# UNITED STATES DEPARTMENT OF EDUCATION

OFFICE OF SPECIAL EDUCATION AND REHABILITATIVE SERVICES

REHABILITATION SERVICES ADMINISTRATION

WASHINGTON, DC 20202

> POLICY DIRECTIVE
>
> RSA-PD-06-01
>
> DATE: October 24, 2005

ADDRESSEES: STATE VOCATIONAL REHABILITATION AGENCIES (GENERAL)

STATE VOCATIONAL REHABILITATION AGENCIES (BLIND)

SUBJECT: RSA-911 - Case Service Report

POLICY

STATEMENT: This is to inform you that the Office of Management and
Budget (OMB) has approved the use of the Case Service Report (RSA-911)
through October 31, 2008. The OMB control number for this collection is

1820-0508.

> The data elements and record layout have not been changed from those
> transmitted with PD-04-04 (September 30, 2004).
>
> The due date for submitting RSA-911 data is November 30, following the
> end of a fiscal year. State VR agencies should examine their data for
> accuracy with the RSA_ERA Program before submitting their file to us.
> The most current version of the RSA_ERA can be downloaded from the
> following URL: http://scvrd.net/g_rsa_era.html. We also recommend
> using the RSA 911 Frequency Distribution Table Application to examine
> your data. This is a supplemental table generator that allows
> comparison of data over multiple fiscal years. Although it is useful,
> agencies are not required to use it. The application is available on
> the Internet at <http://www.rsadev.net/r911>. All information must be
> provided in the format outlined in the edit specifications.
>
> The transition from the Dictionary of Occupational Title (DOT) to
> Standard Occupational Classification (SOC) codes in the RSA 911 data
> is scheduled for October 1, 2006, the first day of FY 2007. Beginning
> with FY 2007, RSA 911 occupational data must be reported using SOC
> codes. Until then, the RSA 911data will continue to require DOT codes.
> It is important that all agencies report similar data for a given
> year. For FY 2005 and FY 2006, agencies need to report DOT codes in
> Record Positions (RPs) 155-160. Beginning in FY 2007, agencies will
> report SOC codes in RPs 155-160. RSA has developed a crosswalk of DOT
> to SOC codes. It is available on the Internet at the following URL or
> Internet address:
> [www.ed.gov/rschstat/eval/rehab/support/doc-soc.xls](http://www.ed.gov/rschstat/eval/rehab/support/doc-soc.xls).

CITATIONS

IN LAW: Sections 12(a), 13, 14(a), 101(a)(10), 131 and 626 of the
Rehabilitation Act of 1973, as amended.

CITATIONS IN

REGULATIONS: 34 CFR 361.38, 361.40 and 361.56.

EFFECTIVE

DATE: Immediately upon issuance

EXPIRATION

DATE: October 31, 2008

INQUIRIES

TO: RSA Central Office, (202) 245-7488

> Edward Anthony, Ph.D.
>
> Delegated the authority to\
> Perform the functions of\
> Commissioner for Rehabilitation\
> Services Administration

Attachments

CC: Client Assistance Programs

Council of State Administrators of Vocational Rehabilitation

National Disability Rights Network

Regional Rehabilitation Continuing Education Programs

**Reporting Manual for the**

**CASE SERVICE REPORT**

**(RSA-911)**

**[State-Federal Program for]{.smallcaps}**

######### Vocational Rehabilitation

Reporting Manual for the Case Service Report (RSA-911)

[Table of Contents]{.underline}

**[Page]{.underline}**

GENERAL INSTRUCTIONS 1

INSTRUCTIONS FOR PREPARATION OF FLOPPY DISKETTE,

CD-ROM OR ELECTRONIC TRANSMITTAL 2

Element-by-Element Instructions: [4](#element-by-element-instructions)

1\. Agency Code [5](#agency-code)

2\. Social Security Number [6](#social-security-number)

3\. Closure Order [6](#closure-order)

4\. Previous Closure [6](#previous-closure)

5\. Date of Application [7](#date-of-application)

6\. Date of Birth [8](#date-of-birth)

7\. Gender [8](#gender)

8\. Race and Ethnicity [8](#race-and-ethnicity)

9\. Source of Referral [10](#source-of-referral)

10\. Level of Education Attained at Application
[10](#level-of-education-attained-at-application)

11\. Individualized Education Program (IEP)
[11](#individualized-education-program-iep)

12\. Living Arrangement at Application
[11](#living-arrangement-at-application)

13\. Primary Disability [12](#primary-disability)

14\. Secondary Disability [12](#secondary-disability)

Codes for Impairments [12](#codes-for-impairments)

Codes for Causes/Sources of Impairments
[13](#codes-for-causessources-of-impairments)

15\. Employment Status at Application
[14](#employment-status-at-application)

16\. Weekly Earnings at Application
[16](#weekly-earnings-at-application)

17\. Hours Worked in a Week at Application
[17](#hours-worked-in-a-week-at-application)

18\. Type of Public Support at Application
[17](#type-of-public-support-at-application)

19\. Monthly Public Support Amount at Application
[18](#monthly-public-support-amount-at-application)

20\. Primary Source of Support at Application
[19](#primary-source-of-support-at-application)

21\. Medical Insurance Coverage at Application
[20](#medical-insurance-coverage-at-application)

22\. Date of Eligibility Determination
[20](#date-of-eligibility-determination)

23\. Date of Individualized Plan for Employment (IPE)
[21](#date-of-individualized-plan-for-employment-ipe)

24\. Cost of Purchased Services [21](#cost-of-purchased-services)

25\. Services Provided [22](#services-provided)

26\. Level of Education Attained At Closure
[30](#level-of-education-attained-at-closure)

27\. Occupation at Closure [31](#occupation-at-closure)

28\. Employment Status at Closure 31

29\. Competitive Employment [33](#competitive-employment)

30\. Weekly Earnings at Closure 34

Reporting Manual for the Case Service Report (RSA-911)

[Table of Contents]{.underline}

**[Page]{.underline}**

31\. Hours Worked in a Week at Closure
[36](#hours-worked-in-a-week-at-closure)

32\. Type of Public Support at Closure 35

33\. Monthly Public Support Amount at Closure
[37](#monthly-public-support-amount-at-closure)

34\. Primary Source of Support at Closure
[38](#primary-source-of-support-at-closure)

35\. Medical Insurance Coverage at Closure 38

36\. Type of Closure [39](#type-of-closure)

37\. Reason for Closure [40](#reason-for-closure)

38\. Date of Closure 41

39\. Supported Employment Status 41

40\. Veteran Status 41

41\. Significant Disability 42

42\. Migrant and Seasonal Farmworkers
[43](#migrant-and-seasonal-farmworkers)

43\. Projects With Industry [44](#projects-with-industry)

RSA-911 Record Layout 45

Edit Specifications BY ELEMENT 49

INDEX 61

## [General Instructions]{.underline}

This section provides detailed edit and relational edit specifications
for reporting RSA-911 data in a 213-character record image layout.
Records longer than 213 characters will not be evaluated.

Reported records pertain to all individuals whose case records were
closed in a given fiscal year. The due date for RSA-911 submittals is
November 30 following the Federal fiscal year of reference (October 1 to
September 30).

All records submitted **[MUST BE UNIQUE]{.underline}**. The Agency Code,
Social Security Number, and Closure Order Code determine the
\"uniqueness\" of a given record.

Duplicate records will be rejected. For example, records with codes in
positions 1 through 13 that are identical to the codes in another record
will be considered duplicates and will be rejected. In order to indicate
that a second closure for an individual has taken place in the same
Federal fiscal year, use Code 2 in position 13 (Closure Order Code). Use
Code 3 for a third closure and Code 4 for a fourth closure.

Records **[MUST]{.underline}** include Type of Closure within the valid
range of 1 through 7. Counts of each code 1 through 7 must equal counts
derived from the 4th Quarter of the Quarterly Cumulative Caseload Report
(Form RSA-113). Agencies may be required to resubmit data if there are
discrepancies in closure counts between these two systems.

All dates in the RSA-911 System must be in the format of YYYYMMDD, where
YYYY is Year, MM is Month and DD is Day.

Unless otherwise noted, all fields will be numeric or \*'s with no
embedded blanks or other special characters.

Actual values must be right justified and zero-filled when reporting
amounts for data elements such as Weekly Earnings at Application and
Closure, Cost of Case Services, and Monthly Amount of Public Support at
Application and Closure. Code values, too, should be right justified and
zero-filled. For example, if the Employment Status at Application, is
extended employment (Code 02) record 02 and not (blank)2.

####### 

####### 

####### 

####### 

####### Instructions for Preparation of Floppy Diskette, CD-ROM

####### or Electronic Transmittal

1.  The floppy diskette or CD-ROM should be in a flat file in the ASCII
    code set.

2.  Data may be recorded on 3.5-inch diskettes or CDs.

3.  Each record must be [213 characters]{.underline} in length.

4.  The diskette or CD-ROM should have an external label identifying the
    contents as \"RSA-911 Data for BAgXFYNN.\" where:

-   BA is the official postal abbreviation for your state/territory

-   g is the type of agency -- g=general, c=combined and b=blind

-   X is the number of the submission -- 1=first, 2=second, etc., and,

-   NN is the last two digits of the reported fiscal year.

5.  Use the following convention to name the file containing your R911
    data "BAgXFYNN" using the same designators as described above.

6.  If you would like to transmit your data electronically, send it
    zipped and password protected. If you need additional information,
    contact Mary Naifeh on 520-547-2078 or Vernita Washington on
    202-245-7479 for specific instructions. Electronic transmissions
    should be compressed and password protected.

```{=html}
<!-- -->
```
7.  RSA-911 data on CDs or floppy disks can be sent using private
    carriers such as FEDEX, UPS or another private carrier to the
    following address:

> US Department of Education
>
> State Monitoring and Program Improvement Division
>
> Data Collection and Analysis Unit
>
> ATTN: Vernita Washington
>
> 550 12^th^ Street, S.W., PCP 5011
>
> Washington, DC 20202-2800

8\. To send RSA-911 data via the US Postal Service, please send it to:

US Department of Education

State Monitoring and Program Improvement Division

Data Collection and Analysis Unit

ATTN: Vernita Washington, PCP 5011

7100 Old Landover Road

Landover, Maryland 20785-1506

**[Paperwork Burden Statement:]{.underline} According to the Paperwork
Reduction Act of 1995, no persons are required to respond to a
collection of information unless such collection displays a valid OMB
control number. The valid OMB control number for this information
collection is 1820-0508 (Expiration Date: 10/31/2008). The time required
to complete this information collection is estimated to average 45 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 20202-4700. If
you have comments or concerns regarding the status of your individual
submission of this form, write directly to: Rehabilitation Services
Administration, Basic State Grants Branch, 400 Maryland Avenue, S.W.,
Potomac Center Plaza Building, Room 5009, Washington, DC 20202-2800.**

# Element-by-Element Instructions:

**CASE SERVICE REPORT**

**[(RSA-911)]{.smallcaps}**

[Element-by-Element Instructions]{.underline}

## 1. [Agency Code]{.underline} 

Record Positions: 1-3

Enter the three-digit code assigned to each State vocational
rehabilitation (VR) agency from the following list. Please note that
codes have been preassigned to nonexistent agencies for individuals who
are blind in the event that they are established in the future.

State or [Agency Code]{.underline} State or [Agency Code]{.underline}

territory General/ Blind territory General/ Blind

Combined Combined

Alabama 001 057 Montana 029 085

Alaska 002 058 Nebraska 030 086

American Samoa 003 059 Nevada 031 087

Arizona 004 060 New Hampshire 032 088

Arkansas 005 061 New Jersey 033 089

California 006 062 New Mexico 034 090

Colorado 007 063 New York 035 091

Connecticut 008 064 North Carolina 036 092

Delaware 009 065 North Dakota 037 093

Dist. of Columbia 010 066 Northern Marianas 038 094

Florida 011 067 Ohio 039 095

Georgia 012 068 Oklahoma 040 096

Guam 013 069 Oregon 041 097

Hawaii 014 070 Pennsylvania 042 098

Idaho 015 071 Puerto Rico 043 099

Illinois 016 072 Rhode Island 044 100

Indiana 017 073 South Carolina 045 101

Iowa 018 074 South Dakota 046 102

Kansas 019 075 Tennessee 047 103

Kentucky 020 076 Texas 048 104

Louisiana 021 077 Utah 049 105

Maine 022 078 Vermont 050 106

Maryland 023 079 Virginia 051 107

Massachusetts 024 080 Virgin Islands 052 108

Michigan 025 081 Washington 053 109

Minnesota 026 082 West Virginia 054 110

Mississippi 027 083 Wisconsin 055 111

Missouri 028 084 Wyoming 056 112

## 2. [Social Security Number]{.underline} 

Record Positions: 4-12

Enter the individual\'s nine-digit Social Security number (SSN). When a
SSN is not available or if the individual prefers not to provide his/her
SSN, assign a unique nine-digit number that does not duplicate a genuine
SSN. Starting the nine-digit number with the digits \"99\" in RP 4 and 5
will avoid duplicating a genuine SSN. Asterisks are not permitted in the
SSN field.

## 3. [Closure Order]{.underline} 

Record Position: 13

Assign the appropriate closure order code for all service records from
the list below:

1 First closure of an individual\'s service record in the FY

2 Second closure of the same individual\'s service record in the same FY

3 Third closure of the same individual\'s service record in the same FY,
and so on.

If an individual\'s service record is closed more than once in the FY,
the RSA-911 data system must contain a separate record for each closure.
Ensure that when a record indicates a closure order code 2, there is
another record with a closure order code 1 with an identical SSN for
that individual, and so on for all multiple closures in the same FY.

## 4. [Previous Closure]{.underline} 

Record Position: 14

Enter the appropriate code listed below to indicate whether the
individual had a previous service record closed by the State VR agency
within a 36-month period prior to the most recent application for
services. If more than one record was closed for the individual within
that 36-month period, consider the most recent previous closure.
Indicate the type of the previous closure using one of the following
codes:

0 No previous closure within 36 months

1 Closed while the individual was an applicant, but before a
determination of eligibility

2 Closed while the individual was an applicant, but during or after a
trial work experience/extended evaluation

3 Closed after the individual achieved an employment outcome

4 Closed after individual received services, without an employment
outcome

5 Closed after an individualized plan for employment (IPE) was signed,
but before receiving services

6.  Closed from an order of selection wait list

7.  Closed after a determination of eligibility, but before an IPE was
    signed

## 5. [Date of Application]{.underline} 

Indicate the date (year, month, and day) that the individual applied for
VR services. An individual is considered to have submitted an
application when the individual has completed and signed an agency
application form or has otherwise requested services; has provided
information necessary to initiate an assessment to determine eligibility
and priority for services; and is available to complete the assessment
process.

Enter the year, month, and day, using the eight-digit protocol described
below:

5(a) [Year of Application]{.underline}

Record Positions: 15-18

Record the year using all four digits of the year.

Example: 1997, 1998, 2000, 2001, etc.

5(b) [Month of Application]{.underline}

Record Positions: 19-20

Record the months as follows:

01 January 07 July

02 February 08 August

03 March 09 September

04 April 10 October

05 May 11 November

06 June 12 December

5(c) [Day of Application]{.underline}

Record Positions: 21-22

Enter 01, 02, etc., using a \"0\" prefix for single digit days.

## 6. [Date of Birth]{.underline}

Record date (year, month, and day) of birth using the eight-digit
protocol:

6(a) [Year of Birth]{.underline}

Record Positions: 23-26

6(b) [Month of Birth]{.underline}

Record Positions: 27-28

6(c) [Day of Birth]{.underline}

Record Positions: 29-30

Use Code \*\*\*\*\*\*\*\* if this information is not available for
Closure Code 1.

## 7. [Gender]{.underline} 

Record Position: 31

Code as follows:

1 Male

2 Female

\* Information is not available for Closure Code 1

## 8. [Race and Ethnicity]{.underline}

Race and ethnicity information should be recorded for all individuals
whose service records were closed in the FY. Use Code 0 if the
individual is not of that race/ethnicity and Code 1 if the person is of
that race/ethnicity.

RSA continues to require self-identification to the greatest extent
possible. It is generally expected that the information recorded will
reflect the individual\'s own identification of race and ethnicity from
the categories provided. However, if a customer truly refuses to
identify his/her race or Hispanic ethnicity status, the counselor
should, at a minimum, notify respondents that if they fail to
self-identify that observer-identification method would be used. The
counselor or interviewer would then provide the best assessment of the
customer\'s race and Hispanic ethnicity. This guidance follows OMB
standards for collecting race/ethnicity data. OMB prefers
self-identification methods, but allows for observer-identification
methods when necessary.

**Both race and ethnicity should be reported.** The ethnic category
Hispanic or Latino (RP 37) should have a code of 0 or 1 and at least one
of the race categories (RP 32 through 36) must be coded as 1 (is this
race). Remaining categories should have codes of 0 (not this race).
Since a person can have more than one race, more than one race variable
can contain a code of 1 for an individual.

