropriate.

c\. **Budget for current and following fiscal years:** Be sure to
outline the budget for the current and subsequent fiscal years. This
item should include a breakdown of dollars expended/allotted for
administrative costs (e.g., salaries for personnel, equipment, etc.);
and services to individuals and other expenses (e.g., training of staff,
travel, etc.). The following chart is recommended:

  ----------------------- ----------------------- -----------------------
  Category                Current Fiscal Year     Next Fiscal Year

  Wages & Salaries                                

  Fringe Benefits (FICA,                          
  unemployment, etc.)                             

  Materials/Supplies                              

  Postage                                         

  Telephone                                       

  Rent                                            

  Travel                                          

  Copying                                         

  Bonding/Insurance                               

  Equipment                                       
  Rental/Purchase                                 

  Legal Services                                  

  Indirect Costs                                  

  Miscellaneous                                   

  Total Budget                                    
  ----------------------- ----------------------- -----------------------

d\. **Number of person-years:** \"Person-years\" refer to the actual
time that positions (both professional and clerical) were filled during
the period covered by this annual report. If a position was filled
throughout the year, it counts as one person-year. Positions filled for
any fraction of the fiscal year should be expressed in \"full-time
equivalents." Person-years should be reported for all CAP personnel
whose salaries are paid totally or partially by Section 112 funds.
Identify the number of person-years staffing CAP this fiscal year. Be
sure to include an explanation of the number of full-time, part-time,
and vacant positions. Enter the full-time equivalent for all part-time
positions. The following chart is recommended:

  ----------------------- ------------- ------------------ ---------------
  Type of position        Full-time     \% of year         Person-years
                          equivalent    position filled    

  Professional                                             

  Full-time                                                

  Part-time                                                

  Vacant                                                   

  Clerical                                                 

  Full-time                                                

  Part-time                                                

  Vacant                                                   
  ----------------------- ------------- ------------------ ---------------

e\. **Summary of presentations made:** Summarize the types of
presentations made about CAP and other rehabilitation programs and
projects. Include in the summary an estimate of the number of persons
attending the presentations.

f\. **Involvement with advisory boards:** Identify in what ways CAP is
involved with advisory boards (e.g., State Rehabilitation Advisory
Council, Statewide Independent Living Council, etc.).

g\. **Outreach to unserved/underserved populations:** Identify the
strategies used to conduct outreach to and to serve individuals
previously unserved or underserved and/or individuals who are members of
minority groups. Describe the impact of your outreach efforts,
especially in terms of how your outreach efforts have benefited
individuals who traditionally have been unserved or underserved.

h\. **Alternative dispute resolutions:** The Act clearly mandates CAPs
to engage in mediation (or other forms of alternative dispute
resolutions) prior to seeking a formal or legal remedy on behalf of the
individual served. Part II-H5 of the Form RSA-227 asks you to identify
the number of times your CAP agency engaged in ADR. In addition to that
numerical data, be sure to describe, in the Narrative portion of your
report, your efforts at engaging in ADR procedures, including how
successful (or not successful) your attempts have been and an
explanation of why CAP did not engage in ADR prior to seeking a formal
or legal remedy.

i\. **Systemic advocacy:** Describe the systemic advocacy undertaken.
Indicate the problems that have been identified in the delivery of VR
and independent living services. To the extent possible, detail
evidence/documentation that substantiates the problems. Summarize the
activities CAP has undertaken to remedy the problems. Outline the State
VR agency\'s responses to those activities and explain the status of the
problems at the close of the fiscal year. As appropriate, provide CAP\'s
plans for continuing to address the problems during the next fiscal
year.

> j\. **Interesting cases:** Describe a few of the more interesting or
> unique
>
> cases that CAP worked on during the fiscal year. Summarize the facts
> of the case and the activities that CAP undertook or is undertaking to
> resolve the issues raised by the individual served. Explain whether
> the case raised systemic or policy-making issues and CAP\'s plan to
> address those issues.

k\. **On-line information/outreach:** Describe efforts CAP may have put
forth to create a web page or some other on-line means of providing
information to the public. Include information about the number of
\"hits\" your on-line site received.

