FOR M 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: __________ Toll -free Phone: __________ 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: __________ Toll -free Phone: __________ TTY: __________ Fax: __________ Name of CAP Director/Coordinator: _______________________________ Person to contact re garding report: _______________________________ Contact Person's phone: _______________________________ **PA RT I. NON**  **- CA** **SE SERVICES A.**  **I nformation and Referral Services (I&R):**  (Multiple responses are not permitted.) 1. Information regarding the Rehabilitation Act ______ 2. Information regarding Title I of the ADA ______ 3. Other information provided ______ 4. Total I&R services provided (Lines A1+A2+A3) ______ **B. Training A ctiv**  **ities** 1. Number of training sessions presented to community groupsand public agencies. ______

2. Number of individuals who attended these training sessions ______ 3. Describe training presented by th e staff. Include the following information: (a) topics covered (b) the purpose of the training (c) a description of the attendees **C. A gency** **Outreach** Describe the agency’s outreach efforts to previously un - served or un derserved individuals including minority communities **D. Information Disseminated To The Public By Your**  **Ag ency**  For each method of dissemination, enter the total number of each method used by your agency during the reporting period to distribute information to the public. For p ublications/booklets/brochures (item 4), enter the total number of documents produced. Agencies should not include website hits. See instructions for details 1. Agency Staff Interviewed or Featured on Radio and TV ______ 2. Articles a bout CAP Featured in Newspaper/Magazine/Journal s ______ 3. PSAs/Videos Aired about the CAP Agency ______ 4. Publications/Booklets/Brochures Disseminated by the Agency ______ 5 . Number of Times CAP Exhibited at Conferences, Community Fairs, etc. 6. Other (specif

y be low) ______ **E. Information Disseminated A bout Your A** **gency By** **External Media Coverage**  Describe the various sources and information disseminated about your agency by an external source. **PA RT II. INDIVIDUA**  **L CA SE SERVICES**  **A. Individuals served**  An individual is counted only once during a fiscal year. Multiple counts are not permitted for Lines A1 -A3.) 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 indiv iduals served (Lines A1+A2) ______ 4. Individuals (from Line A3) who had multiple case files opened/closed this year (In unusual situations, an individual may have more than one case file opened/closed during afiscal year. This number is not added to the tota l in Line A3 above.) ______ 5. Individual still being served as of September 30 (Carryover to next year. This total may not exceed Line A3.) ______ **B. Problem areas (Multiple responses permitted.)** 1. Individual requests information ______ 2. Communication problems betwe en individual and counselor ______ 3. Conflict about services to be provided ______ 4. Related to application/eligibility process ______ 5. Related to IPE development/implementation i. Selection of vendors for provision of services ______ ii. S election of training, post- seco ndary education ______ iii. Selection of employment outcome ______ iv. Transition services ______ 6. Other Rehabilitation Act- related problems ______ 7. Non - Rehabilitation Act related i. TANF ______ ii. SSI/SSDI ______ i ii . Housing ______ i v. Other: ______ 8. Related to Title I of the ADA ______ **C. I ntervention Strategies for closed cases**  (Choose one primary service the CAP provided for each closed case file. There may be more case files t han actual individuals served.) 1. Short Term Technical Assistance ______ 2. Investigation/Monitoring ______ 3. Negotiati on ______ 4. Mediation and other methods of Alternative Dispute Resolution ______ 5. Administrative / Informal Review ______ 6. Formal appeal / Fair Hearing 7. Legal remedy / Litigation ______ 8. Total ______ **D. Reasons for closing individuals’ case files** (Choose one primary re ason for closing each case file. There may be more case files than the total number of individuals served.) 1. All issues resolved in individual’s favor ______ 2. Some issues resolved in individual’s favor (when there are multiple issues) ______3. CAP determines VR agency position/decision was appropriate for the individual ______ 4. Individual’s case lacks legal merit; (inappropriate for CAP intervention) ______ 5. Individual chose alternative representation ______ 6. Individual withdrew complaint ______ 7. Issue not resolved in cli ents favor ______ 8. CAP services not needed due to individual’s death, relocation, etc. ______ 9. Individual not responsive/cooperative with CAP ______ 10. CAP unable to take case due to lack of resources ______ 11. Conflict of interest ______ 1 2. Other (Please explain below) **E. Results achieved for individuals**  (Choose one primary outcome for each closed case file. 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 participated in evaluation ______ 5. IPE developed/implemented /Services Provided ______ 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 complaint made ______ 10. Other ( specify below) **PA RT III.PROGRA** **M DA TA**  **A. A** **ge (Multiple responses not permitted.)** 1. Up to 18 ______ 2. 19 - 24 ______ 3. 25 - 40 ______ 4. 41 - 64 ______ 5. 65 and over ______ 6. Total (Sum of Lines A1 through A5. Total must equal Part II, Line A3.) ______ **B. Gender (Multiple responses not permitted.)** 1 . Females ______ 2 . Males ______ 3 . Total (Lines B1+B2. Total must equal Part II, Line A3.) ______**C. Race/ethnicity of Individuals Served**  1 . Hispanic/L atino of any race ______ For individuals who are non - Hispanic/Latino only 2 . American Indian or Alaskan Native ______ 3 . Asian ______ 4 . Black or African American ______ 5 . Native Hawaiian or Other Pacific Islander ______ 6 . Wh ite ______ 7 . Two or more races ______ 8 . Race/ethnicity unknown ______ **D. Primary**