NOTE: It is known that some Hispanic people treat Hispanic ethnicity
like a race. Since they cannot relate to race categories, they may
refuse or be unable to respond to the race question. In such a case code
the person as Hispanic and follow the same procedure for race as the one
for individuals who refuse to identify both race and Hispanic ethnicity:
notify respondents that if they fail to self-identify then
observer-identification methods will be used. The interviewer or
counselor should make the best possible judgment and enter a 1 in the
race field that best reflects that judgment and enter a 0 in the other
race variables. Hispanics may belong to any race group.

Use Code \* only if the information is not available due to
circumstances beyond the agency's control for closure type 1. Such cases
will be few in number. For example, if the customer is never seen, such
as an applicant who mails a letter and is then closed without any
further contact, one probably would use a code of \* because race and
ethnicity is not known. This is the type of case for which the asterisk
(\*) is intended. No blanks are permitted in any category. **Remember:
race and ethnicity is one of the 9 essential variables in which data is
required for all closure types 1 through 7.**

> [White]{.underline}
>
> Record Position: 32
>
> [Black or African American]{.underline}
>
> Record Position: 33
>
> [American Indian or Alaska Native]{.underline}
>
> Record Position: 34
>
> [Asian]{.underline}
>
> Record Position: 35
>
> [Native Hawaiian or Other Pacific Islander]{.underline}
>
> Record Position: 36
>
> [Hispanic or Latino]{.underline}
>
> Record Position: 37

## 9. [Source of Referral]{.underline}

Record Position: 38

Indicate the individual, agency, or other entity that first referred the
individual to the State VR agency by using one of the following codes.
If the individual approached the VR agency on his/her own, even if based
on information provided by the State VR agency, use Code 8
(self-referral).

1.  Educational Institutions (elementary/secondary)

2.  Educational Institutions (post-secondary)

3.  Physician or other Medical Personnel or Medical Institutions (public
    or private)

4.  Welfare Agency (State or local government)

5.  Community Rehabilitation Programs

6.  Social Security Administration (Disability Determination Service or
    District office)

7.  One-stop Employment/Training Centers

8.  Self-referral

9.  Other sources

> \* Information is not available for Closure Code 1

## 10. [Level of Education Attained at Application]{.underline}

#####  Record Position: 39

Record the level of education the individual has attained at the time of
application. If an actual educational level is not documented, record an
estimated level.

Use the following codes:

0 No formal schooling

1 Elementary education (grades 1-8)

2 Secondary education, no high school diploma (grades 9-12)

3 Special education certificate of completion/diploma or in attendance

4 High school graduate or equivalency certificate (regular education
students)

5 Post-secondary education, no degree

6 Associate degree or Vocational/Technical Certificate

7 Bachelor\'s degree

8 Master\'s degree or higher

\* Information is not available for Closure Code 1

NOTE: Code 3 is intended to capture individuals whose highest level of
education is special education. This includes various situations. Use
code 3 "Special education certificate of completion/diploma or in
attendance": 1) if the individual is currently a special education
student, 2) if the individual received special education and earned a
certificate of completion or high school diploma, or 3) if the
individual received special education but did not receive a
certificate/diploma.

## 11. [Individualized Education Program (IEP)]{.underline}

Record Position: 40

Use one of the following codes to indicate whether the individual ever
received services under an IEP in accordance with the provisions of the
Individuals with Disabilities Education Act (IDEA). Use code 1 if the
individual was in special education or an ungraded classroom.

0 Did not have an IEP

1 Had an IEP

\* Information is not available for Closure Code 1

## 12. [Living Arrangement at Application]{.underline}

Record Positions: 41-42

Indicate the living arrangements of the individual, either temporarily
or permanently, on the date of application to the State VR agency. Codes
for this item are as follows:

> 01 Private Residence (independent, or with family or other person)

02 Community Residential/Group Home

03 Rehabilitation Facility

04 Mental Health Facility

05 Nursing Home

06 Adult Correctional Facility

07 Halfway House

08 Substance Abuse Treatment Center

#####  09 Homeless/Shelter

######## Other

> \*\* Information is not available for Closure Code 1

## 13. [Primary Disability]{.underline}

#####  Record Positions: 43-46

Enter the four-digit code that best describes the individual\'s primary
physical or mental impairment that causes or results in a substantial
impediment to employment. The number reported is a combination of the
impairment code and cause/source code. The first two digits designate
the impairment (sensory, physical or mental), and the last two digits
indicate the cause or source of the impairment.

If the person is found not to have a disability, this item should be
coded 0000. Use Code \*\*\*\* if the information is not available for
Closure Code 1.

## 14. [Secondary Disability]{.underline}

###### Record Positions: 47-50

Enter the four-digit code that best describes the secondary disability.
This is the physical or mental impairment that contributes to, but is
not the primary basis of, the impediment to employment. The number
reported is a combination of the impairment code and cause/source code.
Enter Code 0000 to indicate that the individual does not have a
secondary disability. Use Code \*\*\*\* if the information is not
available for Closure Code 1.

### **[CODES FOR IMPAIRMENTS]{.underline}**

00 No impairment

**SENSORY/COMMUNICATIVE IMPAIRMENTS:**

01 Blindness

02 Other Visual Impairments

03 Deafness, Primary Communication Visual

04 Deafness, Primary Communication Auditory

05 Hearing Loss, Primary Communication Visual

06 Hearing Loss, Primary Communication Auditory

> 07 Other Hearing Impairments (Tinnitus, Meniere\'s Disease,
> hyperacusis, etc.)

08 Deaf-Blindness

09 Communicative Impairments (expressive/receptive)

**PHYSICAL IMPAIRMENTS:**

10 Mobility Orthopedic/Neurological Impairments

11 Manipulation/Dexterity Orthopedic/Neurological Impairments

> 12 Both mobility and Manipulation/Dexterity Orthopedic/Neurological
> Impairments

13. Other Orthopedic Impairments (e.g., limited range of motion)

14. Respiratory Impairments

> 15 General Physical Debilitation (fatigue, weakness, pain, etc.)

16 Other Physical Impairments (not listed above)

**MENTAL IMPAIRMENTS:**

> 17 Cognitive Impairments (impairments involving learning, thinking,
> processing information and concentration)
>
> 18 Psychosocial Impairments (interpersonal and behavioral impairments,
> difficulty coping)
>
> 19 Other Mental Impairments

### **[CODES FOR CAUSES/SOURCES OF IMPAIRMENTS]{.underline}**

> 00 Cause unknown

01 Accident/Injury (other than TBI or SCI)

02 Alcohol Abuse or Dependence

03 Amputations

04 Anxiety Disorders

05 Arthritis and Rheumatism

06 Asthma and other Allergies

07 Attention-Deficit Hyperactivity Disorder (ADHD)

08 Autism

09 Blood Disorders

10 Cancer

11 Cardiac and other Conditions of the Circulatory System

12 Cerebral Palsy

13 Congenital Condition or Birth Injury

14 Cystic Fibrosis

15 Depressive and other Mood Disorders

16 Diabetes Mellitus

17 Digestive

18. Drug Abuse or Dependence (other than alcohol)

19. Eating Disorders (e.g., anorexia, bulimia, or compulsive overeating)

> 20 End-Stage Renal Disease and other Genitourinary System Disorders

21 Epilepsy

22 HIV and AIDS

23. Immune Deficiencies excluding HIV/AIDS

24. Mental Illness (not listed elsewhere)

25 Mental Retardation

26 Multiple Sclerosis

27 Muscular Dystrophy

28 Parkinson\'s Disease and other Neurological Disorders

29 Personality Disorders

30 Physical Disorders/Conditions (not listed elsewhere)

31 Polio

32 Respiratory Disorders other than Cystic Fibrosis or Asthma

33 Schizophrenia and other Psychotic Disorders

34 Specific Learning Disabilities

35 Spinal Cord Injury (SCI)

36 Stroke

37 Traumatic Brain Injury (TBI)

## 15. [Employment Status at Application]{.underline}

Record Positions: 51-52

Enter the two-digit code which best describes the employment status of
the individual at application from the following. Fill in leading zero
when it applies.

01 Employment without Supports in Integrated Setting

02 Extended Employment

03 Self-employment (except BEP)

04 State Agency-managed Business Enterprise Program (BEP)

05 Homemaker

06 Unpaid Family Worker

07 Employment with Supports in Integrated Setting

08 Not employed: Student in Secondary Education

09 Not employed: All other Students

10 Not employed: Trainee, Intern or Volunteer

11 Not employed: Other

\*\* Information is not available for Closure Code 1

The first seven codes are considered \"employment\" for purposes of this
item. Individuals not meeting the definitions for Codes 01 to 07 below
would be classified as \"not employed\" (Codes 08 to 11) at the time of
application for services.

**[Employment Codes]{.underline}** (Codes 01-07)

01 - [Employment without Supports in Integrated Setting]{.underline} is
full-time or part-time employment in an integrated setting without
ongoing support services. For purposes of this report, this is work
performed for wages, salary, commissions, tips, or piece-rates, below,
at, or above the minimum wage. Do not include self-employed individuals.

02 - [Extended Employment]{.underline} refers to work for wages or
salary in a non-integrated setting for a public or nonprofit
organization. Such settings are variously referred to as community
rehabilitation programs, or sheltered, industrial, or occupational
workshops. Individuals are compensated according to the Fair Labor
Standards Act and the organization provides any needed support services
that enable the individual to train or prepare for competitive
employment.

03 - [Self-employment (except BEP)]{.underline} refers to work for
profit or fees including operating one\'s own business, farm, shop, or
office. \"Self-employment\" includes sharecroppers, but not wage earners
on farms.

04 - [State Agency-managed Business Enterprise Program
(BEP)]{.underline} refers to Randolph-Sheppard vending facilities and
other small businesses operated by individuals with significant
disabilities under the management and supervision of a State VR agency.
Include home industry where the work is done under the management and
supervision of a State VR agency in the individual\'s own home or
residence for wages, salary, or on a piece-rate. Individuals capable of
activity outside the home, as well as homebound individuals, may engage
in such employment.

05 - [Homemaker]{.underline} refers to men and women whose activity is
keeping house for persons in their households or for themselves if they
live alone.

06 - [Unpaid Family Worker]{.underline} is an individual who works
without pay on a family farm or in a family business.

07 - [Employment with Supports in Integrated Setting]{.underline} is
full time or part-time employment in an integrated setting with ongoing
support services for individuals with significant disabilities. For
purposes of this report, compensation for such employment may be below,
at, or above the minimum wage.

**[Not employed]{.underline}** (Codes 08-11)

08 - [Student in Secondary Education]{.underline}

09 - [All other Students]{.underline} are persons attending school full
or part-time other than students in secondary education.

> 10 - [Trainee, Intern or Volunteer]{.underline} refers to persons
> engaging in unpaid work experiences, internships or volunteer work for
> purposes of increasing their employability. Such individuals may
> receive a stipend to defray the cost of transportation or other
> incidental expenses.
>
> 11 - [Other]{.underline} refers to persons not in any of the other
> categories (e.g., persons just out of school who are not yet employed;
> persons unable to retain or obtain work; and persons who have recently
> left specialized medical facilities).

When an individual\'s work activity overlaps into two different
employment categories, select the code more descriptive of the
individual\'s employment activity at application.

## 16. [Weekly Earnings at Application]{.underline}

Record Positions: 53-56

Enter the amount of money (to the nearest dollar) earned in a typical
week at the time of application. If the individual had no earnings,
enter 0000. If the person had earnings of \$9999 or more, use 9999. Fill
in leading zeros when they apply. For example, record 0055 for those
earning \$55 at the time of application. Use Code \*\*\*\* if the
information is not available for Closure Code 1

This item collects data on the [cash]{.underline} earnings of
individuals at application and includes all wages, salaries, tips, and
commissions received as income [before]{.underline} payroll deductions
of Federal, State and local income taxes and Social Security payroll
tax. Earnings also include profits derived from self-employed
individuals. Earnings for salespersons, consultants, self-employed
individuals, and other similar occupations are based on the [adjusted
gross income.]{.underline} Adjusted gross income is gross income minus
unreimbursed business expenses. [Do not]{.underline} include estimates
of payments in-kind, such as meals and lodging. Estimate profits of
farmers, if necessary.

**[SPECIAL CASES:]{.underline}** To preclude misleading results such as
a negative earnings situation, the following instructions are provided:

> Where earnings are based on commissions that are irregular (e.g., real
> estate, automobile sales, etc.), to obtain a meaningful figure for a
> typical week's earnings, it should be calculated as an average over a
> representative period of time such as one month.
>
> When, because of the occupation/situation, there are significant
> amounts of unreimbursed business expenses that are irregular (e.g.,
> car lease payments due the first week of every month), the expenses
> should be averaged over a representative period of time to obtain a
> meaningful figure for a typical week's expenses.
>
> Commissions are generally not paid when earned, but rather are paid
> periodically, such as weekly, biweekly, or even monthly. To bring
> standardization to this item, earnings should be based on the actual
> receipt of the payment and not on amounts accruing until the next
> commission payout.

## 17. [Hours Worked in a Week at Application]{.underline}

> Record Positions: 57-58

Enter the number of hours an individual worked for earnings in a typical
week at the time of application. Earnings may have been in the form of
wages, salaries, tips, commissions, profits from self-employment,
adjusted gross income for salespersons, etc. If the individual generated
no earnings, enter 00. If the person worked 99 or more hours in one
week, enter 99. Fill in leading zero when it applies. For example, enter
06 for an individual who worked six (6) hours. Use Code \*\* if the
information is not available for Closure Code 1.

## 18. [Type of Public Support at Application]{.underline}

Enter a Code 0 or a Code 1 in each of the following seven record
positions to indicate whether the individual was receiving that type of
public support at application. Use Code 0 to indicate that the person
did not receive public support from the source cited and Code 1 to
indicate receipt of support payment from the source cited. One payment
is sufficient to establish \"receipt\". Use Code \* in the position if
the information is not available for Closure Code 1 or the information
is not available for all other closure codes due to circumstances beyond
the agency's control.

Public support refers to cash payments made by Federal, State and/or
local governments for any reason, including an individual\'s disability,
age, economic, retirement and survivor status. Include payments to a
[family]{.underline} unit precipitated by the individual\'s disability
or when the individual\'s presence is taken into account in the
computation of the family benefit. Also include any payments that are
sent directly to the individual in an institution or to dependents on
his/her behalf. Exclude any non-cash support payments such as Medicaid,
Medicare, food stamps and rental subsidies. Categories of public support
are as follows:

[Supplemental Security Income (SSI) for the Aged, Blind or
Disabled]{.underline}

Record Position: 59

[Temporary Assistance for Needy Families (TANF)]{.underline}

Record Position: 60

[General Assistance (State or local government)]{.underline}

Record Position: 61

[Social Security Disability Insurance (SSDI)]{.underline}

Record Position: 62

[Veterans\' Disability Benefits]{.underline}

Record Position: 63

[Workers\' Compensation]{.underline}

Record Position: 64

[Other Public Support]{.underline}

Record Position: 65

Veterans\' Disability Benefits are payments made by the Department of
Veterans Affairs for partial or total disability.

Other Public Support payments are cash payments to individuals, not
listed, and include payments made by Federal, State and local
governments for retirement or survivor benefits to the individual as
well as unemployment insurance benefits and other temporary payments.

## 19. [Monthly Public Support Amount at Application]{.underline}

Enter the amount of money (to the nearest dollar) received by the
individual each month in the form of public support payments at the time
of application for the sources listed below. If the individual receives
two or more types of support, record the amount from each source. Fill
in leading zeros for amounts under \$1000. If no public assistance
payments were received, enter 0000. If payments totaled \$9999 or more,
use 9999. Use Code \*\*\*\* in the position if the information is not
available for Closure Code 1 or the information is not available for all
other closure codes due to circumstances beyond the agency's control.

[Social Security Disability Insurance (SSDI)]{.underline}

Record Positions: 66-69

> Enter the amount of SSDI received by the individual each month. This
> figure can be verified through the Social Security Administration
> (SSA) or from a copy of the individual\'s benefit notification letter.

[Supplemental Security Income (SSI) for the Aged, Blind or
Disabled]{.underline}

Record Positions: 70-73

> Enter the monthly payment to the individual under the Federal program
> of SSI for the aged, blind, and disabled. Only the individual\'s
> portion of the payment should be recorded here. This figure can be
> verified through the Social Security Administration (SSA) or from a
> copy of the individual\'s benefit notification letter.

[Temporary Assistance for Needy Families (TANF)]{.underline}

Record Positions: 74-77

> Enter the amount of cash public assistance payments made through the
> federally funded TANF program. If the TANF payment is made to the
> family unit, use the local disbursing agency\'s procedure to estimate
> the individual\'s portion of the payment.
>
> [All other Public Support]{.underline}
>
> Record Positions: 78-81
>
> Enter the monthly amount of public support received from General
> Assistance, Veteran\'s Disability Benefits, Workers\' Compensation and
> all other sources of public support not listed (see Item 18).

## 20. [Primary Source of Support at Application]{.underline}

Record Position: 82

Enter a code from the list below to indicate the individual\'s largest
single source of economic support at application, even if it accounts
for less than one-half of the individual\'s total support.