5\. **[End of form:]{.underline}**

**Transmittal:** The RSA-227 reports should be sent within 90 days of
the end of the fiscal year covered. Reports may be sent by mail or
electronically using one of the options listed below. If you have
questions about filling out this form, contact Patricia A. Nash in
Central Office at 202-205-9412.

[A. Electronic Mail addresses via INTERNET]{.underline}\--

The RSA Central Office Internet E-mail address for the RSA-227 is:
gloria_somerville@ed.gov.

For information about filling out the RSA-227, the RSA Central Office
Internet E-mail address is: patricia_nash@ed.gov.

Regional Office E-mail addresses are:

Region I john_szufnarowski@ed.gov

Region II john_szufnarowski@ed.gov

Region III ralph_pacinelli@ed.gov

Region IV ralph_pacinelli@ed.gov

Region V douglas_burleigh@ed.gov

Region VI loerance_deaver@ed.gov

Region VII douglas_burleigh@ed.gov

Region VIII loerance_deaver@ed.gov

Region IX gilbert_williams@ed.gov

Region X gilbert_williams@ed.gov

[B. US Mail and Facsimile]{.underline}\--

The Central Office fax \# is 202-205-9772; and the US postal address is:

Rehabilitation Services Administration

Financial Management Information Systems Staff

Data Management Unit

Switzer Building

Washington, D.C. 20202-2703

RSA Regional Office fax numbers and addresses are as follows:

Region I

Mr. John J. Szufnarowski

RSA Regional Commissioner

Dept. of Education, OSERS

J.W. McCormack Post Office

and Courthouse, Room 232

Boston, MA 02109

Fax: 617-223-4573

Region II

Mr. John J. Szufnarowski

RSA Regional Commissioner

Dept. of Education, OSERS

75 Park Place, Room 1236

New York, NY 10007

Fax: 212-264-3029

Region III

Dr. Ralph N. Pacinelli

RSA Regional Commissioner

Dept. of Education, OSERS

The Wannamaker Building, Suite 512

100 Penn Square East

Philadelphia, PA 19104

Fax: 215-596-0471

Region IV

Dr. Ralph N. Pacinelli

RSA Regional Commissioner

Dept. of Education, OSERS

61 Forsyth Street, S.W., Room 18-T-91

Atlanta, GA 30303-3104

Fax: 404-562-6346

Region V

Dr. Douglas Burleigh

RSA Regional Commissioner

Dept. of Education, OSERS

111 N. Canal, Room 1048

Chicago, IL 60606-7204

Fax: 312-353-8623

Region VI

Mr. Loerance Deaver

RSA Regional Commissioner

## Dept. of Education, OSERS

Harwood Center

1999 Bryan Street, Suite 2740

Dallas, TX 75201-6817

Fax: 214-880-4931

Region VII

Dr. Douglas Burleigh

RSA Regional Commissioner

Dept. of Education, OSERS

10220 N. Executive Hills Boulevard

Kansas City, MO 64153-1367

Fax: 816-891-0807

Region VIII

Mr. Loerance Deaver

RSA Regional Commissioner

Dept. of Education, OSERS

Federal Office Building, Suite 310

1244 Speer Boulevard

Denver, CO 80204-3582

Fax: 303-844-6269

Region IX

Mr. Gilbert \"Doc\" Williams

RSA Regional Commissioner

Dept. of Education, OSERS

Federal Office Building, Room 215

50 United Nations Plaza

San Francisco, CA 94102

Fax: 415-437-7848

Region X

Mr. Gilbert \"Doc\" Williams

RSA Regional Commissioner

Dept. of Education, OSERS

915 Second Avenue, Room 2848

Seattle, WA 98174-1099

# Fax: 206-220-7842

**Signature and title of CAP program director:** The director of the CAP
agency should sign the form to certify that it is complete and correct.

