RE PORT OF VENDING FACILITY PROGRAM

STATE: REPORTI

NG 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. Th e 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: REPORTI

NG PERIOD: October 1, to September 30, 

### I. **E ARNINGS AND EMPLOYMENT**  1. Gross Sales $ __________ 2. Merchandise Purchases $ __________ 3. Gross Profit ( s ubtract line 2 from line 1 ) $ __________ 4. Pay roll Expenses $ __________ 5. Other Operating Expenses $ __________ 6. Total Expenses ( a dd l ines 4 and 5) $ __________ 7. Operating Profit ( s ubtract 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 l ines 7, 8 , and 9) $ __________ 11. Levied Set Aside Funds $ __________ 12. Net Profit to Vendors ( s ubtract line 11 from line 10) $ __________ 13. Fair Minimum Return to Vendors $ __________ 14. Vendor Earnings ( add l ines 12 and 13) $ __________ 15. Vendor Person Years of Employ ment ___________ 16. Average Vendor Earnings ( divide l ine 14 by l ine 15) $ __________ 17. The Median of Vendor Earning s 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 l ines 18 , 1 9 , and 20)

_______________RE PORT OF VENDING FACILITY PROGRAM

STATE: REPORTI

NG 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 PROPER** **TY, 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 Lo cations ___________ 9. Other Federal Agencies (please i dentify): __________________________ ___________ 10. Total ( a dd l ines 1 through 9 ) ___________ **C. CONTRACTS FOR OPERATION OF CAFET**  **ERIAS AND MILITARY DINING FACILITIES**  **Agency or Branch of Military**  **Awarding Contract Nam**  **e 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 ___________RE PORT OF VENDING FACILITY PROGRAM

STATE: REPORTI

NG PERIOD: October 1, to September 30,

3 **E. FACILITIES ON PUBLIC PROPERTY (State, County,**  **Municipal)** 1. Number at Beginning of the Year ___________ 2. Number Established D uring the Year ___________ 3. Number Closed D uring the Year ___________ 4. Number at End of the Year ___________ a. V ending Facilities on State Property (end of year) ___________ b. Vending Facilities on County Property (end of ye ar) ___________ 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 P**  **ROPERTY** 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 ___________RE PORT OF VENDING FACILITY PROGRAM

STATE: REPORTI

NG PERIOD: October 1, to September 30,

4 

### 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 ProgramRE PORT OF VENDING FACILITY PROGRAM

STATE: REPORTI

NG 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**  **Non**   ** Federal** **(2) Set**  ****

**Aside (3)**  **State**

**Appro**   ** priated** **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) $ $ $ $ $ $ $RE PORT OF VENDING FACILITY PROGRAM

STATE: REPORTI

NG PERIOD: October 1, to September 30,

6 

### V. **DISTRIBUTION AND EXPENDITURE OF PROGRAM FUNDS FROM**  **VENDING MACHINE INCOME AND LEVIED SET -**  **ASIDE**

**Item Vending**  **Machine Income**  **Federal (1)**  **Vending**

**Machine Income**  **Non**   ** Federal** **( 2**  **) Levied** 

**Set -** **Aside (3)**  **Total**

**(4)** 1. Amount at Beginning of the Year $ $ $ $ 2. Funds Added During the Year $ $ $ $ 3. Total Funds Available ( a dd l ines 1 and 2) $ $ $ $ 4. Funds Distributed to Vendors $ $ $ $ 5. Other Funds Expended $ $ $ $ 6. Total Funds Distributed and Expended ( a dd lines 4 and 5) $ $ $ $ 7. Amount at the End of the Year ( s ubtract line 6 from line 3) $ $ $ $RE PORT OF VENDING FACILITY PROGRAM

STATE: REPORTI

NG PERIOD: October 1, to September 30,

7 

### VI. **NUMBER OF SITES SURVEYED Item**  **Federal Property**  **Total (1)**  **Non**  

** Federal** **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 A dded 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 F unds 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 PendingRE PORT OF VENDING FACILITY PROGRAM

STATE: REPORTI

NG 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 Facil ity 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 Nationall y Recognized or State Recogniz ed Program ___________RE PORT OF VENDING FACILITY PROGRAM

STATE: REPORTI

NG 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 Nationall y Recognized or State Recognized Program Notes or Explanations:RE PORT OF VENDING FACILITY PROGRAM

STATE: REPORTI

NG 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 ________________________________ _________