**[NOTE]{.underline}**: If a person is supported by the earnings of a
spouse, or by the spouse\'s unemployment insurance checks, identify Code
2 as the Primary Source of Support (family and friends) and not Code 1
(personal income). If a person is primarily supported by a governmental
entity with no cash support -- for example, incarcerated individuals, --
use code 3 as the primary source of support.

Primary Source of Support Codes:

1 Personal Income (earnings, interest, dividends, rent)

2 Family and Friends

3 Public Support (SSI, SSDI, TANF, etc.)

4 All other sources (e.g., private disability insurance and private
charities)

\* Information is not available for Closure Code 1 or information is not
available for all other closure codes due to circumstances beyond the
agency's control

## 21. [Medical Insurance Coverage at Application]{.underline}

Record whether an individual had medical insurance coverage at the time
he/she applied for VR services. Enter a Code 0 or Code 1 in each of the
following record positions. Use Code 0 if the individual had no medical
coverage and Code 1 if the individual had that type of medical insurance
coverage. Persons with no medical insurance coverage would be coded 0
for each type of medical insurance listed. Use Code \* in the position
if the information is not available for Closure Code 1 or the
information is not available for all other closure codes due to
circumstances beyond the agency's control.

[Medicaid]{.underline}

Record Position: 83

[Medicare]{.underline}

Record Position: 84

[Public Insurance from Other Sources]{.underline}

Record Position: 85

[Private Insurance Through own Employment]{.underline}

Record Position: 86

[Private Insurance Through other Means]{.underline}

Record Position: 87

## 22. [Date of Eligibility Determination]{.underline}

Record the date (year, month, and day) that an eligibility determination
was made. For individuals whose service records were closed before a
determination of eligibility, use Code \*\*\*\*\*\*\*\*.

For those individuals who were initially determined to be eligible but
later in the VR process were determined to be ineligible because of
changed circumstances, record just the date they were determined
eligible in this field. For all others, enter the date that the initial
determination was made that they were either eligible or ineligible.

Code date of eligibility determination using eight-digit protocol.

22(a) [Year eligibility was determined]{.underline}

Record Positions: 88-91

22(b) [Month eligibility was determined]{.underline}

Record Positions: 92-93

22(c) [Day eligibility was determined]{.underline}

Record Positions: 94-95

## 23. [Date of Individualized Plan for Employment (IPE)]{.underline}

Record the date (year, month, and day) on which the first IPE for the
individual became effective. For purposes of this data element, assume
that the IPE is effective on the date on which both parties reach
agreement. If the two signatures bear two different dates, the later
date should govern. If an individual\'s service record is closed before
an IPE is developed, use Code \*\*\*\*\*\*\*\*.

Code date of IPE using the eight-digit protocol.

23(a) [Year IPE became effective]{.underline}

Record Positions: 96-99

23(b) [Month IPE became effective]{.underline}

Record Positions: 100-101

23(c) [Day IPE became effective]{.underline}

Record Positions: 102-103

## 24. [Cost of Purchased Services]{.underline} 

Record Positions: 104-109

Enter, to the nearest dollar, the total amount of money spent by the
State VR agency to purchase services for an individual, over the life of
the current service record.

Include all expenditures made to public and/or private vendors,
individuals or an organization. Include expenditures for all types of
purchased services such as assessment, training, medical services,
maintenance, transportation, tuition for higher education,
rehabilitation technology services, personal assistance, or any other
rehabilitation services. [Exclude]{.underline} costs incurred for
program administration and for salaries of counselors and other staff.
Also [exclude]{.underline} costs for services provided by rehabilitation
programs owned and operated by the State VR agency that are not directly
billed on an individual basis.

If an individual\'s service record is closed without an expense having
been incurred by the State agency, enter 000000. If the agency expended
\$999,999 or more, enter 999999. Fill in leading zeros when they apply.

## 25. [Services Provided]{.underline}

Enter the appropriate two-digit code to indicate the vendor and source
of funding for each service listed. Services must have been provided to
the individual in determining eligibility and/or in developing and
carrying out the IPE.

Include all services furnished over the life of the current service
record whether paid for with VR funds or from other sources (comparable
services). If an individual received the same service from more than one
provider, record only the major provider.

The first digit identifies the vendor or provider of the service. The
second digit indicates the source of funding. Use Code 00 if a service
was not provided to an individual. Funding Code 0 should only be used if
the service was not provided to an individual. If a service was provided
directly by the State VR agency without a direct cost use Code 11.

Codes for Vendors/Providers:

0 Not provided

1 Provided directly by State VR agency

2 Provided by Community Rehabilitation Programs in the Public Sector
(owned and managed by Federal, State, or local government, such as those
run by State VR agencies).

3 Provided by Community Rehabilitation Programs in the Private Sector
(owned and managed by non-governmental entities, such as individuals,
associations, corporations, etc.)

4 Provided by One-stop Employment/Training Centers

5 Provided by other Public Sources

6 Provided by other Private Sources

Codes for Source of Funding

0 Not provided

1 VR funds

2.  Non-VR Sources

3.  Combination of VR and Other Sources

    [Assessment]{.underline}

#####  Record Positions: 110-111

Assessment means services provided and activities performed to determine
an individual\'s eligibility for VR services, to assign an individual to
a priority category of a State VR agency that operates under an order of
selection, and/or to determine the nature and scope of VR services to be
included in the IPE. Include here trial work experiences and extended
evaluation.

[Diagnosis and Treatment of Impairments]{.underline}

Record Positions: 112-113

Diagnosis and treatment of impairments means:

a\) Corrective surgery or therapeutic treatment that is likely, within a
reasonable period of time, to correct or modify substantially a physical
or mental impairment that constitutes a substantial impediment to
employment;

b\) Diagnosis and treatment for mental and emotional disorders by
qualified personnel who meet State licensure laws;

c\) Dentistry;

d\) Nursing services;

e\) Necessary hospitalization (either inpatient or outpatient care) in
connection with surgery or treatment;

f\) Drugs and supplies;

g\) Prosthetic, orthotic, or other assistive devices, including hearing
aids;

h\) Eyeglasses and visual services, including visual training, and the
examination and services necessary for the prescription and provision of
eyeglasses, contact lenses, microscopic lenses, telescopic lenses, and
other visual aids prescribed by personnel who meet State licensure laws
and are selected by the individual;

i\) Podiatry;

j\) Physical therapy;

k\) Occupational therapy;

l\) Speech or hearing therapy;

m\) Mental health services;

n\) Treatment of either acute or chronic medical complications and
emergencies that are associated with or arise out of the provision of
physical and mental restoration services or that are inherent in the
condition under treatment;

o\) Special services for the treatment of individuals with end-stage
renal disease, including transplantation, dialysis, artificial kidneys,
and supplies; and

p\) Other medical or medically related rehabilitation services.

[Vocational Rehabilitation Counseling and Guidance]{.underline}

Record Positions: 114-115

> Vocational rehabilitation counseling and guidance means discrete
> therapeutic counseling and guidance services that are necessary for an
> individual to achieve an employment outcome, including personal
> adjustment counseling, counseling that addresses medical, family, or
> social issues, vocational counseling, and any other form of counseling
> and guidance that is necessary for an individual with a disability to
> achieve an employment outcome. This service is distinct from the
> general counseling and guidance relationship that exists between the
> counselor and the individual during the entire rehabilitation process.

[Training]{.underline}

> General note: Training services are designed to help the individual
> improve educationally or vocationally or to adjust to the functional
> limitations of his or her impairment. If the individual receives more
> than one type of training, each type should be recorded.

[College or University Training]{.underline}

Record Positions: 116-117

> Full-time or part-time [academic training]{.underline} above the high
> school level leading to a degree (associate, baccalaureate, graduate,
> or professional), a certificate or other recognized educational
> credential. Such training may be provided by a four-year college or
> university, community college, junior college, or technical college.

[Occupational/Vocational Training]{.underline}

Record Positions: 118-119

Occupational, vocational, or job skill training provided by a community
college and/or business, vocational/trade or technical school to prepare
students for gainful employment in a recognized occupation, not leading
to an academic degree or certification.

[On-the-job Training]{.underline}

Record Positions: 120-121

Training in specific job skills by a prospective employer. Generally the
individual is paid during this training and will remain in the same or a
similar job upon successful completion. Also include
apprenticeship-training programs conducted or sponsored by an employer,
a group of employers, or a joint apprenticeship committee representing
both employers and a union.

[Basic Academic Remedial or Literacy Training]{.underline}

Record Positions: 122-123

Literacy training or training provided to remediate basic academic
skills that are needed to function on the job in the competitive labor
market.

[Job Readiness Training]{.underline}

Record Positions: 124-125

Training to prepare an individual for the world of work (e.g.,
appropriate work behaviors, getting to work on time, appropriate dress
and grooming, increasing productivity).

[Disability Related Augmentative Skills Training]{.underline}

#####  Record Positions: 126-127

Disability related augmentative skills training includes but is not
limited to: orientation and mobility; rehabilitation teaching; training
in the use of low vision aids; Braille; speech reading; sign language;
and cognitive training/retraining.

[Miscellaneous Training]{.underline}

Record Positions: 128-129

Any training not recorded in one of the other categories listed,
including GED or high school training leading to a diploma.

[Job-Related Services]{.underline}

General note: Job-related services include job search assistance, job
placement assistance, and on-the-job support services.

[Job Search Assistance]{.underline}

Record Positions: 130-131

> Job search activities support and assist a consumer in searching for
> an appropriate job. Job search assistance may include help in resume
> preparation, identifying appropriate job opportunities, developing
> interview skills, and making contacts with companies on behalf of the
> consumer.

[Job Placement Assistance]{.underline}

Record Positions: 132-133

Job placement assistance is a referral to a specific job resulting in an
interview, whether or not the individual obtained the job.

[On-the-job Supports]{.underline}

Record Positions: 134-135

> Support services provided to an individual who has been placed in
> employment in order to stabilize the placement and enhance job
> retention. Such services include job coaching, follow-up and
> follow-along, and job retention services.

[Transportation Services]{.underline}

Record Positions: 136-137

Transportation, including adequate training in the use of public
transportation vehicles and systems, means travel and related expenses
that are necessary to enable an applicant or eligible individual to
participate in a VR service. Examples of transportation
services/expenses include, but are not limited to:

a\) Travel and related expenses for a personal care attendant or aide if
the services of that person are necessary to enable the individual to
travel to participate in any VR service;

b\) Relocation expenses incurred by the individual in connection with a
job placement that is a significant distance from the individual\'s
current residence;

c\) The purchase and repair of vehicles, including vans, but not the
modification of these vehicles; and

> d\) Training in the use of public transportation vehicles and systems.
>
> [Maintenance]{.underline}

Record Positions: 138-139

Maintenance means monetary support provided for those expenses such as
food, shelter and clothing that are in excess of the normal expenses of
the individual, and that are necessitated by the individual\'s
participation in an assessment for determining eligibility and VR needs
or while receiving services under an IPE. Examples of maintenance
expenses include, but are not limited to:

a\) cost of uniforms or other suitable clothing required for an
individual\'s job placement or job seeking activities;

b\) cost of short-term expenses, such as food and shelter, that are
required in order for an individual to participate in assessment or
vocational training at a site that is not within commuting distance of
an individual\'s home;

c\) initial one-time costs, such as security deposits or charges for the
initiation of utilities, that are required in order for an individual to
relocate for a job placement; and

d\) costs of an individual\'s participation in enrichment activities
related to that individual\'s training program.

[Rehabilitation Technology]{.underline}

Record Positions: 140-141

General note: Rehabilitation technology means the systematic application
of technologies, engineering methodologies, or scientific principles to
meet the needs of, and address the barriers confronted by, individuals
with disabilities in areas that include education, rehabilitation,
employment, transportation, independent living, and recreation. The term
includes the following:

[Rehabilitation Engineering Service]{.underline}

Rehabilitation engineering is the systematic application of engineering
sciences to design, develop, test, evaluate, apply, and distribute
technological solutions to problems confronted by individuals with
disabilities in functional areas such as mobility, communications,
hearing, vision, and cognition, and in activities associated with
employment, independent living, education, and integration into the
community.

[Assistive Technology Devices]{.underline}

Assistive technology device means any item, piece of equipment, or
product system, whether acquired commercially off the shelf, modified or
customized, that is used to increase, maintain, or improve the
functional capabilities of an individual with a disability.

[Assistive Technology Services]{.underline}

Assistive technology service is any service that directly assists an
individual with a disability in the selection, acquisition, or use of an
assistive technology device. Services may include:

a\) evaluating the needs of an individual with a disability, including a
functional evaluation of the individual in his/her customary
environment;

b\) purchasing, leasing, or otherwise providing for the acquisition by
an individual with a disability of an assistive technology device;

c\) selecting, designing, fitting, customizing, adapting, applying,
maintaining, repairing, or replacing assistive technology devices;

d\) coordinating and using other therapies, interventions, or services
with assistive technology devices, such as those associated with
existing education and rehabilitation plans and programs;

e\) training or providing technical assistance for an individual with a
disability or, if appropriate, the family members, guardians, advocates,
or authorized representatives of the individual; and

f\) training or providing technical assistance for professionals
(including individuals providing education and rehabilitation services),
employers, or others who provide services to, employ, or are otherwise
substantially involved in the major life functions of individuals with
disabilities to the extent that training or technical assistance is
necessary for an individual with a disability to achieve an employment
outcome.

**[NOTE]{.underline}**: It is possible for these services to be
classifiable under any of the other service categories.

[Personal Assistance Services]{.underline}

General note: Personal assistance services are a range of services
provided by one or more persons designed to assist an individual with a
disability to perform daily living activities on or off the job that the
individual would typically perform without assistance if the individual
did not have a disability. The services must be designed to increase the
individual\'s control in life and ability to perform everyday activities
on or off the job.

Three distinct services that are considered personal assistance services
are reader services, interpreter services, and personal attendant
services. Further information on recording each of these services
follows. Record only whether and which of these services were provided
to the individual (e.g., if the same person provided both reader service
and personal attendant service to an individual, indicate both
services).

[Reader Services]{.underline}

Record Positions: 142-143

Reader services are for individuals who cannot read print because of
blindness or other disability. Reader services include, in addition to
reading aloud, transcription of printed information into Braille or
sound recordings if the individual requests such transcription. Reader
services are generally for individuals who are blind or deaf-blind, but
may also include individuals unable to read because of serious
neurological disorders, specific learning disabilities, or other
physical or mental impairments.

[Interpreter Services]{.underline}

Record Positions: 144-145

Interpreter services are sign language or oral interpretation services
for individuals who are deaf or hard of hearing and tactile
interpretation services for individuals who are deaf-blind. Specially
trained individuals perform sign language or oral interpretation. Also
include here real-time captioning services for persons who are deaf or
hard of hearing. Do not include language interpretation in this
category, but in \"other services\".

[Personal Attendant Services]{.underline}

Record Positions: 146-147

Personal attendant services are those personal services that an
attendant performs for an individual with a disability such as bathing,
feeding, dressing, providing mobility and transportation, etc.

[Technical Assistance Services]{.underline}

Record Positions: 148-149

Technical assistance and other consultation services provided to conduct
market analyses, to develop business plans, and to provide resources to
individuals in the pursuit of self-employment, telecommuting and small
business operation outcomes.

[Information and Referral Services]{.underline}

Record Positions: 150-151

Information and referral services are provided to individuals who need
services from other agencies (through cooperative agreements) not
available through the VR program.

[Other Services]{.underline}

Record Positions: 152-153

Use this category for all other VR services that cannot be recorded
elsewhere. Included here are occupational licenses, tools and equipment,
initial stocks and supplies. Medical care for acute conditions arising
during rehabilitation and constituting a barrier to the achievement of
an employment outcome is also included in this category.

## 26. [Level of Education Attained At Closure]{.underline}

> Record Position: 154

Record the level of education the individual had attained when the
service record was closed. If an actual educational level is not
documented, record an estimated level.

Use the following codes:

0 No formal schooling

1 Elementary education (grades 1-8)

2 Secondary education, no high school diploma (grades 9-12)

3 Special education certificate of completion/diploma or in attendance

4 High school graduate or equivalency certificate (regular education
students)

5 Post-secondary education, no degree

6 Associate degree or Vocational/Technical Certificate

7 Bachelor\'s degree

####  8 Master\'s degree or higher

\* Information is not available for Closure Code 1

NOTE: Code 3 is intended to capture individuals whose highest level of
education is special education. This includes various situations. Use
code 3 "Special education certificate of completion/diploma or in
attendance": 1) if the individual is currently a special education
student, 2) if the individual received special education and earned a
certificate of completion or high school diploma, or 3) if the
individual received special education but did not receive a
certificate/diploma.

## 27. [Occupation at Closure]{.underline}

Record Positions: 155-160

For an individual who achieved an employment outcome, enter a six-digit
code to describe the individual\'s occupation when the service record
was closed.

Using the Dictionary of Occupational Titles (DOT) published by the U.S.
Department of Labor, enter the first six digits of the appropriate DOT
code. Fill in leading zeros when they apply. Closure into an
architectural occupation, for example, should be recorded as 001061.

