FORM RSA-227 OMB NO. 1820- 0528

EXPIRES:

ANNUAL CLIENT ASSISTANCE PROGRAM (CAP) REPORT

Fiscal Year

DESIGNATED AGENCY IDENTIFICATION

Name: _______________________________

Address: _______________________________

E-mail Address (if applicable): _______________________________

Website Address (if applicable): _______________________________

Phone: __________

Toll-free Phone: __________

TTY: __________

Fax: __________

OPERATING AGENCY (IF DIFERENT FROM DESIGNATED 

AGENCY)

Name: _______________________________

Address: _______________________________

E-mail Address (if applicable): _______________________________

Website Address (if applicable): _______________________________

Phone: __________

Toll-free Phone: __________

TTY: __________

Fax: __________

Name of CAP Director/Coordinator: _______________________________

Person to contact regarding report: _______________________________

Contact Person's phone: _______________________________

PART I. NON-CASE SERVICES

A. Information 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 Activities

1. Number of training sessions presented to community groups 
 and public agencies. ______

2. Number of individuals who attended these training sessions ______

3. Describe training presented by the staff. Include the following 

information: 

(a) topics covered

(b) the purpose of the training

(c) a description of the attendees

C. Agency Outreach

Describe the agency’s outreach efforts to previously un-served or 

underserved individuals including minority communities

D. Information Disseminated To The Public By Your Agency

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 

publications/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 about CAP Featured in Newspaper/Magazine/Journals ______

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 (specify below) ______

E. Information Disseminated About Your Agency By External 

Media Coverage

Describe the various sources and information disseminated about 

your agency by an external source.

PART II. INDIVIDUAL CASE 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 individuals 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 a 
fiscal year. This number is not added to the total 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 between 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. Selection of training, post-secondary 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 ______

iii. Housing ______

iv. Other: ______

8. Related to Title I of the ADA ______

C. Intervention Strategies for closed cases 

(Choose one primary service the CAP provided for each closed 

case file. There may be more case files than actual individuals 

served.)

1. Short Term Technical Assistance ______

2. Investigation/Monitoring ______

3. Negotiation ______

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 reason 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 clients 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 ______

12. 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)

PART III.PROGRAM DATA

A. Age (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/Latino 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. White ______

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. Autism ______

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 Disorders/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.) ______

PART IV. SYSTEMIC ACTIVITIES AND LITIGATION

A. Non-Litigation Systemic Activities

1. Number of non-litigation systemic activities not involving 

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. Number 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 individual representation.

PART V. AGENCY INFORMATION

A. Designated Agency

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. External-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 Employed

Provide a description of all CAP positions (see instructions)
PART VI. CASE EXAMPLES

Provide some examples of some interesting cases 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 reminded 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 _______________________________

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