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 i s 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. **I f**  **yo u have comments or concerns regarding**  **the status of y our individual submission of this form, write**  **directly to: Elizabeth A** **kinola** , U.S. De partment of Education, 400 Maryland Ave , S.W., PCP Room 5068, Washington, D.C. 20202
- 2800.

### TABLE OF CONTENTS

**PA RT I: FUNDING SOURCES FOR EXPENDITURES A**  **ND ENCUMB RA**  **NCES .........**  **1 PA**  **RT II: STA FFING**  **................................ ................................**  **................................ .......**  **2 PA**  **RT III: DA TA** 

**ON INDIVIDUA LS**  **SERVED ................................**  **................................ 3**  **PA RT IV: TYPES OF SERVICES PROVIDED A**  **ND RESOURCES A LLOCA** **TED ........**  **5 PA**  **RT V: COMPA RISON OF PRIOR YEA**  **R A CTIVITIES TO CURRENT REPORTED**  **YE AR**  **................................ ................................**  **................................ ..............................**  **6 PA**  **RT VI: PROGRA M OUTCOMES/PERFORMA**  **NCE ME AS**  **URES .............................**  **7 PA**  **RT VII: NA RRA** **TIVE ................................**  **................................ ................................**  **.. 9**  **PA RT VIII: SIGNA** **TURE ................................**  **................................ ...............................**  **11**1

**PA RT I: FUNDING SOURCES FOR EXPENDITURES A**  **ND ENCUMBRA NCES**  **Title VII -** **Chapter 2 federal grant award for reported fiscal y ear**  $ **Other federal grant award for reported fiscal y** **ear Will be entered**  **Title VII -** **Chapter 2 carryover from previous y ear**  $ **Other federal grant carry** **ov er from previous y** **ear 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. **TOTA L**  MATCHING FUNDS (A3+A4+A5) $ A7. **TOTA L**  ALL FUNDS EXPEN DED (A1+A2+A6) $ **B. Total expenditures and encumbrances allocated**  **to administrative, support staff, and general ov** **erhead costs** $ **C. Total expenditures and encumbrances for direct**  **program services** (Line A7 minus Line B) $2

**PA RT II: STA**  **FFING** FTE (full time equivalent) is based upon a 40
- hour workweek or 2080 hours per year. **A. Full**  **- time Equivalent (FTE)**  **Program Staff Ad**  **ministrative & Support**  **Direct**

**Service TOTA**  **L** A1. FTE State Agency a. b. c. A2. FTE Contractors a. b. c. A3. **TOTA L**  FTE (A1 + A2) a. b. c. **B. Employ** **ed or advanced in employ ment**  **No. employ ed**  **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. Employee s 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

**PA RT III: DA** **TA**

**ON INDIVIDUA**  **LS 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 .**  **INDIVIDUA LS**  **SERVED** A1. Number of individuals who began receiving servi ces 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. **TOTA L**  individuals served during the reported fiscal year (A1+ A2) **B. AG**  **E** 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. **TOTA L**  (Add B1 through B10, must agree with A3) **C. GENDER**  C1. Female C2. Male C3. **TOTA L**  (Add C1 + C2, must agree with A3) **D. RA** **CE/ETHN ICITY**  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 Isl ander, not Hispanic/Latino D6. Wh ite, 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. **TOTA L**  (Add D1 through D8, must agree with A3)) **E. DEGREE OF VISUA**  **L IMPA IRMENT**  E1. Totally Blind (LP only or NLP) E2. Legally Blind (excluding totally blind) E3. Severe Visual Impairment E4. **TOTA L**  (Add E1 through E3, must agree with A3) **F. MA** 

**JOR CA USE OF VISUA**  **L IMP AI**  **RMENT** F1. Macular Degene ration4

F2. Diabetic Retinopathy F3. Glaucoma F4. Cataracts F5. Other F6. **TOTA L**  (Add F1 through F5, must agree with A3) **G. OTHER A** **GE -**  **RELA TED IMPA** **IRMENTS** 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 L iving/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 REFERRA**  **L** 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

**PA RT IV: TYPES OF SERVICES PROVIDED A**  **ND RESOURCES A LLOCA** **TED** Provide data related to the number of older i ndividuals 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 As**  **sistive technology devices, aids, services**

**and training Cost**  **Persons Served**  B1a Total Cos t 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 A djustment training** 

**An d Services**  **Cost Persons**  **Serv ed**  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 servi ces, 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**  **Aw areness**  **Ac tiv**  **iti es/Information and Referral**  **Cost Events /**  **Ac tiv**  **ities Persons** 

**Served** D1a Total Cost from VII
- 2 funds D1b Total Cost from Other funds D2 Information and Referral (optional) D3 Community Awareness: Events/Activities6

**PA RT**  **V: COMPA**  **RISON OF**  **PRIOR YE**  **AR A** **CTIVITIES TO**  **CURRENT REPORTED**  **YE AR** 
**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

**PA RT VI: PROGRA** **M OUTCOMES/PERFORMA NCE ME**  **AS URES**  Provide the following data for each of the perf ormance measures below. This will assist RSA in reporting results and outcomes related to the program. **VI. PROGRA**  **M OUTCOMES/PERFORMA NCE**  **MEA SURES**  **Number of Persons**  **Percent of**

**Persons** A1. Number of individuals receiving AT (assistive technology) servi ces 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 th eir 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 servi ces 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. computed8

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 s erved 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 ser ved 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 reporte d 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) computed9

**PA RT VII: NA**  **RRA TIVE**  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.

**PA RT VIII: SIGNA** **TURE** P lease 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) Da te