For the four employment situations unique to the VR program, use the
special codes indicated below. These codes do not duplicate any
six-digit codes in the DOT structure:

599999 [Homemaker (own home)]{.underline} refers to men and women whose
activity is keeping house for their families, or themselves if they live
alone.

799999 [Unpaid family worker (own family), not elsewhere
classified]{.underline} use [only]{.underline} if the type of unpaid
family work cannot be classified according to any of the DOT
occupations. An unpaid family worker is one who works without pay on a
family farm or in a family business.

899999 [Randolph-Sheppard vending facility clerk]{.underline} use this
category for persons employed as clerks, sales persons, or helpers in a
vending facility operated under the Randolph-Sheppard Vending Facility
Program. Use this special code even though these occupations are
classifiable in the DOT. Do not include vending facility operators
(999999), or individuals employed in vending facilities outside the
Vending Facility Program (use their DOT occupation code).

999999 [Randolph-Sheppard vending facility operator]{.underline} use
this category for individuals employed as operators or managers of
vending facilities operated under the Vending Facility Program. Use this
special code even though these occupations are classifiable in the DOT.
Do not include vending facility clerks (899999), or individuals employed
as vending facility operators outside the Randolph-Sheppard Vending
Facility Program (use their DOT occupation code).

[Special Codes]{.underline}

599999 Homemaker

799999 Unpaid family worker, not classifiable in another DOT code

899999 Randolph-Sheppard vending facility clerk

999999 Randolph-Sheppard vending facility operator

\*\*\*\*\*\* Use this code for all closure types other than code 3

**NOTE: Beginning with FY 2007, RSA 911 occupational data must be SOC
codes. Until then, RSA 911data will require DOT codes. It is important
that all agencies report the same data for a given year. For FY 2005 and
FY 2006, agencies need to report DOT codes in Record Position (RP)
155-160. Beginning in FY 2007, agencies will report SOC codes in RP
155-160.**

## 28. [Employment Status at Closure]{.underline} 

#####  Record Position: 161

For an individual who achieved an employment outcome, enter the
applicable one-digit code that describes the employment outcome of the
individual when his or her service record was closed. Codes 1 and 3
through 7 are applicable for individuals who achieved an employment
outcome (closure type 3). Code 2 applies only to an individual who
received services and was placed in extended employment, which is no
longer an employment outcome. Such an individual would have a closure
type of 4. Use Code \* for all closure types other than 3 and for
closure type 4 cases not placed in extended employment. If classifying
the individual into two different employment statuses from Codes 1-7 is
possible, select a code designating the principal status.

1 Employment without Supports in Integrated Setting

2 Extended Employment (Applies only to closure type 4 with a reason for
closure of 14.)

3 Self-employment (except BEP)

4 State Agency-managed Business Enterprise Program (BEP)

5 Homemaker

6 Unpaid Family Worker

7 Employment with Supports in Integrated Setting

1 - [Employment without Supports in Integrated Setting]{.underline} is
full-time or part-time employment in an integrated setting without
ongoing support services. For purposes of this report, this is work
performed for wages, salary, commissions, tips, or piece-rates, below,
at, or above the minimum wage. Do not include self-employed individuals.

2 - [Extended Employment]{.underline} refers to work for wages or salary
in a non-integrated setting for a public or nonprofit organization. Such
settings are variously referred to as community rehabilitation programs,
or sheltered, industrial, or occupational workshops. Individuals are
compensated according to the Fair Labor Standards Act and the
organization provides any needed support services that enable the
individual to train or prepare for competitive employment. This code
applies only to an individual who received services and was placed in
extended employment, which is no longer an employment outcome. The
appropriate closure type for such placements is 4 with a reason for
closure of 14.

3 - [Self-employment (except BEP)]{.underline} is work for profit or
fees including operating one\'s own business, farm, shop or office.
\"Self-employment\" includes sharecroppers, but not wage earners on
farms.

4 - [State Agency-managed Business Enterprise Program (BEP)]{.underline}
refers to Randolph-Sheppard vending facilities and other small
businesses operated by individuals with significant disabilities under
the management and supervision of a State VR agency. Include home
industry where the work is done under the management and supervision of
a State VR agency in the individual\'s own home or residence for wages,
salary, or a piece-rate. Individuals capable of activity outside the
home, as well as by homebound individuals, may engage in such
employment.

5 - [Homemaker]{.underline} refers to men and women whose activity is
keeping house for persons in their households or for themselves if they
live alone.

> 6 - [Unpaid Family Worker]{.underline} refers to persons who work
> without pay on a family farm or in a family business.

7 - [Employment with Supports in Integrated Setting]{.underline} is
full-time or part-time employment in an integrated setting with ongoing
support services for individuals with significant disabilities. For
purposes of this report, compensation for such employment may be below,
at, or above the minimum wage.

## 29. [Competitive Employment]{.underline} 

Record Position: 162

Enter a one-digit code to indicate whether the individual achieved
competitive employment at the time the service record was closed. For
purposes of this report, competitive employment is employment in an
integrated setting, self-employment or a state-managed Business
Enterprise Program (BEP) that is performed on a full-time or part-time
basis for which an individual is compensated at or above the minimum
wage. Minimum wage is the Federal or State minimum wage, whichever is
higher.

Coding this item requires accurately applying several criteria to each
individual. Specifically, item #36, type of closure, has a code of 3;
item #28, employment status at closure, has a code of 1, 3, 4 or 7; the
hourly wage (weekly earnings, item #30/hours worked, item #31) is at
least equal to the higher of the federal or state minimum wage.
Therefore, Code 1 in this item will be a subset of the total number of
individuals coded 1, 3, 4 or 7 in Item #28. Use Code 0 in this item for
individuals in Item #28, Codes 1, 3, 4 or 7, who did not meet the
definition of competitive employment. Also use Code 0 for individuals
whose service records were closed as homemakers, or unpaid family
workers (Codes 5 or 6 in Item #28). Use Code \* for closure types other
than 3.

0 Not competitively employed

#### Competitively employed

Instructions for the accurate computation of hourly earnings for
reporting competitive employment

The RSA 911 requires submission of weekly earnings and weekly hours
worked in integers: file specifications do not permit the entry of
either cents or partial hours. Hourly wages are computed by dividing the
weekly earnings by the weekly hours worked. For hourly earnings that are
at or near the applicable minimum wage, an individual making the minimum
hourly wage may appear to be making less than the minimum wage. For
example, a person making \$5.15 per hour and working 1 hour each week,
would have a weekly earnings of \$5 if one used mathematical rounding
rules to report weekly earnings.

To accurately report those individuals who make the minimum hourly wage
and, at the same time, not introduce error by incorrectly identifying
those who are not competitively employed use the following:

Continue to report weekly earnings and hours worked in integers. Round
both of these variables using mathematical rules [except]{.underline}
for those cases where the individual makes the minimum wage or more but
whose combination of weekly earnings and hours worked would result in a
computation of hourly wages that would be less than the minimum wage.
For those cases, round the weekly earnings up and report this higher
amount. Round up these cases and only these cases.

In mathematical rounding rules, values of .5 or more are rounded up and
values less than .5 are rounded down. Thus \$5.50 becomes \$6 and \$6.45
also becomes \$6. An example of an exception to the application of
mathematical rounding rules occurs in a situation in which a person
works for 35 hours per week at \$5.15 per hour. (Assumption: federal
minimum wage is the applicable minimum wage.) The computed weekly wage
of \$180.25 would be rounded down to \$180 if mathematical rounding
rules were applied. However, if weekly earnings were reported as \$180
then the computed hourly wage would be \$5.143 which is less than the
federal minimum wage of \$5.15. Consequently, this person would appear
to be not competitively employed when in fact he/she was. In order to
accurately reflect this individual's competitive employment status at
the applicable minimum wage, weekly earnings would be rounded up to
\$181 and reported as such on the RSA911. The computed hourly wage would
then be \$5.17.

## 30. [Weekly Earnings at Closure]{.underline} 

Record Positions: 163-166

Enter the amount of money (to the nearest dollar) the individual earned
in a typical week after achieving an employment outcome. Earnings for
this purpose include all income from wages, salaries, tips, and
commissions [before]{.underline} payroll deductions of Federal, State
and local income taxes and Social Security payroll tax. Earnings also
include profits derived from self-employed individuals. Earnings for
salespersons, consultants, self-employed individuals, and other similar
occupations are based on the [adjusted gross income.]{.underline}
Adjusted gross income is gross income minus unreimbursed business
expenses. [Do not]{.underline} include estimates of payments in-kind,
such as meals and lodging. Estimate profits of farmers, if necessary.

[**SPECIAL CASES**:]{.underline} To preclude misleading results such as
a negative earnings situation, the following instructions are provided:

> Where earnings are based on commissions that are irregular (e.g., real
> estate, automobile sales, etc.), to obtain a meaningful figure for a
> typical week's earnings, it should be calculated as an average over a
> representative period of time such as one month.
>
> When, because of the occupation/situation, there are significant
> amounts of unreimbursed business expenses that are irregular (e.g.,
> car lease payments due the first week of every month), the expenses
> should be averaged over a representative period of time to obtain a
> meaningful figure for a typical week's expenses.
>
> Commissions are generally not paid when earned, but rather are paid
> periodically, such as weekly, biweekly, or even monthly. To bring
> standardization to this item, earnings should be based on the actual
> receipt of the payment and not on amounts accruing until the next
> commission payout.

If the individual had no earnings, enter 0000. If the individual's
earnings were \$9999 or more, enter 9999. Fill in leading zeros when
they apply (e.g., 0128 for individuals earning \$128 in a typical week
after achieving an employment outcome). Use Code \*\*\*\* for closure
types other than 3.

## 31. [Hours Worked in a Week at Closure]{.underline}

#####  Record Positions: 167-168

For an individual who achieved an employment outcome, enter the number
of hours the individual worked for earnings in a typical week when the
service record was closed. Earnings may have been in the form of wages,
salaries, tips, commissions, profits from self-employment, adjusted
gross income for salespersons, etc. If the individual generated no
earnings, enter 00. If the person worked 99 or more hours in one week,
enter 99. Fill in leading zero when it applies. Use Code \*\* for
closure types other than 3.

## 32. [Type of Public Support at Closure]{.underline}

Enter a Code 0 or a Code 1 in each of the following seven record
positions to indicate whether the individual was receiving that type of
public support at closure. Use Code 0 to indicate no public support and
Code 1 to indicate receipt of support payment from the source cited. One
payment is sufficient to establish \"receipt\". Use Code \* in the
position if the information is not available for Closure Code 1 or the
information is not available for all other closure codes due to
circumstances beyond the agency's control.

Public support refers to cash payments made by Federal, State and/or
local governments for any reason, including an individual\'s disability,
age, economic, retirement and survivor status. Include payments to a
[family]{.underline} unit precipitated by the individual\'s disability
or when the individual\'s presence is taken into account in the
computation of the family benefit. Also include any payments that are
sent directly to the individual in an institution or to dependents on
his/her behalf. Exclude any non-cash support payments such as Medicaid,
Medicare, food stamps and rental subsidies. Categories of public support
are as follows:

[Supplemental Security Income (SSI) for the Aged, Blind or
Disabled]{.underline}

Record Position: 169

[Temporary Assistance for Needy Families (TANF)]{.underline}

Record Position: 170

[General Assistance (State or local government)]{.underline}

Record Position: 171

[Social Security Disability Insurance (SSDI)]{.underline}

Record Position: 172

[Veterans\' Disability Benefits]{.underline}

Record Position: 173

[Workers\' Compensation]{.underline}

Record Position: 174

[Other Public Support]{.underline}

Record Position: 175

Veterans\' Disability Benefits are payments made by the Department of
Veterans Affairs for partial or total disability.

Other Public Support payments are cash payments to individuals, not
listed, and include payments made by Federal, State and local
governments for retirement or survivor benefits to the individual as
well as unemployment insurance benefits and other temporary payments.

## 33. [Monthly Public Support Amount at Closure]{.underline}

Enter the monthly amount of money (to the nearest dollar) received by
the individual as public support payments at the time the service record
was closed for the sources listed below. If the individual receives two
or more types of support, record the amount from each source. Fill in
leading zeros for amounts under \$1000. If no public assistance payments
were received, enter 0000. If payments totaled \$9999 or more, use 9999.
Use Code \*\*\*\* in the position if the information is not available
for Closure Code 1 or the information is not available for all other
closure codes due to circumstances beyond the agency's control.

[Social Security Disability Insurance (SSDI)]{.underline}

Record Positions: 176-179

> Enter the amount of SSDI received by the individual each month. This
> figure can be verified through the Social Security Administration
> (SSA) or from a copy of the individual\'s benefit notification letter.

[Supplemental Security Income (SSI) for the Aged, Blind or
Disabled]{.underline}

Record Positions: 180-183

> Enter the monthly payment to the individual under the Federal program
> of SSI for the aged, blind, and disabled. Only the individual\'s
> portion of the payment should be recorded here. This figure can be
> verified through the Social Security Administration (SSA) or from a
> copy of the individual\'s benefit notification letter.

[Temporary Assistance for Needy Families (TANF)]{.underline}

Record Positions: 184-187

> Enter the amount of cash public assistance payments made through the
> federally funded TANF program. If the TANF payment is made to the
> family unit, use the local disbursing agency\'s procedure to estimate
> the individual\'s portion of the payment.
>
> [All other Public Support]{.underline}
>
> Record Positions: 188-191
>
> Enter the monthly amount of public support received from General
> Assistance, Veteran\'s Disability Benefits, Workers\' Compensation and
> all other sources of public support not listed (see Item 32).

## 34. [Primary Source of Support at Closure]{.underline} 

Record Position: 192

Enter a code from the list below to indicate the individual\'s largest
single source of economic support at the time the service record was
closed, even if it accounts for less than one-half of the individual\'s
total support.

**[NOTE]{.underline}**: If a person is supported by the earnings of a
spouse, or by the spouse\'s unemployment insurance checks, identify Code
2 as the Primary Source of Support (family and friends) and not Code 1
(personal income). If a person is primarily supported by a governmental
entity with no cash support -- for example, incarcerated individuals, --
use code 3 as the primary source of support.

Primary Source of Support Codes:

1 Personal Income (earnings, interest, dividends, rent)

2 Family and Friends

3 Public Support (SSI, SSDI, TANF, etc.)

4 All other sources (e.g., private disability insurance and private
charities)

\* Information is not available for Closure Code 1 or information is not
available for all other closure codes due to circumstances beyond the
agency's control

## 35. [Medical Insurance Coverage at Closure]{.underline} 

Record whether an individual had medical insurance coverage when his/her
service record was closed. Enter a Code 0 or Code 1 in each of the
following record positions. Use Code 0 if the individual had no medical
coverage and Code 1 if the individual had that type of medical insurance
coverage. Persons with no medical insurance coverage would be coded 0
for each type of medical insurance listed. Use Code \* in the position
if the information is not available for Closure Code 1 or the
information is not available for all other closure codes due to
circumstances beyond the agency's control.

[Medicaid]{.underline}

Record Position: 193

[Medicare]{.underline}

Record Position: 194

[Public Insurance from Other Sources]{.underline}

Record Position: 195

[Private Insurance Through own Employment]{.underline}

Record Position: 196

[Private Insurance Through other Means]{.underline}

Record Position: 197

## 36. [Type of Closure]{.underline} 

Record Position: 198

Enter a one-digit code from the following list to indicate when in the
VR process an individual exited the program:

1 Exited as an applicant (Line D7 on RSA-113)

2 Exited during or after a trial work experience/extended evaluation
(Line D6 on RSA-113)

3 Exited with an employment outcome (Line D1 on RSA-113)

4 Exited without an employment outcome, after receiving services (Line
D2 on RSA-113)

5 Exited without an employment outcome, after a signed IPE, but before
receiving services (Line D4 on RSA-113)

6 Exited from an order of selection waiting list (Line D5 on RSA-113)

7.  Exited without an employment outcome, after eligibility, but before
    an IPE was signed (Line D3 on RSA-113)

Counts of each code 1 through 7 must equal comparable figures reported
in Section D of the agency's 4th quarter RSA-113 (Quarterly Cumulative
Caseload Report). Agencies may be required to resubmit data if there are
discrepancies in closure counts between these two systems.

## 37. [Reason for Closure]{.underline}

Record Positions: 199-200

Enter a two-digit code that identifies the reason for closing the
service record of an individual. The code 00 applies only to cases with
a code of 3 in item #36, type of closure. Codes of 01 or higher apply to
all other types of closure, viz. 1, 2, 4, 5, 6, and 7. Fill in leading
zero when it applies.

00 Achieved employment outcome (applicable only to closure type 3).

01 Unable to locate or contact

Use this code when the individual has moved without a forwarding address
or is otherwise unavailable. Also use this code for persons who have
left the State and show no intentions of continuing in their VR program.

02 Disability too significant to benefit from VR services

Use this code to identify an individual whose mental or physical
disability is so significant that the individual cannot benefit from VR
services in terms of employment.

03 Refused Services or Further Services

Use this code for individuals who choose not to participate or continue
in their VR program at this time.

04 Death

05 Individual in Institution

Use this code when an individual has entered an institution and will be
unavailable to participate in a VR program for an indefinite or
considerable period of time. An institution includes a hospital, a
nursing home, a prison or jail, a treatment center, etc.

