**AN NUA**  **L PERFORMANCE REPORTING FORM**

**For the A merican Indian Vocational Rehabilitation Services Program** 

**OMB #: 1820 -**  **0655 Expiration Date: XX/XX/XXXX** 

# T **h e**  **U .**  **S .**  **D e**  **p a**  **r t**  **m e**  **n t**  **o f**  **E d**  **u c**  **a t**  **i o**  **n** Rehabilitation Services Administration (RSA) **An nual R**  **eporting 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 inform ation 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 com pleting and reviewing the collection of information. The obligation to respon d 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 Educ ation, 400 Maryland Avenue, S W, W ashington, 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 W ith Disabilities ................................ ................................ .......... 8 4. VR Services ................................ ................................ ................................ ......................... 9 5. Educational Goals and Employment Out comes ................................ ................................ . 10 6. Job Training Common Measures ................................ ................................ ...................... 13 7. Interaction with State VR Agency ................................ ................................ ....................... 15 8. Evaluation ................................ ................................ ................................ .......................... 17 9. Consumer Satisfaction ................................ ................................ ................................ ....... 183



## 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:
* P roject 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: **Au thorized representative:** 
* Name:
* Title:
* Telephone:

* E - mail: Note: The ED 524B form with an original signature from the Authorized Re presentative is required to be submitted.5



## 1. **Budget and Narrati ve**  **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.**  Wa s an Order of Selection in effect and approved by RSA for any time during the reporting pe riod? 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 carry over funds? Enter N/A for six- month and first year reports. Yes No NA
**3b.** If yes, enter the dollar amount. **$ 3c.**  We re there carry- ov er 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- ov er funds. If the amount of carry - over funds is not yet available, estimate the amount of carry- ov er 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- ov er 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 a mount 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 th e 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 change s 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.** Wa s the modification(s) a pproved by RSA? If yes, skip to Section 2, Project Goals and Objectives. Yes No **$ $** 7



## 2. **Project Goals and Objectiv es**  **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** 

**(y yyy)**  **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.) **Ad d a Goal** 8



## 3. **Serv ing A**  **merican Indians with Disabilities** Questions 1 – 4 ask for details on individuals who were served during the reporting period. **1.** Enter th e 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 perio d. **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 Serv ices** 

 “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 nu mber 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 - train ing/apprenticeship **4e.** completed any other job - related training. Describe any other job - related training from 4e above:11

**Part B. Employ ment Outcomes**  Definition:

 Employment Outcome: The term "employ ment outcome" means, with res pect to an individual -- entering or retaining full - time or, if appropriate, part - time competitive employ ment in the integrated labor market; satisfying the vocational outcome of supported employ

ment; or satisfying any other vocational outcome the Secretary may determine to be appropriate (including satisfying the vocational outcome of selfemploy ment, telecommuting, or business ownership), in a manner consistent with the Rehabilitation Act of 1973, as amended. An individual is considered to have achieved a n employ ment outcome after the individual has ended participation in the program by maintaining the emplo yment outcome for 90 days and no longer requires VR services. Post - employ

ment services are provided subsequent to achievement of an employ ment 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 ou tcome. 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 outco me 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) o f 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 propo sed 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 witho ut 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 achiev ed 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 employme nt 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 sel f- 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 representati ve 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 outcome s 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 employ ment 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 employe d 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 determ ined eligible, and received VR services in the current reporting period.15



## 7 **Interaction w ith State VR**  **Ag ency or**  **Ag encies**  **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 th e “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 Advisor y 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 informa tion is for use by RSA and is held confidential.

**Ag ency** **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**  **Dissatisfie d**  **2 Somewhat**  **Dissatisfied 3**  **Neutral 4**  **Somewhat**16 **Satisfied 5**  **Very Satisfied**  **Ag ency** **Name Discussion**  A. Agency: B. Types of Interactions: C. Successes/Concerns/Issues with Collaboration or Serv ice 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 A gency17



## 8. **Ev aluation**  **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 reportin g 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 a nd 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. We re any consumer satisfaction activities proposed to be conducted during the reporting period ? Yes No 2. We re 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.