**Date:** Enter the month, day and year in which the form is sent to
RSA.

FORM RSA-227 OMB NO. 1820- 0528

EXPIRES: 02 /29 /2004

**[ANNUAL CLIENT ASSISTANCE PROGRAM (CAP) REPORT]{.underline}**

**Fiscal Year**

+-----------------------------------+---+------------------+----------+
| **DESIGNATED AGENCY               |   |                  |          |
| IDENTIFICATION**                  |   |                  |          |
+-----------------------------------+---+------------------+----------+
| Name:                             |   |                  |          |
+-----------------------------------+---+------------------+----------+
| Address:                          |   |                  |          |
+-----------------------------------+---+------------------+----------+
|                                   |   |                  |          |
+-----------------------------------+---+------------------+----------+
| E-mail Address (if applicable):   |   |                  |          |
+-----------------------------------+---+------------------+----------+
| Website Address (if applicable):  |   |                  |          |
+-----------------------------------+---+------------------+----------+
| Phone: ( )                        | T |                  |          |
|                                   | T |                  |          |
|                                   | Y |                  |          |
|                                   | : |                  |          |
|                                   | ( |                  |          |
|                                   | ) |                  |          |
+-----------------------------------+---+------------------+----------+
| Toll-free Phone: ( )              | T |                  |          |
|                                   | o |                  |          |
|                                   | l |                  |          |
|                                   | l |                  |          |
|                                   | - |                  |          |
|                                   | f |                  |          |
|                                   | r |                  |          |
|                                   | e |                  |          |
|                                   | e |                  |          |
|                                   | T |                  |          |
|                                   | T |                  |          |
|                                   | Y |                  |          |
|                                   | : |                  |          |
|                                   | ( |                  |          |
|                                   | ) |                  |          |
+-----------------------------------+---+------------------+----------+
| Fax: ( )                          |   |                  |          |
+-----------------------------------+---+------------------+----------+
| **OPERATING AGENCY (IF DIFERENT   |   |                  |          |
| FROM DESIGNATED AGENCY)**         |   |                  |          |
+-----------------------------------+---+------------------+----------+
| Name"                             |   |                  |          |
+-----------------------------------+---+------------------+----------+
| Address:                          |   |                  |          |
+-----------------------------------+---+------------------+----------+
|                                   |   |                  |          |
+-----------------------------------+---+------------------+----------+
| E-mail Address (if applicable):   |   |                  |          |
+-----------------------------------+---+------------------+----------+
| Website Address (if applicable):  |   |                  |          |
+-----------------------------------+---+------------------+----------+
| Phone: ( )                        | T |                  |          |
|                                   | T |                  |          |
|                                   | Y |                  |          |
|                                   | : |                  |          |
|                                   | ( |                  |          |
|                                   | ) |                  |          |
+-----------------------------------+---+------------------+----------+
| Toll-free Phone: ( )              | T |                  |          |
|                                   | o |                  |          |
|                                   | l |                  |          |
|                                   | l |                  |          |
|                                   | - |                  |          |
|                                   | f |                  |          |
|                                   | r |                  |          |
|                                   | e |                  |          |
|                                   | e |                  |          |
|                                   | T |                  |          |
|                                   | T |                  |          |
|                                   | Y |                  |          |
|                                   | : |                  |          |
|                                   | ( |                  |          |
|                                   | ) |                  |          |
+-----------------------------------+---+------------------+----------+
| Fax: ( )                          |   |                  |          |
+-----------------------------------+---+------------------+----------+
| Name of CAP Director/Coordinator: |   |                  |          |
+-----------------------------------+---+------------------+----------+
| Person to contact regarding       |   |                  |          |
| report:                           |   |                  |          |
+-----------------------------------+---+------------------+----------+
| Contact Person\'s phone: ( )      |   |                  |          |
+-----------------------------------+---+------------------+----------+
| **PART I. AGENCY WORKLOAD DATA**  |   |                  |          |
+-----------------------------------+---+------------------+----------+
| **A. Information and Referral     |   |                  |          |
| Services (I&R):** (Multiple       |   |                  |          |
| responses are not permitted.)     |   |                  |          |
+-----------------------------------+---+------------------+----------+
| > 1\. Information regarding the   |   |                  |          |
| > Rehabilitation Act              |   |                  |          |