06 Transferred to another agency

Use this code when an individual needs services that are more
appropriately obtained elsewhere. Transfer to the other agency indicates
that appropriate referral information is forwarded to the other agency
so that agency may provide services more effectively. Include
individuals transferred to other State VR agencies.

07 Failure to cooperate

Use this code to indicate when an individual\'s actions (or non-actions)
make it impossible to begin or continue a VR program. Failure to
cooperate includes repeated failures to keep appointments for
assessment, counseling, or other services.

08 No disabling condition

Use this code only for applicants who are not eligible for VR services
because no physical or mental impairment exists, such as when the
reported disability is an acute condition with no residual impairment,
e.g., a broken bone that heals.

09 No impediment to employment

Use this code for applicants who are not eligible for VR services
because their physical or mental impairment does not constitute a
substantial impediment to employment.

10 Transportation not feasible or available

Use this code to indicate that the individual was unable to accept or
maintain employment because suitable transportation was either not
feasible or not available.

####  11 Does not require VR services

Use this code for applicants who do not require VR services to prepare
for, enter into, engage in, or retain gainful employment consistent with
their strengths, resources, priorities, concerns, abilities,
capabilities, and informed choice.

12 Extended services not available

Use this code for individuals who would have benefited from the
provision of supported employment services but for whom no source of
extended services was available.

13. All other reasons

> This code is used for all reasons not covered by Codes 01 to 12 or 14.

14. Extended employment

> Use this code for individuals who received services and were placed in
> a non-integrated setting for a public or non-profit organization. See
> employment status code 2 for further information.

## 38. [Date of Closure]{.underline} 

Record the date (year, month, and day) when the individual\'s service
record was closed by the State VR agency. Use the eight-digit date
protocol.

38(a) [Year of Closure]{.underline}

Record Positions: 201-204

38(b) [Month of Closure]{.underline}

Record Positions: 205-206

38(c) [Day of Closure]{.underline}

Record Positions: 207-208

## 39. [Supported Employment Status]{.underline}

Record Position: 209

Enter a one-digit code to indicate (a) whether the individual\'s IPE
specified an employment outcome/vocational goal in a supported
employment setting and (b) if so, whether any supported employment
services were charged to funds provided under Title VI-B of the Act. Use
code 1 or 2, as applicable, if, at any time during the VR process,
supported employment was established as a goal for the individual in
his/her IPE. Use one of the following codes:

0 Not supported employment

1 Supported employment with some Title VI-B funds expended

2 Supported employment but no Title VI-B funds expended

\* Closure Codes 1, 2, 6 and 7 or information is not available, for
closure codes 3, 4 and 5, due to circumstances beyond the agency's
control

**[NOTE]{.underline}**: The term \"supported employment\" means
competitive work in integrated work settings, or employment in
integrated work settings, in which individuals are working toward
competitive employment, for individuals with the most significant
disabilities who require intensive supported employment services in
order to perform such work.

## 40. [Veteran Status]{.underline}

Record Position: 210

Enter a one-digit code to indicate if the individual had served in the
active military, naval or air service, and was discharged or released
under conditions other than dishonorable.

1.  Not a veteran

2.  Veteran

\* Information is not available for Closure Code 1 or information is not
available for all other closure codes due to circumstances beyond the
agency's control

## 41. [Significant Disability]{.underline}

Record Position: 211

Enter a one-digit code to indicate whether the individual was considered
an individual with a significant disability at any time during his/her
VR program. An individual with a significant disability is an
individual:

> a\) who has a physical or mental impairment that seriously limits one
> or more functional capacities (such as mobility, communication,
> self-care, self-direction, interpersonal skills, work tolerance, or
> work skills) in terms of an employment outcome;
>
> b\) whose VR can be expected to require multiple VR services over an
> extended period of time; and
>
> c\) who has one or more physical or mental disabilities resulting from
> amputation, arthritis, autism, blindness, burn injury, cancer,
> cerebral palsy, cystic fibrosis, deafness, head injury, heart disease,
> hemiplegia, hemophilia, respiratory or pulmonary dysfunction, mental
> retardation, mental illness, multiple sclerosis, muscular dystrophy,
> musculo-skeletal disorders, neurological disorders (including stroke
> and epilepsy), spinal cord conditions (including paraplegia and
> quadriplegia), sickle cell anemia, specific learning disability,
> end-stage renal disease, or another disability or combination of
> disabilities determined on the basis of an assessment for determining
> eligibility and VR needs to cause comparable substantial functional
> limitation.

0 No Significant Disability

1 Significant Disability

\* Information is not available for Closure Code 1

## 42. [Migrant and Seasonal Farmworkers]{.underline}

Record Position: 212

Identify individuals who participated in a migrant or seasonal farm
worker\'s project under Section 304 of the Act during their VR program.

0 Was not a migrant or seasonal farm worker during VR program

1 Participated in a migrant or seasonal farm worker project under
Section 304 of the Act during VR program

2 Was a migrant or seasonal farm worker during VR program but did not
participate in a migrant or seasonal farm worker project

\* Information is not available for Closure Code 1 or information is not
available for all other closure codes due to circumstances beyond the
agency's control

## 43. [Projects With Industry]{.underline}

Record Position: 213

Identify individuals who participated in a project under the Projects
with Industry (PWI) program established in Section 611 of the Act during
their VR program.

1.  Not in PWI

2.  In PWI during VR program

\* Information is not available for Closure Code 1 or information is not
available for all other closure codes due to circumstances beyond the
agency's control

