REPORT OF VENDING FACILITY PROGRAM 

 

STATE:

REPORTING PERIOD: October 1, to September 30, 

 

1

U.S. Department of Education 

Rehabilitation Services Administration

Washington, D.C. 20202 

Form RSA-15 

OMB No. 1820-0009 

Exp. Date: xx/xx/xxxx

REPORT OF VENDING FACILITY PROGRAM

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless 

such collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to 

average 13.5 hours per response, including time for reviewing instructions, searching existing data sources, gathering and 

maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this 

collection is required to obtain or retain benefit (20 U.S.C. 107a(6)(a) and 107b(4))). Send comments regarding the burden 

estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. 

Department of Education, 400 Maryland Ave., SW, Washington, DC 20210-4537 or email ICDocketMgr@ed.gov and 

reference the OMB Control Number 1820-0009. Note: Please do not return the completed RSA-15: Report of Vending Facility 

Program to this address. 

STATE: AGENCY:

REPORTING PERIOD: October 1, to September 30, 

I. EARNINGS AND EMPLOYMENT

1. Gross Sales $ __________

2. Merchandise Purchases $ __________

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

4. Payroll Expenses $ __________

5. Other Operating Expenses $ __________

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

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

8. Vending Machine and Other Income $ __________

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

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

11. Levied Set Aside Funds $ __________

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

13. Fair Minimum Return to Vendors $ __________

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

15. Vendor Person Years of Employment ___________

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

17. The Median of Vendor Earnings in the State $ __________

18. Number of Other Persons with Visual Disabilities Employed __________

19. Number of Other Persons with Disabilities Employed ___________

20. Number of Persons Having No Disability Employed ___________

21. Total Number Employed in the Program (add lines 18, 19, and 20) _______________
REPORT OF VENDING FACILITY PROGRAM 

 

STATE:

REPORTING PERIOD: October 1, to September 30, 

 

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II. VENDING FACILITIES AND VENDORS

A. FACILITIES ON FEDERAL PROPERTY

1. Number at Beginning of the Year ___________

2. Number Established During the Year ___________

3. Number Closed During the Year ___________

4. Number at End of the Year ___________

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

1. General Services Administration ___________

2. U.S. Postal Service ___________

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

a. Military Dining Facility Contracts ___________

b. Other Department of Defense Vending Facilities ___________

4. Department of Homeland Security ___________

5. Department of Health and Human Services

6. Veterans Administration ___________

7. Department of the Interior

8. Vending Routes on Multiple Federal Locations ___________

9. Other Federal Agencies (please identify): __________________________ ___________

10. Total (add lines 1 through 9) ___________

C. CONTRACTS FOR OPERATION OF CAFETERIAS AND MILITARY DINING 

FACILITIES

Agency 

or Branch of Military 

Awarding Contract

Name of Military Installation 

(if applicable)

Beginning 

Date of 

Contract

Anticipated 

Termination 

of Contract

Gross Sales (Value) of 

Contract for the Most 

Recently Completed 

Option Year

$

$

$

$

D. VENDORS ON FEDERAL PROPERTY

1. Number at Beginning of the Year ___________

2. Number Entering During the Year ___________

3. Number Leaving During the Year ___________

4. Number at End of the Year ___________
REPORT OF VENDING FACILITY PROGRAM 

 

STATE:

REPORTING PERIOD: October 1, to September 30, 

 

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

1. Number at Beginning of the Year ___________

2. Number Established During the Year ___________

3. Number Closed During the Year ___________

4. Number at End of the Year ___________

a. Vending Facilities on State Property (end of year) ___________

b. Vending Facilities on County Property (end of year) ___________

c. Vending Facilities on Municipal Property (end of year) ___________

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

1. Number at Beginning of the Year ___________

2. Number Entering During the Year ___________

3. Number Leaving During the Year ___________

4. Number at End of the Year ___________

G. FACILITIES ON PRIVATE PROPERTY

1. Number at Beginning of the Year ___________

2. Number Established During the Year ___________

3. Number Closed During the Year ___________

4. Number at End of the Year ___________

H. VENDORS ON PRIVATE PROPERTY

1. Number at Beginning of the Year ___________

2. Number Entering During the Year ___________

3. Number Leaving During the Year ___________

4. Number at End of the Year ___________
REPORT OF VENDING FACILITY PROGRAM 

 

STATE:

REPORTING PERIOD: October 1, to September 30, 

 

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III. VENDING LOCATIONS UNDER THE INTERSTATE HIGHWAY PROGRAM 

(Transportation Equity Act for the 21st Century of June 1998)

Item

Total 

Number

(1)

Total Vending

Machine Receipts

(2)

1. Total Number of Vending Locations 

2. Number of Locations Operated by Vendors $

3. Number of Locations Operated by Third-Party Contractors $

4. Number of Vendors Operating Locations in the Highway Program
REPORT OF VENDING FACILITY PROGRAM 

 

STATE:

REPORTING PERIOD: October 1, to September 30, 

 

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IV. PROGRAM EXPENDITURES BY SOURCE OF FUNDS

Item

Vending 

Machine 

Income 

Federal

(1)