**disabling condition of individuals served (Multiple responses not permitted.)**  1 . Acquired Brain Injury ______ 2. ADD/ADHD ______ 3 . AIDS/HIV ______ 4 . Amputations or Absence of Extremities ______ 5 . Arthritis or Rheumatism ______ 6 . Anxiety Disorder ______ 7 . A utism ______ 8. Autoimmune or Immune Deficiencies (excluding AIDS/HIV) ______ 9 . Blindness (Both Eyes) ______ 10 . Other Visual Impairments (Not Blind) ______ 11 . Cancer ______ 12 . Cerebral Palsy ______ 13 . Deafness ______ 14 . Hard of Hearing/ Hearing Impaired (Not Deaf) ______ 15 . Deaf- Blind ______ 16 . Diabetes ______ 17 . Digestive Disorders ______ 18 . Epilepsy ______ 19 . Heart & Other Circulatory Conditions ______ 20 . Intellectual Disability ______ 21 . Mental Illness ______ 22 . Multiple Sclerosis ______ 23 . Muscular Dystrophy ______ 24 . Muscular/Skeletal Impairment ______ 25 . Neurological Diso rders/Impairment ______ 26 . Orthopedic Impairments ______ 27 . Personality Disorders ______ 28 . Respiratory Disorders/Impairment ______ 29 . Skin Conditions ______ 30 . Specific Learning Disabilities (SLD) ______ 31 . Speech Impairments ______ 32 . Spina Bifida ______33 . Substance Abuse (Alcohol or Drugs) ______

34. Other Disability ______ 35. Total (Sum of Lines D1through D34 . Total must equal Part II, Line A3.) ______ **PA RT IV. SYSTEMIC A** **CTIVITIES A ND LITIGA** **TION A.**  **Non -**  **Litigation Systemic A ctiv**  **ities** 1. Number of non - litigation systemic activities not involvin g individual representation that resulted in the change of one or more policy or practice of an agency. ______ 2. Describe the systemic activities conducted by CAP during the fiscal year and its impact on other agency’s policies or practices. **B. Litigation** 1. Total number of CAP cases requiring litigation involving individual representation resulting in, or with the potential for, systemic change. a. Number of cases requiring litigation involving individual representation filed during fiscal year. ______ b. Numbe r of on - going cases pending at start of fiscal year (carryover from prior fiscal year). ______ c. Number of cases resolved through litigation during fiscal year. 2. Describe the agency’s on - going and completed systemic litigation activities involving individua l representation . **PA RT V. A** **GENCY INFORMA TION**  **A. Designated A** **gency** A. Agency Type (check only one option for Lines 1.a through 1.e) a. Internal to the State VR agency ______ b. External - other public agency ______ c. External - Protection and Advocacy agency ______ d. Exte rnal - other nonprofit agency ______ e. External - all other private agencies ______ B. Name of designate agency _______________________________ C. Is the designated agency contracting CAP services? Yes/No D. If yes, name of contracting agency: _____________________________ **B. Staff Employ** **ed** Provide a description of all CA P po sitions (see instructions)**PA RT VI. CA** **SE EXAMPLES**

Provide some examples of some interesting ca ses during the past fiscal year Reports are to be submitted to RSA within 90 days after the end of the fiscal year covered by this report. Please be remind ed that you can enter data directly into RSA’s website via the Internet. Information on transmittal of the form is found on pages 19 and 20 of the reporting instructions. Signature and title of designated agency official _______________________________ Date _______________________________ Paperwork Burden Statem ent: 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 -052 8. The time required to complete this information collection is estimated to average 6.25 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: U.S. Department of Education, Washington, DC 20202 - 2703. If you have comments or concerns regarding the status of your individual submission of this form, write directly to: OSERS/RSA, U.S. Department of Education, 550 12 th Street, S.W., Washington, DC 20202 - 2703.