# RSA-911 Record Layout

**CASE SERVICE REPORT**

**[(RSA-911)]{.smallcaps}**

+----------+--------------------------------------+---+------------------+
| **RP**   | **ELEMENT**                          |   |                  |
+----------+--------------------------------------+---+------------------+
| 1        | 1\. Agency Code                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 2        |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 3        |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 4        | 2\. Social Security Number           |   |                  |
+----------+--------------------------------------+---+------------------+
| 5        |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 6        |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 7        |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 8        |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 9        |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 10       |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 11       |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 12       |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 13       | 3\. Closure Order                    |   |                  |
+----------+--------------------------------------+---+------------------+
| 14       | 4\. Previous Closure                 |   |                  |
+----------+--------------------------------------+---+------------------+
| 15       | Year                                 |   | 5\. Date of      |
|          |                                      |   | Application      |
+----------+--------------------------------------+---+------------------+
| 16       |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 17       |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 18       |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 19       | Month                                |   |                  |
+----------+--------------------------------------+---+------------------+
| 20       |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 21       | Day                                  |   |                  |
+----------+--------------------------------------+---+------------------+
| 22       |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 23       | Year                                 |   | 6\. Date of      |
|          |                                      |   | Birth            |
+----------+--------------------------------------+---+------------------+
| 24       |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 25       |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 26       |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 27       | Month                                |   |                  |
+----------+--------------------------------------+---+------------------+
| 28       |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 29       | Day                                  |   |                  |
+----------+--------------------------------------+---+------------------+
| 30       |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 31       | 7\. Gender                           |   |                  |
+----------+--------------------------------------+---+------------------+
| 32       | White                                |   | 8\. Race &       |
|          |                                      |   |                  |
|          |                                      |   | Ethnicity        |
+----------+--------------------------------------+---+------------------+
| 33       | Black or African American            |   |                  |
+----------+--------------------------------------+---+------------------+
| 34       | American Indian or Alaska Native     |   |                  |
+----------+--------------------------------------+---+------------------+
| 35       | Asian                                |   |                  |
+----------+--------------------------------------+---+------------------+
| 36       | Native Hawaiian or Other Pacific     |   |                  |
|          | Islander                             |   |                  |
+----------+--------------------------------------+---+------------------+
| 37       | Hispanic or Latino                   |   |                  |
+----------+--------------------------------------+---+------------------+
| 38       | 9\. Source of Referral               |   |                  |
+----------+--------------------------------------+---+------------------+
| 39       | 10\. Level of Education Attained at  |   |                  |
|          | Application                          |   |                  |
+----------+--------------------------------------+---+------------------+
| 40       | 11\. Individualized Education        |   |                  |
|          | Program (IEP)                        |   |                  |
+----------+--------------------------------------+---+------------------+
| 41       | 12\. Living Arrangement at           |   |                  |
|          | Application                          |   |                  |
+----------+--------------------------------------+---+------------------+
| 42       |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 43       | 13 Primary Disability                |   |                  |
+----------+--------------------------------------+---+------------------+
| 44       |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 45       |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 46       |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 47       | 14\. Secondary Disability            |   |                  |
+----------+--------------------------------------+---+------------------+
| 48       |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 49       |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 50       |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 51       | 15\. Employment Status at            |   |                  |
|          | Application                          |   |                  |
+----------+--------------------------------------+---+------------------+
| 52       |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| **RP**   | **ELEMENT**                          |   |                  |
+----------+--------------------------------------+---+------------------+
| 53       | 16\. Weekly Earnings at Application  |   |                  |
+----------+--------------------------------------+---+------------------+
| 54       |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 55       |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 56       |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 57       | 17\. Hours Worked in a Week at       |   |                  |
|          | Application                          |   |                  |
+----------+--------------------------------------+---+------------------+
| 58       |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 59       | SSI                                  | 1 |                  |
|          |                                      | 8 |                  |
|          |                                      | \ |                  |
|          |                                      | . |                  |
|          |                                      | T |                  |
|          |                                      | y |                  |
|          |                                      | p |                  |
|          |                                      | e |                  |
|          |                                      | o |                  |
|          |                                      | f |                  |
|          |                                      | P |                  |
|          |                                      | u |                  |
|          |                                      | b |                  |
|          |                                      | l |                  |
|          |                                      | i |                  |
|          |                                      | c |                  |
|          |                                      | S |                  |
|          |                                      | u |                  |
|          |                                      | p |                  |
|          |                                      | p |                  |
|          |                                      | o |                  |
|          |                                      | r |                  |
|          |                                      | t |                  |
|          |                                      | a |                  |
|          |                                      | t |                  |
|          |                                      | A |                  |
|          |                                      | p |                  |
|          |                                      | p |                  |
|          |                                      | l |                  |
|          |                                      | i |                  |
|          |                                      | c |                  |
|          |                                      | a |                  |
|          |                                      | t |                  |
|          |                                      | i |                  |
|          |                                      | o |                  |
|          |                                      | n |                  |
+----------+--------------------------------------+---+------------------+
| 60       | TANF                                 |   |                  |
+----------+--------------------------------------+---+------------------+
| 61       | General Assistance                   |   |                  |
+----------+--------------------------------------+---+------------------+
| 62       | SSDI                                 |   |                  |
+----------+--------------------------------------+---+------------------+
| 63       | Veteran\'s Disability                |   |                  |
+----------+--------------------------------------+---+------------------+
| 64       | Worker's Compensation                |   |                  |
+----------+--------------------------------------+---+------------------+
| 65       | Other Public Support                 |   |                  |
+----------+--------------------------------------+---+------------------+
| 66       | SSDI                                 | 1 |                  |
|          |                                      | 9 |                  |
|          |                                      | \ |                  |
|          |                                      | . |                  |
|          |                                      | M |                  |
|          |                                      | o |                  |
|          |                                      | n |                  |
|          |                                      | t |                  |
|          |                                      | h |                  |
|          |                                      | l |                  |
|          |                                      | y |                  |
|          |                                      | P |                  |
|          |                                      | u |                  |
|          |                                      | b |                  |
|          |                                      | l |                  |
|          |                                      | i |                  |
|          |                                      | c |                  |
|          |                                      | S |                  |
|          |                                      | u |                  |
|          |                                      | p |                  |
|          |                                      | p |                  |
|          |                                      | o |                  |
|          |                                      | r |                  |
|          |                                      | t |                  |
|          |                                      | A |                  |
|          |                                      | m |                  |
|          |                                      | o |                  |
|          |                                      | u |                  |
|          |                                      | n |                  |
|          |                                      | t |                  |
|          |                                      | a |                  |
|          |                                      | t |                  |
|          |                                      | A |                  |
|          |                                      | p |                  |
|          |                                      | p |                  |
|          |                                      | l |                  |
|          |                                      | i |                  |
|          |                                      | c |                  |
|          |                                      | a |                  |
|          |                                      | t |                  |
|          |                                      | i |                  |
|          |                                      | o |                  |
|          |                                      | n |                  |
+----------+--------------------------------------+---+------------------+
| 67       |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 68       |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 69       |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 70       | SSI                                  |   |                  |
+----------+--------------------------------------+---+------------------+
| 71       |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 72       |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 73       |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 74       | TANF                                 |   |                  |
+----------+--------------------------------------+---+------------------+
| 75       |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 76       |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 77       |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 78       | All Other Public Support             |   |                  |
+----------+--------------------------------------+---+------------------+
| 79       |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 80       |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 81       |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 82       | 20\. Primary Source of Support at    |   |                  |
|          | Application                          |   |                  |
+----------+--------------------------------------+---+------------------+
| 83       | Medicaid                             | 2 |                  |
|          |                                      | 1 |                  |
|          |                                      | \ |                  |
|          |                                      | . |                  |
|          |                                      | M |                  |
|          |                                      | e |                  |
|          |                                      | d |                  |
|          |                                      | i |                  |
|          |                                      | c |                  |
|          |                                      | a |                  |
|          |                                      | l |                  |
|          |                                      | I |                  |
|          |                                      | n |                  |
|          |                                      | s |                  |
|          |                                      | u |                  |
|          |                                      | r |                  |
|          |                                      | a |                  |
|          |                                      | n |                  |
|          |                                      | c |                  |
|          |                                      | e |                  |
|          |                                      | C |                  |
|          |                                      | o |                  |
|          |                                      | v |                  |
|          |                                      | e |                  |
|          |                                      | r |                  |
|          |                                      | a |                  |
|          |                                      | g |                  |
|          |                                      | e |                  |
|          |                                      | a |                  |
|          |                                      | t |                  |
|          |                                      | A |                  |
|          |                                      | p |                  |
|          |                                      | p |                  |
|          |                                      | l |                  |
|          |                                      | i |                  |
|          |                                      | c |                  |
|          |                                      | a |                  |
|          |                                      | t |                  |
|          |                                      | i |                  |
|          |                                      | o |                  |
|          |                                      | n |                  |
+----------+--------------------------------------+---+------------------+
| 84       | Medicare                             |   |                  |
+----------+--------------------------------------+---+------------------+
| 85       | Public Insurance from Other Sources  |   |                  |
+----------+--------------------------------------+---+------------------+
| 86       | Private thru Own Employment          |   |                  |
+----------+--------------------------------------+---+------------------+
| 87       | Private thru Other Means             |   |                  |
+----------+--------------------------------------+---+------------------+
| 88       | Year                                 | 2 |                  |
|          |                                      | 2 |                  |
|          |                                      | \ |                  |
|          |                                      | . |                  |
|          |                                      | D |                  |
|          |                                      | a |                  |
|          |                                      | t |                  |
|          |                                      | e |                  |
|          |                                      | o |                  |
|          |                                      | f |                  |
|          |                                      | E |                  |
|          |                                      | l |                  |
|          |                                      | i |                  |
|          |                                      | g |                  |
|          |                                      | i |                  |
|          |                                      | b |                  |
|          |                                      | i |                  |
|          |                                      | l |                  |
|          |                                      | i |                  |
|          |                                      | t |                  |
|          |                                      | y |                  |
|          |                                      | D |                  |
|          |                                      | e |                  |
|          |                                      | t |                  |
|          |                                      | e |                  |
|          |                                      | r |                  |
|          |                                      | m |                  |
|          |                                      | i |                  |
|          |                                      | n |                  |
|          |                                      | a |                  |
|          |                                      | t |                  |
|          |                                      | i |                  |
|          |                                      | o |                  |
|          |                                      | n |                  |
+----------+--------------------------------------+---+------------------+
| 89       |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 90       |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 91       |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 92       | Month                                |   |                  |
+----------+--------------------------------------+---+------------------+
| 93       |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 94       | Day                                  |   |                  |
+----------+--------------------------------------+---+------------------+
| 95       |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 96       | Year                                 | 2 |                  |
|          |                                      | 3 |                  |
|          |                                      | \ |                  |
|          |                                      | . |                  |
|          |                                      | D |                  |
|          |                                      | a |                  |
|          |                                      | t |                  |
|          |                                      | e |                  |
|          |                                      | o |                  |
|          |                                      | f |                  |
|          |                                      | I |                  |
|          |                                      | n |                  |
|          |                                      | d |                  |
|          |                                      | i |                  |
|          |                                      | v |                  |
|          |                                      | i |                  |
|          |                                      | d |                  |
|          |                                      | u |                  |
|          |                                      | a |                  |
|          |                                      | l |                  |
|          |                                      | i |                  |
|          |                                      | z |                  |
|          |                                      | e |                  |
|          |                                      | d |                  |
|          |                                      | P |                  |
|          |                                      | l |                  |
|          |                                      | a |                  |
|          |                                      | n |                  |
|          |                                      | f |                  |
|          |                                      | o |                  |
|          |                                      | r |                  |
|          |                                      | E |                  |
|          |                                      | m |                  |
|          |                                      | p |                  |
|          |                                      | l |                  |
|          |                                      | o |                  |
|          |                                      | y |                  |
|          |                                      | m |                  |
|          |                                      | e |                  |
|          |                                      | n |                  |
|          |                                      | t |                  |
|          |                                      | ( |                  |
|          |                                      | I |                  |
|          |                                      | P |                  |
|          |                                      | E |                  |
|          |                                      | ) |                  |
+----------+--------------------------------------+---+------------------+
| 97       |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 98       |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 99       |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 100      | Month                                |   |                  |
+----------+--------------------------------------+---+------------------+
| 101      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 102      | Day                                  |   |                  |
+----------+--------------------------------------+---+------------------+
| 103      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| **RP**   | **ELEMENT**                          |   |                  |
+----------+--------------------------------------+---+------------------+
| 104      | 24\. Cost of Purchased Services      |   |                  |
+----------+--------------------------------------+---+------------------+
| 105      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 106      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 107      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 108      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 109      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 110      | Assessment                           | 2 |                  |
|          |                                      | 5 |                  |
|          |                                      | \ |                  |
|          |                                      | . |                  |
|          |                                      | S |                  |
|          |                                      | e |                  |
|          |                                      | r |                  |
|          |                                      | v |                  |
|          |                                      | i |                  |
|          |                                      | c |                  |
|          |                                      | e |                  |
|          |                                      | s |                  |
|          |                                      | P |                  |
|          |                                      | r |                  |
|          |                                      | o |                  |
|          |                                      | v |                  |
|          |                                      | i |                  |
|          |                                      | d |                  |
|          |                                      | e |                  |
|          |                                      | d |                  |
+----------+--------------------------------------+---+------------------+
| 111      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 112      | Diagnosis & Treatment                |   |                  |
+----------+--------------------------------------+---+------------------+
| 113      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 114      | Vocational Rehabilitation Counseling |   |                  |
|          | & Guidance                           |   |                  |
+----------+--------------------------------------+---+------------------+
| 115      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 116      | College or University Training       |   |                  |
+----------+--------------------------------------+---+------------------+
| 117      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 118      | Occupational/Vocational Training     |   |                  |
+----------+--------------------------------------+---+------------------+
| 119      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 120      | On-the-job Training                  |   |                  |
+----------+--------------------------------------+---+------------------+
| 121      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 122      | Basic Academic Remedial or Literacy  |   |                  |
|          | Training                             |   |                  |
+----------+--------------------------------------+---+------------------+
| 123      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 124      | Job Readiness Training               |   |                  |
+----------+--------------------------------------+---+------------------+
| 125      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 126      | Disability Related Augmentative      |   |                  |
|          | Skills Training                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 127      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 128      | Miscellaneous Training               |   |                  |
+----------+--------------------------------------+---+------------------+
| 129      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 130      | Job Search Assistance                |   |                  |
+----------+--------------------------------------+---+------------------+
| 131      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 132      | Job Placement Assistance             |   |                  |
+----------+--------------------------------------+---+------------------+
| 133      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 134      | On-the-job Supports                  |   |                  |
+----------+--------------------------------------+---+------------------+
| 135      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 136      | Transportation                       |   |                  |
+----------+--------------------------------------+---+------------------+
| 137      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 138      | Maintenance                          |   |                  |
+----------+--------------------------------------+---+------------------+
| 139      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 140      | Rehabilitation Technology            |   |                  |
+----------+--------------------------------------+---+------------------+
| 141      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 142      | Reader                               |   |                  |
+----------+--------------------------------------+---+------------------+
| 143      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 144      | Interpreter                          |   |                  |
+----------+--------------------------------------+---+------------------+
| 145      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 146      | Personal Attendant                   |   |                  |
+----------+--------------------------------------+---+------------------+
| 147      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 148      | Technical Assistance                 |   |                  |
+----------+--------------------------------------+---+------------------+
| 149      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 150      | Information & Referral               |   |                  |
+----------+--------------------------------------+---+------------------+
| 151      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 152      | Other                                |   |                  |
+----------+--------------------------------------+---+------------------+
| 153      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 154      | 26\. Level of Education Attained at  |   |                  |
|          | Closure                              |   |                  |
+----------+--------------------------------------+---+------------------+
| 155      | 27\. Occupation at Closure           |   |                  |
+----------+--------------------------------------+---+------------------+
| 156      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 157      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 158      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 159      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 160      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| **RP**   | **ELEMENT**                          |   |                  |
+----------+--------------------------------------+---+------------------+
| 161      | 28\. Employment Status at Closure    |   |                  |
+----------+--------------------------------------+---+------------------+
| 162      | 29\. Competitive Employment          |   |                  |
+----------+--------------------------------------+---+------------------+
| 163      | 30\. Weekly Earnings at Closure      |   |                  |
+----------+--------------------------------------+---+------------------+
| 164      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 165      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 166      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 167      | 31\. Hours Worked at Closure         |   |                  |
+----------+--------------------------------------+---+------------------+
| 168      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 169      | SSI                                  | 3 |                  |
|          |                                      | 2 |                  |
|          |                                      | \ |                  |
|          |                                      | . |                  |
|          |                                      | T |                  |
|          |                                      | y |                  |
|          |                                      | p |                  |
|          |                                      | e |                  |
|          |                                      | o |                  |
|          |                                      | f |                  |
|          |                                      | P |                  |
|          |                                      | u |                  |
|          |                                      | b |                  |
|          |                                      | l |                  |
|          |                                      | i |                  |
|          |                                      | c |                  |
|          |                                      | S |                  |
|          |                                      | u |                  |
|          |                                      | p |                  |
|          |                                      | p |                  |
|          |                                      | o |                  |
|          |                                      | r |                  |
|          |                                      | t |                  |
|          |                                      | a |                  |
|          |                                      | t |                  |
|          |                                      | C |                  |
|          |                                      | l |                  |
|          |                                      | o |                  |
|          |                                      | s |                  |
|          |                                      | u |                  |
|          |                                      | r |                  |
|          |                                      | e |                  |
+----------+--------------------------------------+---+------------------+
| 170      | TANF                                 |   |                  |
+----------+--------------------------------------+---+------------------+
| 171      | General Assistance                   |   |                  |
+----------+--------------------------------------+---+------------------+
| 172      | SSDI                                 |   |                  |
+----------+--------------------------------------+---+------------------+
| 173      | Veteran\'s Disability                |   |                  |
+----------+--------------------------------------+---+------------------+
| 174      | Workers\' Compensation               |   |                  |
+----------+--------------------------------------+---+------------------+
| 175      | Other Public Support                 |   |                  |
+----------+--------------------------------------+---+------------------+
| 176      | SSDI                                 | 3 |                  |
|          |                                      | 3 |                  |
|          |                                      | \ |                  |
|          |                                      | . |                  |
|          |                                      | M |                  |
|          |                                      | o |                  |
|          |                                      | n |                  |
|          |                                      | t |                  |
|          |                                      | h |                  |
|          |                                      | l |                  |
|          |                                      | y |                  |
|          |                                      | P |                  |
|          |                                      | u |                  |
|          |                                      | b |                  |
|          |                                      | l |                  |
|          |                                      | i |                  |
|          |                                      | c |                  |
|          |                                      | S |                  |
|          |                                      | u |                  |
|          |                                      | p |                  |
|          |                                      | p |                  |
|          |                                      | o |                  |
|          |                                      | r |                  |
|          |                                      | t |                  |
|          |                                      | A |                  |
|          |                                      | m |                  |
|          |                                      | o |                  |
|          |                                      | u |                  |
|          |                                      | n |                  |
|          |                                      | t |                  |
|          |                                      | a |                  |
|          |                                      | t |                  |
|          |                                      | C |                  |
|          |                                      | l |                  |
|          |                                      | o |                  |
|          |                                      | s |                  |
|          |                                      | u |                  |
|          |                                      | r |                  |
|          |                                      | e |                  |
+----------+--------------------------------------+---+------------------+
| 177      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 178      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 179      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 180      | SSI                                  |   |                  |
+----------+--------------------------------------+---+------------------+
| 181      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 182      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 183      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 184      | TANF                                 |   |                  |
+----------+--------------------------------------+---+------------------+
| 185      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 186      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 187      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 188      | All Other Public Support             |   |                  |
+----------+--------------------------------------+---+------------------+
| 189      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 190      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 191      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 192      | 34\. Primary Source of Support at    |   |                  |
|          | Closure                              |   |                  |
+----------+--------------------------------------+---+------------------+
| 193      | Medicaid                             | 3 |                  |
|          |                                      | 5 |                  |
|          |                                      | \ |                  |
|          |                                      | . |                  |
|          |                                      | M |                  |
|          |                                      | e |                  |
|          |                                      | d |                  |
|          |                                      | i |                  |
|          |                                      | c |                  |
|          |                                      | a |                  |
|          |                                      | l |                  |
|          |                                      | I |                  |
|          |                                      | n |                  |
|          |                                      | s |                  |
|          |                                      | u |                  |
|          |                                      | r |                  |
|          |                                      | a |                  |
|          |                                      | n |                  |
|          |                                      | c |                  |
|          |                                      | e |                  |
|          |                                      | C |                  |
|          |                                      | o |                  |
|          |                                      | v |                  |
|          |                                      | e |                  |
|          |                                      | r |                  |
|          |                                      | a |                  |
|          |                                      | g |                  |
|          |                                      | e |                  |
|          |                                      | a |                  |
|          |                                      | t |                  |
|          |                                      | C |                  |
|          |                                      | l |                  |
|          |                                      | o |                  |
|          |                                      | s |                  |
|          |                                      | u |                  |
|          |                                      | r |                  |
|          |                                      | e |                  |
+----------+--------------------------------------+---+------------------+
| 194      | Medicare                             |   |                  |
+----------+--------------------------------------+---+------------------+
| 195      | Public Insurance from Other Sources  |   |                  |
+----------+--------------------------------------+---+------------------+
| 196      | Private thru Own Employment          |   |                  |
+----------+--------------------------------------+---+------------------+
| 197      | Private thru Other Means             |   |                  |
+----------+--------------------------------------+---+------------------+
| 198      | 36\. Type of Closure                 |   |                  |
+----------+--------------------------------------+---+------------------+
| 199      | 37\. Reason for Closure              |   |                  |
+----------+--------------------------------------+---+------------------+
| 200      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 201      | Year                                 | 3 |                  |
|          |                                      | 8 |                  |
|          |                                      | \ |                  |
|          |                                      | . |                  |
|          |                                      | D |                  |
|          |                                      | a |                  |
|          |                                      | t |                  |
|          |                                      | e |                  |
|          |                                      | o |                  |
|          |                                      | f |                  |
|          |                                      | C |                  |
|          |                                      | l |                  |
|          |                                      | o |                  |
|          |                                      | s |                  |
|          |                                      | u |                  |
|          |                                      | r |                  |
|          |                                      | e |                  |
+----------+--------------------------------------+---+------------------+
| 202      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 203      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 204      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 205      | Month                                |   |                  |
+----------+--------------------------------------+---+------------------+
| 206      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 207      | Day                                  |   |                  |
+----------+--------------------------------------+---+------------------+
| 208      |                                      |   |                  |
+----------+--------------------------------------+---+------------------+
| 209      | 39\. Supported Employment Status     |   |                  |
+----------+--------------------------------------+---+------------------+
| 210      | 40\. Veteran Status                  |   |                  |
+----------+--------------------------------------+---+------------------+
| 211      | 41\. Significant Disability          |   |                  |
+----------+--------------------------------------+---+------------------+
| 212      | 42\. Migrant & Seasonal Farm workers |   |                  |
+----------+--------------------------------------+---+------------------+
| 213      | 43\. Projects With Industry          |   |                  |
+----------+--------------------------------------+---+------------------+

# Edit Specifications by Element

**CASE SERVICE REPORT**

**[(RSA-911)]{.smallcaps}**

+-------------------+--------+----------------------+-----------------+
| **ELEMENT NAME**  | **RE   | **EDIT               | **APPLICABLE**  |
|                   | CORD** | SPECIFICATION**      |                 |
|                   |        |                      | **TYPE OF**     |
|                   | **POSI |                      |                 |
|                   | TION** |                      | **CLOSURE       |
|                   |        |                      | CODE**          |
+===================+========+======================+=================+
| 1\. Agency code   | 1-3    | Valid codes listed   | 1 thru 7        |
|                   |        | in Agency Code Table |                 |
|                   |        | in reporting         | **REQUIRED      |
|                   |        | instructions         | ELEMENT**       |
+-------------------+--------+----------------------+-----------------+
| 2\. Social        | 4-12   | a\. Must be numeric  | 1 thru 7        |
| Security Number   |        |                      |                 |
|                   |        | b\. If SSN is not    | **REQUIRED      |
|                   |        | available, start the | ELEMENT**       |
|                   |        | nine-digit number    |                 |
|                   |        | with \'99\' in RP 4  |                 |
|                   |        | and 5.               |                 |
+-------------------+--------+----------------------+-----------------+
| 3\. Closure Order | 13     | a\. Valid codes: 1,  | 1 thru 7        |
|                   |        | 2, 3, and so on.     |                 |
|                   |        |                      | **REQUIRED      |
|                   |        | b\. Individuals      | ELEMENT**       |
|                   |        | whose service        |                 |
|                   |        | records are closed   |                 |
|                   |        | more than once in    |                 |
|                   |        | the FY should have a |                 |
|                   |        | separate record for  |                 |
|                   |        | each closure.        |                 |
+-------------------+--------+----------------------+-----------------+
| 4\. Previous      | 14     | Valid codes: 0 thru  | 1 thru 7        |
| Closure           |        | 7.                   |                 |
|                   |        |                      | **REQUIRED      |
|                   |        |                      | ELEMENT**       |
+-------------------+--------+----------------------+-----------------+
| 5\. Date of       | 15-22  | Format YYYYMMDD      | 1 thru 7        |
| Application       |        |                      |                 |
|                   | 15-18  | Code year using all  | **REQUIRED      |
| Year              |        | four digits (no      | ELEMENT**       |
|                   | 19-20  | blanks). Cannot be   |                 |
| Month             |        | prior to 1921.       |                 |
|                   | 21-22  |                      |                 |
| Day               |        | Valid codes: 01 thru |                 |
|                   |        | 12.                  |                 |
|                   |        |                      |                 |
|                   |        | Valid codes: 01 thru |                 |
|                   |        | 31.                  |                 |
+-------------------+--------+----------------------+-----------------+
| 6\. Date of Birth | 23-30  | a\. See edit         | 1 thru 7        |
|                   |        | specifications for   |                 |
|                   |        | Element #5 (Date of  |                 |
|                   |        | Application).        |                 |
+-------------------+--------+----------------------+-----------------+
|                   |        | b\. Use Code         | 1               |
|                   |        | \*\*\*\*\*\*\*\* if  |                 |
|                   |        | information is not   |                 |
|                   |        | available.           |                 |
+-------------------+--------+----------------------+-----------------+

+-------------------+--------+----------------------+-----------------+
| **ELEMENT NAME**  | **RE   | **EDIT               | **APPLICABLE**  |
|                   | CORD** | SPECIFICATION**      |                 |
|                   |        |                      | **TYPE OF**     |
|                   | **POSI |                      |                 |
|                   | TION** |                      | **CLOSURE       |
|                   |        |                      | CODE**          |
+-------------------+--------+----------------------+-----------------+
| 7\. Gender        | 31     | a\. Valid codes: 1   | 1 thru 7        |
|                   |        | or 2.                |                 |
+-------------------+--------+----------------------+-----------------+
|                   |        | b\. Use Code \* if   | 1               |
|                   |        | information is not   |                 |
|                   |        | available.           |                 |
+-------------------+--------+----------------------+-----------------+
| 8\. Race and      | 32-37  | a\. Valid codes: 0   | 1 thru 7        |
| Ethnicity         |        | or 1 for each        |                 |
|                   |        | position.            | **REQUIRED      |
|                   |        |                      | ELEMENT**       |
|                   |        | **b. Entries are     |                 |
|                   |        | required for both    |                 |
|                   |        | Hispanic ethnicity   |                 |
|                   |        | and race. Hispanic   |                 |
|                   |        | ethnicity should     |                 |
|                   |        | have a code of 0 or  |                 |
|                   |        | 1 and at least one   |                 |
|                   |        | of the race          |                 |
|                   |        | categories must be   |                 |
|                   |        | coded as 1.**        |                 |
+-------------------+--------+----------------------+-----------------+
|                   |        | c\. Use Code \* in   | 1               |
|                   |        | the position if      |                 |
|                   |        | information is not   |                 |
|                   |        | available due to     |                 |
|                   |        | circumstances beyond |                 |
|                   |        | the agency's         |                 |
|                   |        | control.             |                 |
+-------------------+--------+----------------------+-----------------+
| 9\. Source of     | 38     | a\. Valid codes: 1   | 1 thru 7        |
| Referral          |        | thru 9.              |                 |
+-------------------+--------+----------------------+-----------------+
|                   |        | b\. Use Code \* if   | 1               |
|                   |        | information is not   |                 |
|                   |        | available.           |                 |
+-------------------+--------+----------------------+-----------------+
| 10\. Level of     | 39     | a\. Valid codes: 0   | 1 thru 7        |
| Education         |        | thru 8.              |                 |
| Attained at       |        |                      |                 |
| Application       |        | **b. If level        |                 |
|                   |        | attained is coded 3  |                 |
|                   |        | (Special Education   |                 |
|                   |        | Certificate of       |                 |
|                   |        | completion/diploma   |                 |
|                   |        | or in attendance),   |                 |
|                   |        | then Individualized  |                 |
|                   |        | Education Program    |                 |
|                   |        | should be coded 1    |                 |
|                   |        | (had an IEP).**      |                 |
+-------------------+--------+----------------------+-----------------+
|                   |        | c\. Use Code \* if   | 1               |
|                   |        | information is not   |                 |
|                   |        | available.           |                 |
+-------------------+--------+----------------------+-----------------+
| 11\.              | 40     | a\. Valid codes: 0   | 1 thru 7        |
| Individualized    |        | or 1.                |                 |
| Education Program |        |                      |                 |
| (IEP)             |        |                      |                 |
+-------------------+--------+----------------------+-----------------+
|                   |        | b\. Use Code \* if   | 1               |
|                   |        | information is not   |                 |
|                   |        | available.           |                 |
+-------------------+--------+----------------------+-----------------+
| 12\. Living       | 41-42  | a\. Valid codes: 01  | 1 thru 7        |
| Arrangement at    |        | thru 10.             |                 |
| Application       |        |                      |                 |
+-------------------+--------+----------------------+-----------------+
|                   |        | b\. Use Code \*\* if | 1               |
|                   |        | information is not   |                 |
|                   |        | available.           |                 |
+-------------------+--------+----------------------+-----------------+

