ANNUAL PERFORMANCE REPORTING FORM

For the American Indian Vocational Rehabilitation Services Program

OMB #: 1820-0655

Expiration Date: XX/XX/XXXX
The U.S. Department of Education

Rehabilitation Services Administration (RSA)

Annual Reporting Form

For

American Indian Vocational Rehabilitation Services Program

OMB Number: 1820-0655

Expiration Date: xx/xx/xxxx

PR/Federal Award Number:

(Type in your PR/Award number exactly as it appears on your Grant Award 

Notification.)

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 displays a valid OMB control number. Public reporting burden for this 

collection of information is estimated to average 12.5 hours per response, including the time for reviewing 

instructions, searching existing data resources, 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 75.118). 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 Avenue, SW, Washington, DC, 20210-4536 or email 

ICDocketMgr@ed.gov and reference the OMB Control Number 1820-0655. Note: Please do not return 

the completed Annual Reporting Form for American Indian Vocational Rehabilitation Services to this 

address.
Table of Contents

Section Page

General Information ....................................................................................................................3

1. Budget and Narrative...........................................................................................................5

2. Project Goals and Objectives...............................................................................................7

3. Serving American Indians With Disabilities ..........................................................................8

4. VR Services.........................................................................................................................9

5. Educational Goals and Employment Outcomes.................................................................10

6. Job Training Common Measures ......................................................................................13

7. Interaction with State VR Agency.......................................................................................15

8. Evaluation..........................................................................................................................17

9. Consumer Satisfaction.......................................................................................................18
3

General Information

* Required fields

*Grantee Name:

*Grantee Address:

*City:

*State:

*Zip:

*Grant Start, First 

Year:

10/1/####

*Grant End, Final 

Year:

9/30/####

*Project Title:

*Project Director:

*Telephone:

*E-mail:

Grantee URL

(if applicable):

Grantee/Project 

E-mail (if applicable):

Grantee 800 Number 

(if applicable):
4

Person responsible for completing this form (if other than the project 

director/principal investigator):

*Name:

*Title:

*Telephone:

Fax:

*E-mail:

Authorized representative:

*Name:

*Title:

*Telephone:

*E-mail:

Note: The ED 524B form with an original signature from the Authorized Representative 

is required to be submitted.
5

1. Budget and Narrative

1a. Enter the grant amount awarded by RSA for the entire 

fiscal year for this reporting period. Do not include 

carry-over funds. $

1b. Enter the match contribution for this reporting 

 period. $

1c. The sum of 1a plus Line 1b equals the total 

 cost of the project. $

2. Was an Order of Selection in effect and approved by 

RSA for any time during the reporting period? 

An Order of Selection consists of priority categories that 

determine the order in which eligible individuals are 

provided vocational rehabilitation (VR) services, in the 

event that sufficient fiscal or personnel resources are 

unavailable to provide VR services to all eligible 

individuals who apply. Eligible individuals are assigned 

to priority categories based on the significance of their 

disability and individuals with the most significant 

disabilities are placed in the highest priority category.

Yes No

3a. Did the reporting period start with any carryover funds? Enter N/A for six-month and 

first year reports.

Yes No NA

3b. If yes, enter the dollar amount. $

3c. Were there carry-over funds at the end of the 

reporting period? Enter N/A for six-month 

reports.

Yes No N/A

3d. If yes, enter the dollar amount of carry-over funds. If 

the amount of carry-over funds is not yet available, 

estimate the amount of carry-over funds. $

3e. Use the box below to explain why there are carry-over funds and the reason for not 

expending funds at the rate expected. (NOTE: Discuss the use of any carry-over 

funds with your assigned ED program Contact.) If there are no carry-over funds, 

enter “None” in the box.
6

4a. Enter any program income generated for the reporting 

period. Enter 0 (zero) if none.

4b. Enter the total amount of cash funding in support of the 

 grant received during the reporting period from sources other 

than program income (4a), grant award (1a), or match

 contribution (1b). Enter 0 (zero) if no other funding was provided.

4c. List the full name of the source(s) of any other cash funding identified in 4b. If there 

are no other sources, enter “None” in the box.

5c. If the answer is no, use this space to describe the modification(s) and the resulting 

budget changes.

5a. During the reporting period, were changes made to 

the budget due to programmatic changes? 

Examples of programmatic changes under 34 CFR 

80.30 (d)(1)-(4) include revision of the scope or 

objectives of the project and changes in key 

personnel. If no, skip to Section 2, Project Goals 

and Objectives.

Yes No

5b. Was the modification(s) approved by RSA? If yes, skip 

 to Section 2, Project Goals and Objectives. Yes No

$

$
7

2. Project Goals and Objectives

Goal Start Date

(Month/Year) Goal End Date

(Month/Year)

Goal #1: Expected Date of 

Completion

Status of Objective for 

Current Year

Month 

(mm)

Year 

(yyyy)

Status Options:

Not Started, Dropped, In 

Progress, Met, Not Met

Obj.1. (Select One.)

2. (Select One.)