+-----------------------------------+---+------------------+----------+
| > 2\. Information regarding Title |   |                  |          |
| > I of the ADA                    |   |                  |          |
+-----------------------------------+---+------------------+----------+
| > 3\. Other information provided  |   |                  |          |
+-----------------------------------+---+------------------+----------+
| > 4\. Total I&R services provided |   |                  |          |
| > (Lines A1+A2+A3)                |   |                  |          |
+-----------------------------------+---+------------------+----------+
| > 5\. Individuals attending       |   |                  |          |
| > trainings by CAP staff          |   |                  |          |
| > (approximate)                   |   |                  |          |
+-----------------------------------+---+------------------+----------+
| **B. Individuals served** (An     |   |                  |          |
| individual is counted only once   |   |                  |          |
| during a fiscal year. Multiple    |   |                  |          |
| counts are not permitted for      |   |                  |          |
| Lines B1-B3.)                     |   |                  |          |
+-----------------------------------+---+------------------+----------+
| > 1\. Individuals who are still   |   |                  |          |
| > being served as of October 1    |   |                  |          |
| > (carryover from prior year)     |   |                  |          |
+-----------------------------------+---+------------------+----------+
| > 2\. Additional individuals who  |   |                  |          |
| > were served during the year     |   |                  |          |
+-----------------------------------+---+------------------+----------+
| > 3\. Total individuals served    |   |                  |          |
| > (Lines B1+B2)                   |   |                  |          |
+-----------------------------------+---+------------------+----------+
| > 4\. Individuals (from Line B3)  |   |                  |          |
| > who had multiple case files     |   |                  |          |
| > opened/closed this year. (In    |   |                  |          |
| > unusual situations, an          |   |                  |          |
| > individual may have more than   |   |                  |          |
| > one case file opened/closed     |   |                  |          |
| > during a fiscal year. This      |   |                  |          |
| > number is not added to the      |   |                  |          |
| > total in Line B3 above.)        |   |                  |          |
+-----------------------------------+---+------------------+----------+
| **C. Individual still being       |   |                  |          |
| served as of September 30**       |   |                  |          |
| (carryover to next year) (This    |   |                  |          |
| total may not exceed Line I.B3.)  |   |                  |          |
+-----------------------------------+---+------------------+----------+
| **PART I. AGENCY WORKLOAD DATA    |   |                  |          |
| (continued)**                     |   |                  |          |
+-----------------------------------+---+------------------+----------+
| **D. Reasons for closing          |   |                  |          |
| individuals' case files** (Choose |   |                  |          |
| one primary reason for closing    |   |                  |          |
| each case file. There may be more |   |                  |          |
| case files than the total number  |   |                  |          |
| of individuals served to account  |   |                  |          |
| for those unusual situations,     |   |                  |          |
| referred to in Line I.B4, when an |   |                  |          |
| individual had multiple case      |   |                  |          |
| files closed during the year.)    |   |                  |          |
+-----------------------------------+---+------------------+----------+
| > 1\. All issues resolved in      |   |                  |          |
| > individual's favor              |   |                  |          |
+-----------------------------------+---+------------------+----------+
| > 2\. Some issues resolved in     |   |                  |          |
| > individual's favor (when there  |   |                  |          |
| > are multiple issues)            |   |                  |          |
+-----------------------------------+---+------------------+----------+
| > 3\. CAP determines VR agency    |   |                  |          |
| > position/decision was           |   |                  |          |
| > appropriate for the individual  |   |                  |          |
+-----------------------------------+---+------------------+----------+
| > 4\. Individual's case lacks     |   |                  |          |
| > legal merit; (inappropriate for |   |                  |          |
| > CAP intervention)               |   |                  |          |
+-----------------------------------+---+------------------+----------+
| > 5\. Individual chose            |   |                  |          |
| > alternative representation      |   |                  |          |
+-----------------------------------+---+------------------+----------+
| > 6\. Individual decided not to   |   |                  |          |
| > pursue resolution               |   |                  |          |
+-----------------------------------+---+------------------+----------+
| > 7\. Appeals were unsuccessful   |   |                  |          |
+-----------------------------------+---+------------------+----------+
| > 8\. CAP services not needed due |   |                  |          |
| > to individual's death,          |   |                  |          |
| > relocation, etc.                |   |                  |          |
+-----------------------------------+---+------------------+----------+
| > 9\. Individual refused to       |   |                  |          |
| > cooperate with CAP              |   |                  |          |
+-----------------------------------+---+------------------+----------+
| > 10\. CAP unable to take case    |   |                  |          |
| > due to lack of resources        |   |                  |          |
+-----------------------------------+---+------------------+----------+
| > 11\. Other (Please explain on   |   |                  |          |
| > separate sheet)                 |   |                  |          |
+-----------------------------------+---+------------------+----------+

