ED(RSA)-7-OB Form

OMB No. 1820-0608

Expiration Date: xx/xx/201x

UNITED STATES DEPARTMENT OF EDUCATION

OFFICE OF SPECIAL EDUCATION AND REHABILITATIVE SERVICES

REHABILITATION SERVICES ADMINISTRATION

Washington D.C. 20202

FISCAL YEAR

ANNUAL REPORT

INDEPENDENT LIVING SERVICES FOR

OLDER INDIVIDUALS WHO ARE BLIND

GRANTEE

GRANT NO.

Title VII Chapter 2, of the Rehabilitation Act, as amended

Section 752(I)(2)(A) of the Rehabilitation Act, as amended

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 OMB control number for this collection is 1820-0608. Public reporting 

burden for this collection of information is estimated to average 360 minutes/6 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 Sec. 752(i)(2)(A) of the 

Rehabilitation Act of 1973, as amended; Sec. 410, Pub. L. 105-220, Workforce Investment Act of 1998. 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 Ave., SW, Washington, DC 20210-4537 or email ICDocketMgr@ed.gov and 

reference the OMB Control Number 1820-0608. Note: Please do not return the completed ED RSA 7-OB application to this 

address. If you have comments or concerns regarding the status of your individual submission of this form, write 

directly to: Elizabeth Akinola, U.S. Department of Education, 400 Maryland Ave, S.W., PCP Room 5068, Washington, D.C. 

20202-2800.
TABLE OF CONTENTS

PART I: FUNDING SOURCES FOR EXPENDITURES AND ENCUMBRANCES ......... 1

PART II: STAFFING ....................................................................................................... 2

PART III: DATA ON INDIVIDUALS SERVED ................................................................ 3

PART IV: TYPES OF SERVICES PROVIDED AND RESOURCES ALLOCATED ........ 5

PART V: COMPARISON OF PRIOR YEAR ACTIVITIES TO CURRENT REPORTED 

YEAR .............................................................................................................................. 6

PART VI: PROGRAM OUTCOMES/PERFORMANCE MEASURES ............................. 7

PART VII: NARRATIVE.................................................................................................. 9

PART VIII: SIGNATURE............................................................................................... 11
1

PART I: FUNDING SOURCES FOR EXPENDITURES AND ENCUMBRANCES

Title VII-Chapter 2 federal grant award for reported fiscal year $

Other federal grant award for reported fiscal year Will be entered

Title VII-Chapter 2 carryover from previous year $

Other federal grant carryover from previous year Will be entered

A. Funding Sources for Expenditures and encumbrances 

in Reported FY

Expended or 

encumbered 

A1. Title VII-Chapter 2 $

A2. Total other federal (a)+(b)+(c)+(d)+(e) $

(a) Title VII-Chapter 1-Part B $

(b) SSA reimbursement $

(c) Title XX - Social Security Act $

(d) Older Americans Act $

(e) Other $

A3. State (excluding in-kind) $

A4. Third party $

A5. In-kind $

A6. TOTAL MATCHING FUNDS (A3+A4+A5) $

A7. TOTAL ALL FUNDS EXPENDED (A1+A2+A6) $

B. Total expenditures and encumbrances allocated 

to administrative, support staff, and general 

overhead costs $

C. Total expenditures and encumbrances for direct

program services

(Line A7 minus Line B) $
2

PART II: STAFFING

FTE (full time equivalent) is based upon a 40-hour workweek or 2080 hours per year.

A. Full-time Equivalent (FTE) 

Program Staff

Administrative 

& Support 

Direct 

Service TOTAL

A1. FTE State Agency a. b. c.

A2. FTE Contractors a. b. c.

A3. TOTAL FTE (A1 + A2) a. b. c.

B. Employed or advanced in employment No. employed FTE

B1. Employees with Disabilities (include blind and 

 visually impaired not 55 or older)

a. b.

B2. Employees with Blindness Age 55 and Older a. b.

B3. Employees who are Racial/Ethnic Minorities a. b.

B4. Employees who are Women a. b.

B5. Employees Age 55 and Older (not blind and 

 visually impaired)

a. b.

C. Volunteers

C1. FTE program volunteers (no. of volunteer hours ÷ 2080)
3

PART III: DATA ON INDIVIDUALS SERVED

Provide data in each of the categories below related to the number of individuals for 

whom one or more services were provided during the reported fiscal year.