3. (Select One.)

4. (Select One.)

5. (Select One.)

6. (Select One.)

7. (Select One.)

8. (Select One.)

9. (Select One.)

10. (Select One.)

Add a Goal
8

3. Serving American Indians with Disabilities

Questions 1 – 4 ask for details on individuals who were served during the reporting 

period.

1. Enter the total number of individuals the project proposed

to serve under an Individualized Plan for Employment 

(IPE) during the reporting period.

2a. Enter the number of individuals who received VR 

services under an IPE developed during this reporting 

period.

2b. Enter the number of individuals who received VR 

services under an IPE developed prior to this reporting 

period. 

2c The total actual number of individuals who received VR 

services under an IPE during the reporting period.

3. This percentage is based on the ratio of the number of 

individuals the project had proposed to serve compared to 

the number of the individuals the project actually served 

during the reporting period.

4. In the box below, please explain if:

4a. The number actually served is substantially fewer 

than the number proposed for this reporting period; or 

4b. The number actually served substantially exceeds 

the number proposed for this reporting period.
9

4. VR Services

 “VR Services provided” means VR services provided by project staff, purchased 

with any type of project funds, or procured from another source, such as 

comparable/similar services.

 List the VR services provided during the reporting period in accordance with 

Section 103(a) and 103(b) of the Rehabilitation Act of 1973, as amended, that 

were paid for in full by AIVRS funds.

 List the VR services provided during the reporting period in accordance with 

Section 103(a) and 103(b) of the Rehabilitation Act of 1973, as amended, that 

were paid for in part or in full with funds other than AIVRS funds.
10

5. Educational Goals and Employment Outcomes

Part A. Educational Goals

 Educational goals are for the purpose of increasing the skills needed for 

achieving an employment outcome consistent with the IPE.

Enter the number of individuals who were enrolled in an educational program during 

the reporting period.

1. Enter the number of individuals enrolled in a two-year

post-secondary education program.

2. Enter the number of individuals enrolled in a four-year 

post-secondary education program.

3. Enter the number of individuals enrolled in one or more training 

programs.

Enter the number of individuals who achieved an educational goal consistent with their 

IPE. Include those who achieved one or more of the following educational goals during 

the reporting period, whether or not they ended their participation in the program.

4. Enter the total number who achieved an educational goal 

Of the total number entered in Question 4, how many: 

4a. obtained a GED

4b. obtained a post-secondary degree

4c. obtained a post-secondary certificate

4d. completed on-the-job-training/apprenticeship

4e. completed any other job-related training.

Describe any other job-related training from 4e above:
11

Part B. Employment Outcomes

Definition:

 Employment Outcome: The term "employment outcome" means, with respect to an 

individual-- entering or retaining full-time or, if appropriate, part-time competitive 

employment in the integrated labor market; satisfying the vocational outcome of 

supported employment; or satisfying any other vocational outcome the Secretary may

determine to be appropriate (including satisfying the vocational outcome of selfemployment, telecommuting, or business ownership), in a manner consistent with the 

Rehabilitation Act of 1973, as amended. An individual is considered to have achieved an 

employment outcome after the individual has ended participation in the program by

maintaining the employment outcome for 90 days and no longer requires VR services. 

Post-employment services are provided subsequent to achievement of an employment 

outcome and are not considered an additional outcome.

1. Enter the number of individuals the project proposed to achieve an 

 employment outcome during the reporting period.

2. Enter the actual number of individuals who achieved an employment 

 outcome. If the answer is none, enter a zero (0) in the box and go to 

item #3.

Of those individuals in #2 above who achieved an employment outcome, enter the 

number:

2a. Employed full-time in the integrated labor market at or above 

the applicable minimum wage for 32 or more hours per week.

2b. Employed part-time in the integrated labor market at or above 

the applicable minimum wage for 31 or fewer hours per week.

2c. Achieved an employment outcome of self-employment

2d. Achieved an employment outcome of extended employment 

in

a community rehabilitation program (extended employment defined in 

Section 7(13) of the Rehabilitation Act of 1973).

2e. Achieved an employment outcome in supported 

employment (supported employment defined in Section 7(35) 

of the Rehabilitation Act of 1973).

2f. Achieved any other type of employment outcome e.g., 

homemaking, subsistence activities, unpaid work on a family 

farm or business.
12

3. This percentage is based on the ratio of those individuals who the project had 

proposed to achieve an employment outcome divided by the individuals who 

actually achieved an employment outcome. 

 

4. Enter Number of individuals who received VR services under an IPE 

but ended participation in the program during the reporting period 

without achieving an employment outcome (formerly Status 28).

5. In the box below, please explain if:

5a. The number of employment outcomes achieved is substantially fewer than 

proposed for this reporting period; or 

5b. The number of employment outcomes achieved substantially exceeds the 

number proposed for this reporting period. 
13

6. Job Training Common Measures

Data entered in this section is used to provide supplemental information for reporting 

on the Job Training Common Measures.