Vending 

Machine 

Income 

NonFederal 

(2)

SetAside

(3)

State 

Appropriated 

Fund

(4)

Federal 

Funds

(5)

Other

(6)

TOTAL

(7)

1. Purchase of New Equipment $ $ $ $ $ $ $

2. Maintenance of Equipment $ $ $ $ $ $ $

3. Replacement of Equipment $ $ $ $ $ $ $

4. Refurbishment of Facilities $ $ $ $ $ $ $

5. Management Services $ $ $ $ $ $ $

6. Fair Minimum Return $ $ $ $ $ $

7. Retirement/Pension Programs $ $ $ $ $ $

8. Health Insurance Programs $ $ $ $ $ $

9. Paid Sick Leave/Vacation $ $ $ $ $ $

10. Initial Stock and Supplies $ $ $ $ $

11. All Other Expenditures $ $ $ $

12. TOTAL (add 1-11) $ $ $ $ $ $ $
REPORT OF VENDING FACILITY PROGRAM 

 

STATE:

REPORTING PERIOD: October 1, to September 30, 

 

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V. DISTRIBUTION AND EXPENDITURE OF PROGRAM FUNDS FROM 

VENDING MACHINE INCOME AND LEVIED SET-ASIDE

Item

Vending 

Machine 

Income

Federal

(1)

Vending 

Machine 

Income 

NonFederal

(2)

Levied 

Set-Aside

(3)

Total

(4)

1. Amount at Beginning of the Year $ $ $ $

2. Funds Added During the Year $ $ $ $

3. Total Funds Available (add lines 1 and 2) $ $ $ $

4. Funds Distributed to Vendors $ $ $ $

5. Other Funds Expended $ $ $ $

6. Total Funds Distributed and Expended 

 (add lines 4 and 5) $ $ $ $

7. Amount at the End of the Year 

 (subtract line 6 from line 3) $ $ $ $
REPORT OF VENDING FACILITY PROGRAM 

 

STATE:

REPORTING PERIOD: October 1, to September 30, 

 

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VI. NUMBER OF SITES SURVEYED

Item

Federal 

Property

Total

(1)

NonFederal 

Property

(2)

Total

(3)

1. Number of Sites Surveyed During the Reporting Year

2. Number of Sites Accepted by the SLA (add a., b., c., and d.)

a. Number of Accepted Sites Added to Existing Vending Facilities

b. Number of Accepted Sites Used to Create New Vending Facilities

c. Number of Accepted Sites Pending Assignment to a Blind Vendor

d. Number of Accepted Sites Contracted to a Third-Party 

3. Number of Sites Not Accepted by the SLA (add a., b., and c.)

a. Due to Infeasibility of Site

b. Due to Lack of Available SLA Funds

c. Due to Lack of Qualified Vendors

4. Number of Sites Denied to the SLA by Property Management Officials

5. Number of Surveyed Sites with a Decision Pending
REPORT OF VENDING FACILITY PROGRAM 

 

STATE:

REPORTING PERIOD: October 1, to September 30, 

 

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VII. VENDOR TRAINING

1. Number of Individuals Completing Training in the Reporting Year 

 to Become Vendors: (add a through d) ___________

a. Number Licensed and Placed as Vendors ___________

b. Number Certified Awaiting Placement as Vendors ___________

c. Number Placed as Employees in the Vending Facility Program ___________

d. Number Employed in Allied Food Service Occupations ___________

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

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

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

5. Number of Vendors Participating in National Consumer-Driven Conferences ___________

6. Number of Vendors Who Received Certification or Re-Certification in Food Safety

Through a Nationally Recognized or State Recognized Program ___________
REPORT OF VENDING FACILITY PROGRAM 

 

STATE:

REPORTING PERIOD: October 1, to September 30, 

 

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VIII. STATE AND NOMINEE AGENCY PERSONNEL

A. Agency Personnel

Type of Personnel

State 

Agency 

Personnel

(1)

Nominee 

Agency 

Personnel

(2)

Total

(3)

I. Vending Facility Program Staff (FTE)

 a. Number of Business Consultants/Counselors Staff (FTE)

B. Training

Type of Training

State 

Agency 

Personnel

(1)

Nominee 

Agency 

Personnel

(2)

Total

(3)

1. Number Who Received Training Related to Blindness, 

Business Management, or Aspects of the 

 Randolph-Sheppard Vending Facility Program

2. Number Who Participated in National Consumer-Driven 

 Conferences

3. The Number Who Received Certification or Re-Certification 

 in Food Safety Through a Nationally Recognized or State 

 Recognized Program

Notes or Explanations:
REPORT OF VENDING FACILITY PROGRAM 

 

STATE:

REPORTING PERIOD: October 1, to September 30, 

 

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CERTIFICATION: 

I do hereby certify that, to the best of my knowledge, the information given in this 

report is complete and accurate. 

___________________________________________________________________________________

Name of Authorized Official

___________________________________________________________________________________

Title

___________________________________________________________________________________

Date Certified

___________________________________________________________________________________

Contact Person

Telephone Number _________________________________________

Email Address _________________________________________