+-----------------------------------------------------------+----------+
| **PART II. PROGRAM DATA**                                 |          |
+-----------------------------------------------------------+----------+
| **A. Age** (as of the beginning of the fiscal             |          |
| year)(Multiple responses not permitted.)                  |          |
+-----------------------------------------------------------+----------+
| > 1\. 21 and under                                        |          |
+-----------------------------------------------------------+----------+
| > 2\. 22 -- 40                                            |          |
+-----------------------------------------------------------+----------+
| > 3\. 41 -- 64                                            |          |
+-----------------------------------------------------------+----------+
| > 4\. 65 and over                                         |          |
+-----------------------------------------------------------+----------+
| > 5\. Total (Sum of Lines A1 through A4. Total must equal |          |
| > Line I. B3.)                                            |          |
+-----------------------------------------------------------+----------+
| **B. Gender** (Multiple responses not permitted.)         |          |
+-----------------------------------------------------------+----------+
| > 1\. Females                                             |          |
+-----------------------------------------------------------+----------+
| > 2\. Males                                               |          |
+-----------------------------------------------------------+----------+
| > 3\. Total (Lines B1+B2. Total must equal Line I.B3.)    |          |
+-----------------------------------------------------------+----------+
| **C. Race/ethnicity** (Multiple responses are permitted.) |          |
+-----------------------------------------------------------+----------+
| > 1\. American Indian or Alaskan Native                   |          |
+-----------------------------------------------------------+----------+
| > 2\. Asian                                               |          |
+-----------------------------------------------------------+----------+
| > 3\. Native Hawaiian or Other Pacific Islander           |          |
+-----------------------------------------------------------+----------+
| > 4\. Black or African American                           |          |
+-----------------------------------------------------------+----------+
| > 5\. Hispanic or Latino                                  |          |
+-----------------------------------------------------------+----------+
| > 6\. White                                               |          |
+-----------------------------------------------------------+----------+
| > 7\. Race/ethnicity unknown                              |          |
+-----------------------------------------------------------+----------+
| # D. Primary disabling condition of i                     |          |
| ndividuals served **(Multiple responses not permitted.)** |          |
+-----------------------------------------------------------+----------+
| > 1\. Blindness (both eyes)                               |          |
+-----------------------------------------------------------+----------+
| > 2\. Other visual impairments                            |          |
+-----------------------------------------------------------+----------+
| > 3\. Deafness                                            |          |
+-----------------------------------------------------------+----------+
| > 4\. Hard of hearing                                     |          |
+-----------------------------------------------------------+----------+
| > 5\. Deaf-blind                                          |          |
+-----------------------------------------------------------+----------+
| > 6\. Orthopedic impairments                              |          |
+-----------------------------------------------------------+----------+
| > 7\. Absence of extremities                              |          |
+-----------------------------------------------------------+----------+
| > 8\. Mental illness                                      |          |
+-----------------------------------------------------------+----------+
| **PART II. Program Data (continued)**                     |          |
+-----------------------------------------------------------+----------+
| **D. Primary disabling conditions of individuals served   |          |
| (continued)** (Multiple responses not permitted.)         |          |
+-----------------------------------------------------------+----------+
| > 9\. Substance abuse (alcohol or drugs)                  |          |
+-----------------------------------------------------------+----------+
| > 10\. Mental retardation                                 |          |
