FORM RSA

- 227 OMB NO. 1820

- 0528 EXPIRES:

**AN NUA**  **L CLIENT AS**  **SISTA NCE PROGRAM (CA**  **P) REPORT**

**Fiscal Year DESIGNA** **TED AG**  **ENCY IDENTIFICA TION**  Name:
Address:

E

- mail Address (if applicable): We bsite Address (if applicable): Phone: ( ) TTY: ( ) Toll

-free Phone: ( ) Toll

-free TTY: ( ) Fax: ( ) **OPERA TING**  **AG ENCY (IF DIFERENT FROM DESIGNA** **TED AG**  **ENCY)** Name: Address:

E

- mail Address (if applicable): We bsite Address (if applicable): Phone: ( ) TTY: ( ) Toll

-free Phone: ( ) Toll

-free TTY: ( ) Fax: ( ) Name of CAP Director/Coordinator: Person to contact regarding report: Contact Person's phone: ( ) **PA RT I.**  **AG ENCY WORKLO**  **AD D AT** **A A.**  **Information and Referral Services (I&R):** (Multiple response s are not permitted.) 1. Information regarding the Rehabilitation Act 2. Information regarding Title I of the ADA 3. Other information provided 4. Total I&R services provided (Lines A1+A2+A3) 5. Individuals attending trainings by CAP staff (approx imate) **B. Individuals served** (An individual is counted only once during a fiscal year. Multiple counts are not permitted for Lines B1

- B3.) 1. Individuals who are still being served as of October 1 (carryover from prior year) 2. Additional individuals who were served during the year 3. Total individuals served (Lines B1+B2) 4. Individuals (from Line B3) who had multiple case files opened/closed this year. (In unusual situations, an individual may have more than one case file opened/closed during a fiscal year. This number is not added to the total in Line B3 above.)**PA RT I.**  **AG ENCY WORKLO**  **AD D AT** **A (continued)** 

**C. Individual still being served as of September 30** (Carryover to next ye ar) (This total may not exceed Line I.B3.) **D. Reasons for closi ng individuals’ case files**  (Choose one primary reason for closing each case file. There may be more case files than the total number of individuals served to account for those unusual situations, referred to in Line I.B4, when an individual had multiple c ase files closed during the year.) 1. All issues resolved in individual’s favor 2. Some issues resolved in individual’s favor (when there are multiple issues) 3. CAP determines VR agency position/decision was appropriate for the individual 4. Indivi dual’s case lacks legal merit; (inappropriate for CAP intervention) 5. Individual chose alternative representation 6. Individual decided not to pursue resolution 7. Appeals were unsuccessful 8. CAP services not needed due to individual’s death, rel ocation, etc. 9. Individual refused to cooperate with CAP 10. CAP unable to take case due to lack of resources 11. Other (Please explain on separate sheet) **E. Results achieved for individuals** (Choose one primary outcome for each closed case file. As stated in Section D, there may be more case files than the total number of individuals served.) 1. Controlling law/policy explained to individual 2. Application for services completed 3. Eligibility determination expedited 4. Individual p articipated in evaluation 5. IPE developed/implemented 6. Communication re

- established between individual and other party 7. Individual assigned to new counselor/office 8. Alternative resources identified for individual 9. ADA/504/EEO/OCR co mplaint made 10. Other (Please explain on separate sheet) **PA RT II. PROGRA** **M DA TA**  **A. A** **ge** (As of the beginning of the fiscal year.) (Multiple responses not permitted.) 1. 21 and under 2. 22

– 40 3. 41

– 64 4. 65 and over 5. Total (Sum of Lines A1 through A4. Total must equal Line I. B3.) **B. Gender** (Multiple responses not permitted.) 1. Females 2. Males 3. Total (Lines B1+B2. Total must equal Line I.B3.) **PA RT II. Program Data (continued)** **C. Race/ethnicity** (Multiple responses are perm itted.)

1. American Indian or Alaskan Native 2. Asian 3. Native Hawaiian or Other Pacific Islander 4. Black or African American 5. Hispanic or Latino 6. Wh ite 7. Race/ethnicity unknown **D. Primary**

**disabling condition of individuals served** (M ultiple responses not permitted.) 1. Blindness (both eyes) 2. Other visual impairments 3. Deafness 4. Hard of hearing 5. Deaf

- blind 6. Orthopedic impairments 7. Absence of extremities 8. Mental illness 9. Substance abuse (alcohol or drugs ) 10. Mental retardation 11. Specific learning disabilities (SLD) 12. Neurological disorders 13. Respiratory disorders 14. Heart and other circulatory conditions 15. Digestive disorders 16. Genitourinary conditions 17. Speech impairments 18. AIDS/HIV positive 19. Traumatic brain injury (TBI) 20. All other disabilities 21. Disabilities not known 22. Total ( Sum of Lines D1 through D21. Total must equal Line I. B3.) **E. Ty pes of individuals served**  (Multiple responses permitted.) 1 . Applicants of VR Program 2. Clients of VR Program 3. Applicants or clients of IL Program 4. Applicants or clients of other programs and projects funded under the Act **F. Source of individual’s concern** (Multiple responses permitted.) 1. VR agency only 2. Other Rehabilitation Act sources only 3. Both VR agency and other Rehabilitation Act sources 4. Employer

**PA RT II. PROGRA** **M DA TA**  **(continued) G. Problem areas**  (Multiple responses permitted.)

1. Individual requests information 2. Communica tion problems between individual and counselor 3. Conflict about services to be provided 4. Related to application/eligibility process 5. Related to IPE development/implementation 6. Other Rehabilitation Act

- related problems 7. Non

- Rehabilitation Act related 8. Related to Title I of the ADA **H. Types of CA P services provided**  (Choose one primary service CAP provided for each closed case file. As stated above, there may be more case files than actual individuals served.) 1. Information/referral 2. Advisory/interpretational 3. Negotiation 4. Administrative/informal review 5. Alternative dispute resolution 6. Formal appeal/fair hearing 7. Legal remedy 8. Transportation **PA RT III. NA**  **RRA TIVE (A**  **ttach separate sheet(s).)** Refer to pages 16

- 19 of the instructions for guidelines on the contents of the narrative.

Reports are to be submitted to RSA within 90 days after the end of the fiscal year covered by this report . Please be reminded that you can enter data directly into RSA’s Manag ement Information System (MIS) via the Internet. Information on transmittal of the form, including electronic transmission, is found on pages 19 and 20 of the reporting instructions.

Signature and title of designated agency official D ate

**Paperwork Burden Statement: According**  **to the**  **Paperwork Reduction**  **Act of**  **1995, no**  **persons are**  **required to**  **respond to**  **a collection**  **of information**  **unless such**  **collection display** **s a**  **valid OMB**  **control number.**  **Public reporting**  **burden for**  **this collection**  **of information**  **is estimated**  **to average**  **16 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 (34**  **CFR 370.44).**  **Send comments**  **regarding the**  **burden estimate**  **or any**  **o ther**  **aspect of**  **this collection**  **of information,**  **including suggestions**  **for reducing**  **this burden,**  **to the**  **U.S. Department**  **of Education,**  **400 Mary** **land Ave., SW, Washington, DC 20210** 

**- 4537 or email**  **ICDocketMgr@ed.gov and reference the OMB Control**  **Number 1820** 

**- 0528.**  **Note: Please**  **do not**  **return the**  **completed Annual**  **Client Assistance**  **Program (CAP) Report to this address.**