Goal: To improve employment outcomes of American Indians with 

disabilities who live on or near reservations by providing effective 

VR services.

Objective: To ensure that eligible American Indians with disabilities receive VR 

services and achieve employment outcomes consistent with their 

individual strengths, resources, abilities, capabilities, priorities, 

concerns, and informed choice.

Definition:

 Earnings: The amount of money earned in a typical week, including cash 

earnings and profits derived by self-employed individuals. In certain cases, 

earnings may be based on payment of commissions and reimbursement of 

business expenses that may or may not occur on a regular or weekly basis. In 

these cases, calculate the weekly average income over a representative time 

period, such as one month.

Enter the appropriate number for each question and for questions that ask for a dollar 

amount, round the amount to the nearest dollar and do not enter cents.

1. Enter the number of individuals whose employment outcomes resulted in 

earnings.

2. Of those individuals entered in #1 above,:

2a. enter the number of individuals who had earnings at the time of being 

determined eligible 

2b. enter the average weekly earnings for those individuals who had earnings at

the time of being determined eligible

2c. enter the number of individuals who had earnings at the time of achieving an 

employment outcome 

2d. enter the average weekly earnings for those individuals who had earnings at 

the time of achieving an employment outcome 

2e. This is the average weekly change in earnings from eligibility determination to 

achieving an employment outcome (2d above minus 2b above) 

$

$
14

3. Enter the number of individuals who during this reporting period, were still 

employed three months after achieving an employment outcome (formerly ‘Status 

26’).

4. Enter the number of individuals who during this reporting period, were still 

employed six months after achieving an employment outcome (formerly ‘Status 

26’). 

5. Enter the number of individuals who received post-

 employment services in the current reporting period. 

6. Enter the number of individuals who achieved an employment outcome 

during the current or prior reporting period, but have reapplied, were 

determined eligible, and received VR services in the current reporting period.
15

7 Interaction with State VR Agency or Agencies

1. During the reporting period, was a collaborative 

agreement entered into or participated in with the 

State VR Agency or Agencies? 

 Yes No

2. Of the number of individuals served under an IPE during this reporting 

 period, how many were jointly served with the State VR Agency or 

 Agencies?

List the interactions with the State VR Agency or State VR Agencies during the 

reporting period. List the state name and agency (Combined/General/Blind; e.g, Utah 

Combined). Space is provided for each interaction with up to two Agencies. If 

additional State VR Agencies need to be added, please click the “Add an Agency” 

button at the bottom of this section. If additional space is needed, feel free to utilize 

space in the Executive Summary of the 524B form.

For each agency listed:

A. List the State VR Agency the Tribe interacted with during the reporting period.

B. Describe or give examples of interactions including, but not limited to, 

training/cross training; serving on the State Rehabilitation Council; working jointly 

with the same individual; referrals; or having a VR representative on the project 

Advisory Board.

C. Describe or give examples of concerns or issues such as a lack of a cooperative 

agreement or non-representation on the State Council. If no concerns exist, enter 

“None”.

D. Rate the overall satisfaction of interactions with the agency. 

This information is for use by RSA and is held confidential.

Agency Name Discussion

A. Agency: 

B. Types of Interactions:

C. Successes/Concerns/Issues with 

Collaboration or Service Provision:

D. On a scale of 1 to 5, rate the level of 

satisfaction of interactions with this 

agency:

1

Very

Dissatisfied

2

Somewhat

Dissatisfied

3

Neutral

4

Somewhat
16

Satisfied

5

Very

Satisfied

Agency Name Discussion

A. Agency: 

B. Types of Interactions:

C. Successes/Concerns/Issues with 

Collaboration or Service Provision:

D. On a scale of 1 to 5, rate the level of 

satisfaction of interactions with this 

agency:

1

Very

Dissatisfied

2

Somewhat

Dissatisfied

3

Neutral

4

Somewhat

Satisfied

5

Very

Satisfied

 Add an Agency
17

8. Evaluation

A. Briefly describe self-evaluation efforts of the project and the results of those efforts 

for the reporting period. 

B. Briefly describe any other independent evaluation effort and results for the reporting 

period. If none were conducted, enter “none.”

C. List future evaluation plans. If none were planned, enter “none.”

D. Describe the most effective activities and services provided in meeting project goals 

and why they were effective. Examples include developing new approaches for 

service provision, native healing, advisory board activities, outreach, collaboration 

with a particular state rehabilitation counselor or administrator, or being involved with 

the one-stop program.
18

9. Consumer Satisfaction

This section refers to activities conducted for the purpose of determining consumer 

satisfaction with project services. 

1. Were any consumer satisfaction activities proposed to be 

conducted during the reporting period?

Yes No

2. Were any consumer satisfaction activities actually conducted 

during the reporting period? 

(The information provided in this section is for use by RSA and 

is held confidential.)

If yes, describe in the box below the types of consumer 

satisfaction activities conducted during the reporting period.

Yes No

If no, but consumer satisfaction activities were proposed to be conducted in the 

reporting period, explain in the box why activities were not conducted.