+-----------------------------------------------------------+----------+
| > 11\. Specific learning disabilities (SLD)               |          |
+-----------------------------------------------------------+----------+
| > 12\. Neurological disorders                             |          |
+-----------------------------------------------------------+----------+
| > 13\. Respiratory disorders                              |          |
+-----------------------------------------------------------+----------+
| > 14\. Heart and other circulatory conditions             |          |
+-----------------------------------------------------------+----------+
| > 15\. Digestive disorders                                |          |
+-----------------------------------------------------------+----------+
| > 16\. Genitourinary conditions                           |          |
+-----------------------------------------------------------+----------+
| > 17\. Speech impairments                                 |          |
+-----------------------------------------------------------+----------+
| > 18\. AIDS/HIV positive                                  |          |
+-----------------------------------------------------------+----------+
| > 19\. Traumatic brain injury (TBI)                       |          |
+-----------------------------------------------------------+----------+
| > 20\. All other disabilities                             |          |
+-----------------------------------------------------------+----------+
| > 21\. Disabilities not known                             |          |
+-----------------------------------------------------------+----------+
| > 22\. Total (Sum of Lines D1 through D21. Total must     |          |
| > equal Line I. B3.)                                      |          |
+-----------------------------------------------------------+----------+
| **E. Types of individuals served** (Multiple responses    |          |
| permitted.)                                               |          |
+-----------------------------------------------------------+----------+
| > 1\. Applicants of VR Program                            |          |
+-----------------------------------------------------------+----------+
| > 2\. Clients of VR Program                               |          |
+-----------------------------------------------------------+----------+
| > 3\. Applicants or clients of IL Program                 |          |
+-----------------------------------------------------------+----------+
| > 4\. Applicants or clients of other programs and         |          |
| > projects funded under the Act                           |          |
+-----------------------------------------------------------+----------+
| **F. Source of individual's concern** (Multiple responses |          |
| permitted.)                                               |          |
+-----------------------------------------------------------+----------+
| > 1\. VR agency only                                      |          |
+-----------------------------------------------------------+----------+
| > 2\. Other Rehabilitation Act sources only               |          |
+-----------------------------------------------------------+----------+
| > 3\. Both VR agency [and]{.underline} other              |          |
| > Rehabilitation Act sources                              |          |
+-----------------------------------------------------------+----------+
| > 4\. Employer                                            |          |
+-----------------------------------------------------------+----------+
| **G. Problem areas** (Multiple responses permitted.)      |          |
+-----------------------------------------------------------+----------+
| > 1\. Individual requests information                     |          |
+-----------------------------------------------------------+----------+
| > 2\. Communication problems between individual and       |          |
| > counselor                                               |          |
+-----------------------------------------------------------+----------+
| > 3\. Conflict about services to be provided              |          |
+-----------------------------------------------------------+----------+
| > 4\. Related to application/eligibility process          |          |
+-----------------------------------------------------------+----------+
| > 5\. Related to IWRP development/implementation          |          |
+-----------------------------------------------------------+----------+
| > 6\. Other Rehabilitation Act-related problems           |          |
+-----------------------------------------------------------+----------+
| > 7\. Non-Rehabilitation Act related                      |          |
+-----------------------------------------------------------+----------+
| > 8\. Related to Title I of the ADA                       |          |
+-----------------------------------------------------------+----------+