A. INDIVIDUALS SERVED

A1. Number of individuals who began receiving services in the previous FY 

and continued to receive services in the reported FY 

A2. Number of individuals who began receiving services in the reported FY

A3. TOTAL individuals served during the reported fiscal year (A1+ A2)

B. AGE 

B1. 55-59

B2. 60-64

B3. 65-69

B4. 70-74

B5. 75-79

B6. 80-84

B7. 85-89

B8. 90-94

B9. 95-99

B10. 100 & over

B11. TOTAL (Add B1 through B10, must agree with A3)

C. GENDER

C1. Female

C2. Male

C3. TOTAL (Add C1 + C2, must agree with A3)

D. RACE/ETHNICITY

D1. Hispanic/Latino of any race or Hispanic/ Latino only 

D2. American Indian or Alaska Native, not Hispanic/Latino

D3. Asian, not Hispanic/Latino 

D4. Black or African American, not Hispanic/Latino 

D5. Native Hawaiian or Other Pacific Islander, not Hispanic/Latino 

D6. White, not Hispanic/Latino 

D7. Two or more races, not Hispanic/Latino

D8. Race and ethnicity unknown, not Hispanic/Latino (only if consumer 

refuses to identify)

D9. TOTAL (Add D1 through D8, must agree with A3))

E. DEGREE OF VISUAL IMPAIRMENT 

E1. Totally Blind (LP only or NLP)

E2. Legally Blind (excluding totally blind)

E3. Severe Visual Impairment

E4. TOTAL (Add E1 through E3, must agree with A3)

F. MAJOR CAUSE OF VISUAL IMPAIRMENT 

F1. Macular Degeneration
4

F2. Diabetic Retinopathy

F3. Glaucoma

F4. Cataracts

F5. Other

F6. TOTAL (Add F1 through F5, must agree with A3)

G. OTHER AGE-RELATED IMPAIRMENTS

G1. Hearing Impairment

G2. Diabetes 

G3. Cardiovascular Disease and Strokes

G4. Cancer

G5. Bone, Muscle, Skin, Joint, and Movement Disorders

G6. Alzheimer’s Disease/Cognitive Impairment

G7. Depression/Mood Disorder

G8. Other Major Geriatric Concerns

H TYPE OF RESIDENCE 

H1. Private residence (house or apartment)

H2. Senior Living/Retirement Community

H3. Assisted Living Facility

H4. Nursing Home/Long-term Care facility

H5. Homeless 

H6 TOTAL (Add H1 through H5, must agree with A3)

I. SOURCE OF REFERRAL

I1. Eye care provider (ophthalmologist, optometrist)

I2. Physician/medical provider

I3. State VR agency

I4. Government or Social Service Agency 

I5. Veterans Administration

I6. Senior Program

I7. Assisted Living Facility

I8. Nursing Home/Long-term Care facility

I9 Faith-based organization

I10 Independent Living center

I11. Family member or friend

I12 Self-referral

I13. Other

I14. TOTAL (Add I1 through I13, must agree with A3)
5

PART IV: TYPES OF SERVICES PROVIDED AND RESOURCES ALLOCATED

Provide data related to the number of older individuals who are blind receiving each 

type of service and resources committed to each type of service.

A Clinical/functional vision assessments and 

services

Cost Persons 

Served

A1a Total Cost from VII-2 funds 

A1b Total Cost from Other funds

A2 Vision screening / vision examination / low vision 

evaluation

A3 Surgical or therapeutic treatment to prevent, 

correct, or modify disabling eye conditions

B Assistive technology devices, aids, services 

and training

Cost Persons 

Served

B1a Total Cost from VII-2 funds 

B1b Total Cost from Other funds

B2 Provision of assistive technology devices and aids

B3 Provision of assistive technology services and 

training .

C Independent Living And Adjustment training 

And Services

Cost Persons 

Served

C1a Total Cost from VII-2 funds 

C1b Total Cost from Other funds

C2 Orientation and Mobility training

C3 Communication skills 

C4 Daily living skills

C5 Supportive services (reader services, 

transportation, personal attendant services, support 

service providers, interpreters, etc)

C6 Advocacy training and support networks

C7 Counseling (peer, individual and group)

C8 Information, referral and community integration 

C9 Other IL services 

D Community Awareness 

Activities/Information and Referral

Cost Events / 

Activities

Persons 

Served

D1a Total Cost from VII-2 funds 

D1b Total Cost from Other funds

D2 Information and Referral (optional)

D3 Community Awareness: Events/Activities
6

PART V: COMPARISON OF PRIOR YEAR ACTIVITIES TO CURRENT REPORTED 

YEAR

Prior FY

Reported 

FY

Change

(+ / -)

A1. Program Cost (all sources) a. b. c.