+-------------------+--------+----------------------+-----------------+
| **ELEMENT NAME**  | **RE   | **EDIT               | **APPLICABLE**  |
|                   | CORD** | SPECIFICATION**      |                 |
|                   |        |                      | **TYPE OF**     |
|                   | **POSI |                      |                 |
|                   | TION** |                      | **CLOSURE       |
|                   |        |                      | CODE**          |
+-------------------+--------+----------------------+-----------------+
| 13\. Primary      | 43-46  | a\. Valid codes      | 1 thru 7        |
| Disability        |        | listed in Codes for  |                 |
|                   |        | Impairments and      |                 |
|                   |        | Codes for            |                 |
|                   |        | Causes/Sources of    |                 |
|                   |        | Impairments in       |                 |
|                   |        | reporting            |                 |
|                   |        | instructions.        |                 |
+-------------------+--------+----------------------+-----------------+
| 14\. Secondary    | 47-50  |                      |                 |
| Disability        |        |                      |                 |
+-------------------+--------+----------------------+-----------------+
|                   |        | b\. Use Code         | 1               |
|                   |        | \*\*\*\* if          |                 |
|                   |        | information is not   |                 |
|                   |        | available.           |                 |
+-------------------+--------+----------------------+-----------------+
| 15\. Employment   | 51-52  | a\. Valid codes: 01  | 1 thru 7.       |
| Status at         |        | thru 11.             |                 |
| Application       |        |                      |                 |
|                   |        | b\. Fill in leading  |                 |
|                   |        | zero when it         |                 |
|                   |        | applies.             |                 |
+-------------------+--------+----------------------+-----------------+
|                   |        | c\. Use Code \*\* if | 1               |
|                   |        | information is not   |                 |
|                   |        | available.           |                 |
+-------------------+--------+----------------------+-----------------+
| 16\. Weekly       | 53-56  | a\. Valid codes:     | 1 thru 7        |
| Earnings at       |        | 0000 thru 9999.      |                 |
| Application       |        |                      |                 |
|                   |        | b\. Fill in leading  |                 |
|                   |        | zeros when they      |                 |
|                   |        | apply.               |                 |
|                   |        |                      |                 |
|                   |        | c\. Must be numeric. |                 |
|                   |        |                      |                 |
|                   |        | d\. Must NOT be      |                 |
|                   |        | negative.            |                 |
|                   |        |                      |                 |
|                   |        | **e. Must be greater |                 |
|                   |        | than 0000 if         |                 |
|                   |        | Employment Status at |                 |
|                   |        | Application (RP      |                 |
|                   |        | 51-52) equals 01,    |                 |
|                   |        | 02, 03, 04 or 07.**  |                 |
+-------------------+--------+----------------------+-----------------+
|                   |        | f\. Use Code         | 1               |
|                   |        | \*\*\*\* if          |                 |
|                   |        | information is not   |                 |
|                   |        | available.           |                 |
+-------------------+--------+----------------------+-----------------+
| 17\. Hours Worked | 57-58  | a\. Valid codes: 00  | 1 thru 7        |
| in a Week at      |        | thru 99.             |                 |
| Application       |        |                      |                 |
|                   |        | b\. Fill in leading  |                 |
|                   |        | zero when it         |                 |
|                   |        | applies.             |                 |
|                   |        |                      |                 |
|                   |        | **c. MUST range 01   |                 |
|                   |        | thru 99 if Weekly    |                 |
|                   |        | Earnings at          |                 |
|                   |        | Application (RP      |                 |
|                   |        | 53-56) is greater    |                 |
|                   |        | than 0000.**         |                 |
|                   |        |                      |                 |
|                   |        | **d. MUST equal 00   |                 |
|                   |        | if Weekly Earnings   |                 |
|                   |        | at Application equal |                 |
|                   |        | 0000.**              |                 |
+-------------------+--------+----------------------+-----------------+
|                   |        | e\. Use Code \*\* if | 1               |
|                   |        | information is not   |                 |
|                   |        | available.           |                 |
+-------------------+--------+----------------------+-----------------+

+-------------------+--------+----------------------+-----------------+
| **ELEMENT NAME**  | **RE   | **EDIT               | **APPLICABLE**  |
|                   | CORD** | SPECIFICATION**      |                 |
|                   |        |                      | **TYPE OF**     |
|                   | **POSI |                      |                 |
|                   | TION** |                      | **CLOSURE       |
|                   |        |                      | CODE**          |
+-------------------+--------+----------------------+-----------------+
| **\--             | **5    | **Calculate hourly   | 1 thru 7        |
| Earnings/Hours    | 3-58** | wage rate; verify if |                 |
| Comparison**      |        | \$40 per hour or     |                 |
|                   |        | more and correct     |                 |
|                   |        | earnings and/or      |                 |
|                   |        | hours, as            |                 |
|                   |        | needed.**[^1]        |                 |
+-------------------+--------+----------------------+-----------------+
| 18\. Type of      | 59-65  | a\. Valid codes: 0   | 1 thru 7        |
| Public Support at |        | or 1 for each        |                 |
| Application       |        | position.            |                 |
+-------------------+--------+----------------------+-----------------+
|                   |        | b\. Use Code \* in   | 2 thru 7        |
|                   |        | the position if      |                 |
|                   |        | information is not   |                 |
|                   |        | available due to     |                 |
|                   |        | circumstances beyond |                 |
|                   |        | the agency's         |                 |
|                   |        | control.             |                 |
+-------------------+--------+----------------------+-----------------+
|                   |        | c\. Use Code \* in   | 1               |
|                   |        | the position if      |                 |
|                   |        | information is not   |                 |
|                   |        | available.           |                 |
+-------------------+--------+----------------------+-----------------+
| 19\. Monthly      | 66-81  | a\. Valid codes:     | 1 thru 7        |
| Public Support    |        | 0000 thru 9999 for   |                 |
| Amount at         |        | each position.       |                 |
| Application       |        |                      |                 |
|                   |        | b\. Must be numeric. |                 |
|                   |        |                      |                 |
|                   |        | c\. Must NOT be      |                 |
|                   |        | negative.            |                 |
|                   |        |                      |                 |
|                   |        | d\. Fill in leading  |                 |
|                   |        | zeros when they      |                 |
|                   |        | apply.               |                 |
|                   |        |                      |                 |
|                   |        | **e. MUST be greater |                 |
|                   |        | than 0000 if         |                 |
|                   |        | comparable Type of   |                 |
|                   |        | Public Support at    |                 |
|                   |        | Application is coded |                 |
|                   |        | 1 in any RP 59 thru  |                 |
|                   |        | 65.**                |                 |
|                   |        |                      |                 |
|                   |        | **f. If amount for a |                 |
|                   |        | given type of public |                 |
|                   |        | support is 0000, the |                 |
|                   |        | code for receipt of  |                 |
|                   |        | that type of public  |                 |
|                   |        | support (RP 59 thru  |                 |
|                   |        | 65) is expected to   |                 |
|                   |        | be 0.**              |                 |
+-------------------+--------+----------------------+-----------------+
|                   |        | g\. Use Code         | 2 thru 7        |
|                   |        | \*\*\*\* if          |                 |
|                   |        | information is not   |                 |
|                   |        | available due to     |                 |
|                   |        | circumstances beyond |                 |
|                   |        | the agency's         |                 |
|                   |        | control.             |                 |
+-------------------+--------+----------------------+-----------------+
|                   |        | h\. Use Code         | 1               |
|                   |        | \*\*\*\* if          |                 |
|                   |        | information is not   |                 |
|                   |        | available.           |                 |
+-------------------+--------+----------------------+-----------------+

+-------------------+--------+----------------------+-----------------+
| **ELEMENT NAME**  | **RE   | **EDIT               | **APPLICABLE**  |
|                   | CORD** | SPECIFICATION**      |                 |
|                   |        |                      | **TYPE OF**     |
|                   | **POSI |                      |                 |
|                   | TION** |                      | **CLOSURE       |
|                   |        |                      | CODE**          |
+-------------------+--------+----------------------+-----------------+
| 20\. Primary      | 82     | a\. Valid codes: 1   | 1 thru 7        |
| Source of Support |        | thru 4.              |                 |
| at Application    |        |                      |                 |
+-------------------+--------+----------------------+-----------------+
|                   |        | b\. Use Code \* if   | 2, 4 thru 7     |
|                   |        | information is not   |                 |
|                   |        | available due to     |                 |
|                   |        | circumstances beyond |                 |
|                   |        | the agency's         |                 |
|                   |        | control.             |                 |
+-------------------+--------+----------------------+-----------------+
|                   |        | c\. Use Code \* if   | 1               |
|                   |        | information is not   |                 |
|                   |        | available.           |                 |
+-------------------+--------+----------------------+-----------------+
| 21\. Medical      | 83-87  | a\. Valid codes: 0   | 1 thru 7        |
| Insurance         |        | or 1 for each        |                 |
| Coverage at       |        | position.            |                 |
| Application       |        |                      |                 |
+-------------------+--------+----------------------+-----------------+
|                   |        | b\. Use Code \* in   | 2 thru 7        |
|                   |        | the position if      |                 |
|                   |        | information is not   |                 |
|                   |        | available due to     |                 |
|                   |        | circumstances beyond |                 |
|                   |        | the agency's         |                 |
|                   |        | control.             |                 |
+-------------------+--------+----------------------+-----------------+
|                   |        | c\. Use Code \* in   | 1               |
|                   |        | the position if      |                 |
|                   |        | information is not   |                 |
|                   |        | available.           |                 |
+-------------------+--------+----------------------+-----------------+
| 22\. Date of      | 88-95  | a\. See edit         | 3 thru 7        |
| Eligibility       |        | specifications for   |                 |
| Determination     |        | Element #5 (Date of  |                 |
|                   |        | Application).        |                 |
+-------------------+--------+----------------------+-----------------+
|                   |        | b\. Use Code         | 1 and 2         |
|                   |        | \*\*\*\*\*\*\*\* if  |                 |
|                   |        | records were closed  |                 |
|                   |        | before a             |                 |
|                   |        | determination of     |                 |
|                   |        | eligibility.         |                 |
+-------------------+--------+----------------------+-----------------+
| 23\. Date of      | 96-103 | a\. See edit         | 3 thru 5        |
| Individualized    |        | specifications for   |                 |
| Plan for          |        | Element #5 (Date of  |                 |
| Employment (IPE)  |        | Application).        |                 |
+-------------------+--------+----------------------+-----------------+
|                   |        | b\. Use Code         | 1, 2, 6 and 7   |
|                   |        | \*\*\*\*\*\*\*\* if  |                 |
|                   |        | records were closed  |                 |
|                   |        | before an IPE is     |                 |
|                   |        | developed.           |                 |
+-------------------+--------+----------------------+-----------------+
| 24\. Cost of      | 1      | a\. Valid codes:     | 1 thru 7        |
| Purchased         | 04-109 | 000000 thru 999999.  |                 |
| Services          |        |                      |                 |
|                   |        | b\. MUST be numeric  |                 |
|                   |        | and may not be       |                 |
|                   |        | negative.            |                 |
|                   |        |                      |                 |
|                   |        | c\. Fill in leading  |                 |
|                   |        | zeros when they      |                 |
|                   |        | apply.               |                 |
+-------------------+--------+----------------------+-----------------+

+-------------------+--------+----------------------+-----------------+
| **ELEMENT NAME**  | **RE   | **EDIT               | **APPLICABLE**  |
|                   | CORD** | SPECIFICATION**      |                 |
|                   |        |                      | **TYPE OF**     |
|                   | **POSI |                      |                 |
|                   | TION** |                      | **CLOSURE       |
|                   |        |                      | CODE**          |
+-------------------+--------+----------------------+-----------------+
| 25\. Services     | 1      | Valid codes listed   | 1 thru 7        |
| Provided          | 10-153 | in Codes for         |                 |
|                   |        | Vendors/Providers    |                 |
|                   |        | and Codes for Source |                 |
|                   |        | of Funding in        |                 |
|                   |        | instructions.        |                 |
+-------------------+--------+----------------------+-----------------+
| 26\. Level of     | 154    | a\. Valid codes: 0   | 1 thru 7        |
| Education         |        | thru 8.              |                 |
| Attained at       |        |                      |                 |
| Closure           |        | b\. Level attained   |                 |
|                   |        | at closure must be   |                 |
|                   |        | greater than or      |                 |
|                   |        | equal to level at    |                 |
|                   |        | application.         |                 |
|                   |        |                      |                 |
|                   |        | **c. If level        |                 |
|                   |        | attained is coded 3  |                 |
|                   |        | (Special Education   |                 |
|                   |        | Certificate of       |                 |
|                   |        | completion/diploma   |                 |
|                   |        | or in attendance),   |                 |
|                   |        | then Individualized  |                 |
|                   |        | Education Program    |                 |
|                   |        | (IEP)(RP 40) should  |                 |
|                   |        | be coded 1.**        |                 |
+-------------------+--------+----------------------+-----------------+
|                   |        | d\. Use Code \* if   | 1               |
|                   |        | information is not   |                 |
|                   |        | available.           |                 |
+-------------------+--------+----------------------+-----------------+
| 27\. Occupation   | 1      | a\. Valid codes:     | 3               |
| at Closure        | 55-160 | Except for special   |                 |
|                   |        | VR codes use         |                 |
|                   |        | Dictionary of        |                 |
|                   |        | Occupational Titles  |                 |
|                   |        | (DOT) published by   |                 |
|                   |        | the U.S. Department  |                 |
|                   |        | of Labor.            |                 |
|                   |        |                      |                 |
|                   |        | b\. Fill in leading  |                 |
|                   |        | zeros when they      |                 |
|                   |        | apply.               |                 |
|                   |        |                      |                 |
|                   |        | **c. MUST equal      |                 |
|                   |        | 599999 if Employment |                 |
|                   |        | Status at Closure    |                 |
|                   |        | (RP 161) equals 5.** |                 |
+-------------------+--------+----------------------+-----------------+
|                   |        | d\. Use Code         | 1, 2, 4, 5, 6   |
|                   |        | \*\*\*\*\*\* for all | and 7           |
|                   |        | other closure codes. |                 |
+-------------------+--------+----------------------+-----------------+
| 28\. Employment   | 161    | a\. Valid codes: 1,  | 3               |
| Status at Closure |        | and 3 thru 7.        |                 |
|                   |        |                      |                 |
|                   |        | **b. If code=5, then |                 |
|                   |        | Occupation at        |                 |
|                   |        | Closure (RP 155-160) |                 |
|                   |        | MUST equal 599999.** |                 |
+-------------------+--------+----------------------+-----------------+
|                   |        | **c. Valid code: 2.  | 4               |
|                   |        | A code of 2 is       |                 |
|                   |        | applicable only to   |                 |
|                   |        | closure type (RP     |                 |
|                   |        | 198) 4.**            |                 |
+-------------------+--------+----------------------+-----------------+
|                   |        | d\. Use code \* for  | 1, 2, 4, 5, 6   |
|                   |        | all other closure    | and 7           |
|                   |        | codes.               |                 |
+-------------------+--------+----------------------+-----------------+