| **H. Types of CAP services provided** (Choose one primary |          |
| service CAP provided for each closed case file. As stated |          |
| above, there may be more case files than actual           |          |
| individuals served.)                                      |          |
+-----------------------------------------------------------+----------+
| > 1\. Information/referral                                |          |
+-----------------------------------------------------------+----------+
| > 2\. Advisory/interpretational                           |          |
+-----------------------------------------------------------+----------+
| > 3\. Negotiation                                         |          |
+-----------------------------------------------------------+----------+
| > 4\. Administrative/informal review                      |          |
+-----------------------------------------------------------+----------+
| > 5\. Alternative dispute resolution                      |          |
+-----------------------------------------------------------+----------+
| > 6\. Formal appeal/fair hearing                          |          |
+-----------------------------------------------------------+----------+
| > 7\. Legal remedy                                        |          |
+-----------------------------------------------------------+----------+
| > 8\. Transportation                                      |          |
+-----------------------------------------------------------+----------+
| # PART II. PROGRAM DATA (continued)                       |          |
+-----------------------------------------------------------+----------+
| # I. Satisfaction of individuals served                   |          |
+-----------------------------------------------------------+----------+
| > 1\. Number of satisfaction surveys mailed (Number       |          |
| > cannot exceed total on Line I.B3.)                      |          |
+-----------------------------------------------------------+----------+
| > 2\. Number of satisfaction surveys returned (Number     |          |
| > cannot exceed total on Line II.I1.)                     |          |
+-----------------------------------------------------------+----------+
| > 3\. Of the total number of surveys returned, indicate   |          |
| > how many individuals rated their overall satisfaction   |          |
| > with CAP in the following ways: (Total for this entire  |          |
| > question cannot exceed the total on Line II.I2 above.)  |          |
+-----------------------------------------------------------+----------+
| > a\. very satisfied                                      |          |
+-----------------------------------------------------------+----------+
| > b\. satisfied                                           |          |
+-----------------------------------------------------------+----------+
| > c\. not satisfied                                       |          |
+-----------------------------------------------------------+----------+
| > 4\. Of the total number of surveys returned, indicate   |          |
| > whether the individual served would use CAP again:      |          |
| > (Total cannot exceed total on Line II.I2 above.)        |          |
+-----------------------------------------------------------+----------+
| > a\. yes                                                 |          |
+-----------------------------------------------------------+----------+
| > b\. no                                                  |          |
+-----------------------------------------------------------+----------+
| **PART III. NARRATIVE (Attach separate sheet(s))** Refer  |          |
| to pages 16-19 of the instructions for guidelines on the  |          |
| contents of the narrative.                                |          |
+-----------------------------------------------------------+----------+

Within 90 days after the end of the fiscal year covered by this report,
mail one copy of this report to the RSA Regional Office and one copy to
the RSA Central Office specified in the instructions.

Signature and title of designated agency official Date

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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 1820-0528. The time required to complete this information
collection is estimated to average 6.25 hours per response, including
the time to review instructions, search existing data resources, gather
the data needed, and complete and review the information collection. If
you have any comments concerning the accuracy of the time estimate or
suggestions for improving this form, please write to: U.S. Department of
Education, Washington, DC 20202-4651. If you have comments or concerns
regarding the status of your individual submission of this form, write
directly to: OSERS/RSA/FMISS, U.S. Department of Education, 400 Maryland
Avenue, S.W., Room 3030 MES, Washington, DC 20202-2703.**