A2. Number of Individuals Served a. b. c.

A3. Number of Minority Individuals Served a. b. c.

A4. Number of Community Awareness

Activities a. b. c.

A5. Number of Collaborating agencies and 

Organizations (other than sub-grantees) a. b. c.

A6. Number of Sub-grantees a. b. c.
7

PART VI: PROGRAM OUTCOMES/PERFORMANCE MEASURES

Provide the following data for each of the performance measures below. This will assist 

RSA in reporting results and outcomes related to the program.

VI. PROGRAM OUTCOMES/PERFORMANCE 

MEASURES

Number of 

Persons

Percent of 

Persons

A1. Number of individuals receiving AT (assistive 

technology) services and training (must be same as 

Part IV B3).

Computed computed

A2. Number of individuals receiving AT (assistive 

technology) services and training who maintained or 

improved functional abilities that were previously lost or 

diminished as a result of vision loss. (closed/inactive 

cases only)

computed

A3. Number of individuals for whom functional gains have 

not yet been determined at the close of the reporting 

period.

computed

B1. Number of individuals who received orientation and 

mobility (O & M) services (must be same as Part IV 

C2).

Computed computed

B2. Of those receiving orientation and mobility (O & M) 

services, the number of individuals who experienced 

functional gains or maintained their ability to travel 

safely and independently in their residence and/or 

community environment as a result of services. 

(closed/inactive cases only)

computed

B3. Number of individuals for whom functional gains have 

not yet been determined at the close of the reporting 

period.

computed

C1 Number of individuals who received communication 

skills training. (must be same as Part IV C3)

Computed Computed

C2 Of those receiving communication skills training, the 

number of individuals who gained or maintained their 

functional abilities as a result of services they received. 

(Closed/inactive cases only)

computed

C3 Number of individuals for whom functional gains have 

not yet been determined at the close of the reporting 

period.

computed
8

D1 Number of individuals who received daily living skills 

training (must be same as Part IV C4).

Computed computed

D2. Number of individuals that experienced functional gains 

or successfully restored or maintained their functional 

ability to engage in their customary daily life activities as 

a result of services or training in personal management 

and daily living skills. (closed/inactive cases only)

computed

D3. Number of individuals for whom functional gains have 

not yet been determined at the close of the reporting 

period.

computed

E1. Number of individuals served who reported feeling that 

they are in greater control and are more confident in 

their ability to maintain their current living situation as a 

result of services they received. (closed/inactive cases 

only)

computed

E2. Number of individuals served who reported feeling that 

they have less control and confidence in their ability to 

maintain their current living situation as a result of 

services they received. (closed/inactive cases only)

Computed

E3. Number of individuals served who reported no change 

in their feelings of control and confidence in their ability 

to maintain their current living situation as a result of 

services they received. (closed/inactive cases only)

Computed

E4. Number of individuals served who experienced changes 

in lifestyle for reasons unrelated to vision loss. 

(closed/inactive cases only) 

Computed

E5. Number of individuals served who died before achieving 

functional gain or experiencing changes in lifestyle as a 

result of services they received. (closed/inactive cases 

only) 

computed
9

PART VII: NARRATIVE

A. Briefly describe the agency’s method of implementation for the Title VII-Chapter 

2 program (i.e. in-house, through sub-grantees/contractors, or a combination) 

incorporating outreach efforts to reach underserved and/or unserved populations. 

Please list all sub-grantees/contractors.

B. Briefly describe any activities designed to expand or improve services including 

collaborative activities or community awareness; and efforts to incorporate new 

methods and approaches developed by the program into the State Plan for 

Independent Living (SPIL) under Section 704.
10

C. Briefly summarize results from any of the most recent evaluations or satisfaction 

surveys conducted for your program and attach a copy of applicable reports.

D. Briefly describe the impact of the Title VII-Chapter 2 program, citing examples 

from individual cases (without identifying information) in which services 

contributed significantly to increasing independence and quality of life for the 

individual(s).
11

E. Finally, note any problematic areas or concerns related to implementing the Title 

VII-Chapter 2 program in your state.

PART VIII: SIGNATURE

Please sign and print the name, title and telephone number of the IL-OIB Program 

Director below.

I certify that the data herein reported are statistically accurate to the best of my 

knowledge.

Name (Printed) Title Telephone Number

Name (Signature) Date