+-------------------+--------+----------------------+-----------------+
| **ELEMENT NAME**  | **RE   | **EDIT               | **APPLICABLE**  |
|                   | CORD** | SPECIFICATION**      |                 |
|                   |        |                      | **TYPE OF**     |
|                   | **POSI |                      |                 |
|                   | TION** |                      | **CLOSURE       |
|                   |        |                      | CODE**          |
+-------------------+--------+----------------------+-----------------+
| 29\. Competitive  | 162    | a\. Valid codes: 0   | 3               |
| Employment        |        | or 1.                |                 |
|                   |        |                      |                 |
|                   |        | **b. Must equal 0 if |                 |
|                   |        | Employment Status    |                 |
|                   |        | (RP 161) is coded 5  |                 |
|                   |        | or 6.**              |                 |
+-------------------+--------+----------------------+-----------------+
|                   |        | c\. Use Code \* for  | 1, 2, 4, 5, 6   |
|                   |        | all other closure    | and 7           |
|                   |        | codes.               |                 |
+-------------------+--------+----------------------+-----------------+
| 30\. Weekly       | 1      | a\. Valid codes:     | 3               |
| Earnings at       | 63-166 | 0000 thru 9999.      |                 |
| Closure           |        |                      |                 |
|                   |        | b\. Must be numeric. |                 |
|                   |        |                      |                 |
|                   |        | c\. Must NOT be      |                 |
|                   |        | negative.            |                 |
|                   |        |                      |                 |
|                   |        | d\. Fill in leading  |                 |
|                   |        | zeros when they      |                 |
|                   |        | apply.               |                 |
|                   |        |                      |                 |
|                   |        | **e. MUST be greater |                 |
|                   |        | then 0000 if         |                 |
|                   |        | Employment Status    |                 |
|                   |        | (RP 161) equals 1,   |                 |
|                   |        | 3, 4 or 7.**         |                 |
+-------------------+--------+----------------------+-----------------+
|                   |        | f\. Use Code         | 1, 2, 4, 5, 6   |
|                   |        | \*\*\*\* for all     | and 7           |
|                   |        | other closure codes. |                 |
+-------------------+--------+----------------------+-----------------+
| 31\. Hours Worked | 1      | a\. Valid codes:     | 3               |
| in a Week at      | 67-168 | 00-99.               |                 |
| Closure           |        |                      |                 |
|                   |        | **b. MUST range 01   |                 |
|                   |        | thru 99 if Weekly    |                 |
|                   |        | earnings at Closure  |                 |
|                   |        | (RP 163-166) are     |                 |
|                   |        | greater than 0000.** |                 |
|                   |        |                      |                 |
|                   |        | **c. MUST be 00 if   |                 |
|                   |        | Weekly Earnings at   |                 |
|                   |        | Closure (RP 163-166) |                 |
|                   |        | is 0000.**           |                 |
+-------------------+--------+----------------------+-----------------+
|                   |        | d\. Use Code \*\*    | 1, 2, 4, 5, 6   |
|                   |        | for all other        | and 7           |
|                   |        | closure codes.       |                 |
+-------------------+--------+----------------------+-----------------+
| **\--             | **163  | **Calculate hourly   | **3**           |
| Earnings/Hours    | -168** | wage rate; verify if |                 |
| Comparison**      |        | \$40/hour or more    |                 |
|                   |        | and correct earnings |                 |
|                   |        | and/or hours, as     |                 |
|                   |        | needed.**[^2]        |                 |
+-------------------+--------+----------------------+-----------------+

+-------------------+--------+----------------------+-----------------+
| **ELEMENT NAME**  | **RE   | **EDIT               | **APPLICABLE**  |
|                   | CORD** | SPECIFICATION**      |                 |
|                   |        |                      | **TYPE OF**     |
|                   | **POSI |                      |                 |
|                   | TION** |                      | **CLOSURE       |
|                   |        |                      | CODE**          |
+-------------------+--------+----------------------+-----------------+
| 32\. Type of      | 1      | a\. Valid codes: 0   | 1 thru 7        |
| Public Support at | 69-175 | or 1 for each        |                 |
| Closure           |        | position.            |                 |
+-------------------+--------+----------------------+-----------------+
|                   |        | b\. Use Code \* in   | 2 thru 7        |
|                   |        | the position if      |                 |
|                   |        | information is not   |                 |
|                   |        | available due to     |                 |
|                   |        | circumstances beyond |                 |
|                   |        | the agency's         |                 |
|                   |        | control.             |                 |
+-------------------+--------+----------------------+-----------------+
|                   |        | c\. Use Code \* in   | 1               |
|                   |        | the position if the  |                 |
|                   |        | information is not   |                 |
|                   |        | available.           |                 |
+-------------------+--------+----------------------+-----------------+
| 33\. Monthly      | 1      | a\. Valid codes:     | 1 thru 7        |
| Public Support    | 76-191 | 0000 thru 9999 for   |                 |
| Amount at Closure |        | each position.       |                 |
|                   |        |                      |                 |
|                   |        | b\. Must be numeric. |                 |
|                   |        |                      |                 |
|                   |        | c\. Must NOT be      |                 |
|                   |        | negative.            |                 |
|                   |        |                      |                 |
|                   |        | d\. Fill in leading  |                 |
|                   |        | zeros when they      |                 |
|                   |        | apply.               |                 |
|                   |        |                      |                 |
|                   |        | **e. MUST be greater |                 |
|                   |        | than 0000 if         |                 |
|                   |        | comparable Type of   |                 |
|                   |        | Public Support at    |                 |
|                   |        | Closure (RP 169-175) |                 |
|                   |        | is coded 1.**        |                 |
|                   |        |                      |                 |
|                   |        | **f. If amount for a |                 |
|                   |        | given type of public |                 |
|                   |        | support is 0000, the |                 |
|                   |        | code for receipt of  |                 |
|                   |        | that type of public  |                 |
|                   |        | support (RP 169 thru |                 |
|                   |        | 175) is expected to  |                 |
|                   |        | be 0.**              |                 |
+-------------------+--------+----------------------+-----------------+
|                   |        | g\. Use Code         | 2 thru 7        |
|                   |        | \*\*\*\* in the      |                 |
|                   |        | position if          |                 |
|                   |        | information is not   |                 |
|                   |        | available due to     |                 |
|                   |        | circumstances beyond |                 |
|                   |        | the agency's         |                 |
|                   |        | control.             |                 |
+-------------------+--------+----------------------+-----------------+
|                   |        | h\. Use Code         | 1               |
|                   |        | \*\*\*\* in the      |                 |
|                   |        | position if          |                 |
|                   |        | information is not   |                 |
|                   |        | available.           |                 |
+-------------------+--------+----------------------+-----------------+

+-------------------+--------+----------------------+-----------------+
| **ELEMENT NAME**  | **RE   | **EDIT               | **APPLICABLE**  |
|                   | CORD** | SPECIFICATION**      |                 |
|                   |        |                      | **TYPE OF**     |
|                   | **POSI |                      |                 |
|                   | TION** |                      | **CLOSURE       |
|                   |        |                      | CODE**          |
+-------------------+--------+----------------------+-----------------+
| 34\. Primary      | 192    | a\. Valid codes: 1   | 1 thru 7.       |
| Source of Support |        | thru 4.              |                 |
| at Closure        |        |                      |                 |
+-------------------+--------+----------------------+-----------------+
|                   |        | b\. Use Code \* if   | 2, 4 thru 7     |
|                   |        | information is not   |                 |
|                   |        | available due to     |                 |
|                   |        | circumstances beyond |                 |
|                   |        | the agency's         |                 |
|                   |        | control.             |                 |
+-------------------+--------+----------------------+-----------------+
|                   |        | c\. Use Code \* if   | 1               |
|                   |        | information is not   |                 |
|                   |        | available.           |                 |
+-------------------+--------+----------------------+-----------------+
| 35\. Medical      | 1      | a\. Valid codes: 0   | 1 thru 7        |
| Insurance         | 93-197 | or 1 for each        |                 |
| Coverage at       |        | position.            |                 |
| Closure           |        |                      |                 |
+-------------------+--------+----------------------+-----------------+
|                   |        | b\. Use Code \* in   | 2 thru 7        |
|                   |        | the position if      |                 |
|                   |        | information is not   |                 |
|                   |        | available due to     |                 |
|                   |        | circumstances beyond |                 |
|                   |        | the agency's         |                 |
|                   |        | control.             |                 |
+-------------------+--------+----------------------+-----------------+
|                   |        | c\. Use Code \* in   | 1               |
|                   |        | the position if the  |                 |
|                   |        | information is not   |                 |
|                   |        | available.           |                 |
+-------------------+--------+----------------------+-----------------+
| 36\. Type of      | 198    | Valid codes: 1 thru  | 1 thru 7        |
| Closure[^3]       |        | 7.                   |                 |
|                   |        |                      | **REQUIRED      |
|                   |        |                      | ELEMENT**       |
+-------------------+--------+----------------------+-----------------+
| **ELEMENT NAME**  | **RE   | **EDIT               | **APPLICABLE**  |
|                   | CORD** | SPECIFICATION**      |                 |
|                   |        |                      | **TYPE OF**     |
|                   | **POSI |                      |                 |
|                   | TION** |                      | **CLOSURE       |
|                   |        |                      | CODE**          |
+-------------------+--------+----------------------+-----------------+
| 37\. Reason for   | 1      | a\. Valid codes: 00  | 1 thru 7        |
| Closure           | 99-200 | thru 14.             |                 |
|                   |        |                      | **REQUIRED      |
|                   |        | **b. Use Code 00 if  | ELEMENT**       |
|                   |        | Type of Closure (RP  |                 |
|                   |        | 198) is Code 3.**    |                 |
|                   |        |                      |                 |
|                   |        | **c. Cannot equal    |                 |
|                   |        | Code 08, 09 or 11 if |                 |
|                   |        | Type of Closure      |                 |
|                   |        | equals 4, 5, 6 or    |                 |
|                   |        | 7.**                 |                 |
|                   |        |                      |                 |
|                   |        | **d. The reason for  |                 |
|                   |        | closure code of 14   |                 |
|                   |        | is applicable only   |                 |
|                   |        | if Type of Closure   |                 |
|                   |        | equals 4 AND         |                 |
|                   |        | Employment Status at |                 |
|                   |        | Closure (RP 161)     |                 |
|                   |        | equals 2 (extended   |                 |
|                   |        | employment).**       |                 |
|                   |        |                      |                 |
|                   |        | e\. Fill in leading  |                 |
|                   |        | zero when it         |                 |
|                   |        | applies.             |                 |
+-------------------+--------+----------------------+-----------------+
| 38\. Date of      | 2      | See edit             | 1 thru 7        |
| Closure           | 01-208 | specifications for   |                 |
|                   |        | Element #5 (Date of  | **REQUIRED      |
| Year              | 2      | Application).        | ELEMENT**       |
|                   | 01-204 |                      |                 |
|                   |        | **a. Must equal      |                 |
|                   |        | Federal Fiscal Year  |                 |
|                   |        | of closure if Month  |                 |
|                   |        | of Closure (RP       |                 |
|                   |        | 205-206) equals      |                 |
|                   |        | 01-09.**             |                 |
|                   |        |                      |                 |
|                   |        | **b. Must equal      |                 |
|                   |        | Federal Fiscal Year  |                 |
|                   |        | of Closure minus one |                 |
|                   |        | if Month of Closure  |                 |
|                   |        | (RP 205-206) equals  |                 |
|                   |        | 10-12.**             |                 |
+-------------------+--------+----------------------+-----------------+
| 39\. Supported    | 209    | a\. Valid codes: 0   | 3 thru 5        |
| Employment Status |        | thru 2.              |                 |
+-------------------+--------+----------------------+-----------------+
|                   |        | b\. Use Code \* if   | 3 thru 5        |
|                   |        | information is not   |                 |
|                   |        | available due to     |                 |
|                   |        | circumstances beyond |                 |
|                   |        | the agency's         |                 |
|                   |        | control..            |                 |
+-------------------+--------+----------------------+-----------------+
|                   |        | c\. Use Code \* for  | 1, 2, 6 and 7   |
|                   |        | all other closure    |                 |
|                   |        | codes                |                 |
+-------------------+--------+----------------------+-----------------+
| **ELEMENT NAME**  | **RE   | **EDIT               | **APPLICABLE**  |
|                   | CORD** | SPECIFICATION**      |                 |
|                   |        |                      | **TYPE OF**     |
|                   | **POSI |                      |                 |
|                   | TION** |                      | **CLOSURE       |
|                   |        |                      | CODE**          |
+-------------------+--------+----------------------+-----------------+
| 40\. Veteran      | 210    | a\. Valid codes: 0   | 1 thru 7        |
| Status            |        | or 1.                |                 |
+-------------------+--------+----------------------+-----------------+
|                   |        | b\. Use Code \* if   | 2 thru 7        |
|                   |        | information is not   |                 |
|                   |        | available due to     |                 |
|                   |        | circumstances beyond |                 |
|                   |        | the agency's         |                 |
|                   |        | control.             |                 |
+-------------------+--------+----------------------+-----------------+
|                   |        | c\. Use Code \* if   | 1               |
|                   |        | the information is   |                 |
|                   |        | not available.       |                 |
+-------------------+--------+----------------------+-----------------+
| 41\. Significant  | 211    | a\. Valid codes: 0   | 1 thru 7        |
| Disability        |        | or 1.                |                 |
+-------------------+--------+----------------------+-----------------+
|                   |        | b\. Use Code \* if   | 1               |
|                   |        | the information is   |                 |
|                   |        | not available.       |                 |
+-------------------+--------+----------------------+-----------------+
|                   |        | c\. If Type of       | 1 thru 7        |
|                   |        | Public Support       |                 |
|                   |        | (SSDI) is coded 1 at |                 |
|                   |        | application (RP 62)  |                 |
|                   |        | or closure (RP 172), |                 |
|                   |        | then significant     |                 |
|                   |        | disability should be |                 |
|                   |        | coded 1.             |                 |
+-------------------+--------+----------------------+-----------------+
| 42\. Migrant and  | 212    | a\. Valid codes: 0   | 1 thru 7        |
| Seasonal          |        | thru 2.              |                 |
| Farmworkers       |        |                      |                 |
+-------------------+--------+----------------------+-----------------+
|                   |        | b\. Use Code \* if   | 2 thru 7        |
|                   |        | the information is   |                 |
|                   |        | not available due to |                 |
|                   |        | circumstances beyond |                 |
|                   |        | the agency's         |                 |
|                   |        | control.             |                 |
+-------------------+--------+----------------------+-----------------+
|                   |        | c\. Use Code \* if   | 1               |
|                   |        | the information is   |                 |
|                   |        | not available.       |                 |
+-------------------+--------+----------------------+-----------------+
| 43\. Projects     | 213    | a\. Valid codes: 0   | 1 thru 7        |
| With Industry     |        | or 1.                |                 |
+-------------------+--------+----------------------+-----------------+
|                   |        | b\. Use Code \* if   | 2 thru 7        |
|                   |        | the information is   |                 |
|                   |        | not available due to |                 |
|                   |        | circumstances beyond |                 |
|                   |        | the agency's         |                 |
|                   |        | control.             |                 |
+-------------------+--------+----------------------+-----------------+
|                   |        | c\. Use Code \* if   | 1               |
|                   |        | the information is   |                 |
|                   |        | not available.       |                 |
+-------------------+--------+----------------------+-----------------+

Index

A

Agency Code · 4

C

Closure Order · 5

Competitive Employment · 32

Cost of Purchased Services · 20

D

Date

Application · 6

Birth · 7

Closure · 41

Eligibility Determination · 19

Individualized Plan for Employment (IPE) · 20

Disability

Primary · 11

Secondary · 11

Significant · 42

E

Edit Specifications

by Element · 49

General Instructions · 1

Preparation of Floppy Diskette or CD-ROM · 2

Employment Status

at Application · 13

at Closure · 31

G

Gender · 7

H

Hours Worked

at Application · 16

at Closure · 35

I

Individualized Education Program · 10

L

Level of Education

at Application · 9

at Closure · 29

Living Arrangement at Application · 10

M

Medical Insurance Coverage

at Application · 19

at Closure · 38

Migrant and Seasonal Farmworkers · 42

Monthly Public Support Amount

at Application · 17

at Closure · 36

O

Occupation at Closure · 30

P

Previous Closure · 5

Primary Source of Support

at Application · 18

at Closure · 37

Projects With Industry · 43

R

Race and Ethnicity · 7

Reason for Closure · 39

RSA-911 Record Layout · 45

S

Services Provided · 21

Assessment · 22

Diagnosis and Treatment · 22

Information and Referral · 29

Job-Related · 25

Maintenance · 26

Other · 29

Personal Assistance · 28

Rehabilitation Technology · 26

Technical Assistance · 29

Training · 23

Transportation · 25

VR Counseling & Guidance · 23

Social Security Number · 5

Source of Referral · 9

Supported Employment Status · 41

T

Type of Closure · 38

Type of Public Support

at Application · 16

at Closure · 35

V

Veteran Status · 41

W

Weekly Earnings

at Application · 15

at Closure · 34

[^1]: **Agencies are encouraged to set criteria for flagging below \$40
    per hour.**

[^2]: **Agencies are encouraged to set criteria for flagging below
    \$40/hour.**

[^3]: **Counts of each code 1 thru 7 [MUST]{.underline}** equal counts
    derived from the 4th Quarter, Quarterly Cumulative Caseload Report
    (Form RSA-113). Agencies may be required to resubmit data, if there
    are discrepancies in counts of closure between the two systems.