Page 1 of 3 **Form RSA -**  **2 OMB Number: 1820**  **- 0017**  **Expires: xx/xx/xxx U.S.**  **Department of Education O**  **ffice of Special Education and Rehabilitative Services Rehabilitation Services Administration**  **ANNUAL VOCATIONAL REHABILITATION PROGRAM/COST REPORT (RSA**  **- 2)**  State: ___________________________________ Fiscal Year: ___________________ Agency : ________________________________ [ ] Blind [ ] Combined [ ] General **S CHEDULE I**  **: Agency Expenditures**  **Line Items Am**  **ount 1. Administration Expenditures**  A. Administration Personnel Costs $ B. Direct Administration Costs $ C
. Indirect Costs $ D
. Administration Expenditures for the SE Program Included in 1
. A, 1.B and 1.C **$ 2**  **. Service Expenditures**  **A. Services**  **Provided by Agency 1.**  **Services Provided by Agency Field Office Staff** a . Assessment, Counseling, Guidance, and Placement Costs $ b
. A ll other services, including Orientation, Mobility and Rehab Teaching/Training Services Costs $ **2. Services Provided by Agency**  **- Operated Community Rehabilitation**  **Program (CRP) Staff**  a . Assessment, Counseling, Guidance, and Placement Costs $ b
. A ll other services, including Orientation, Mobility and Rehab Teaching/Training Services Costs $ **B. Services Purchased by**  **Agency From**  **:** 1. Public Community

Rehabilitation Programs $ 2. Private Community

Rehabilitation Programs $ 3. Other Public Vendors $ 4. Other Private Vendors $ **3 . Services**  **to Groups**  **Expenditures** A. Establishment, Development or Improvement of CRPs $ B. Construction of Facilities fo r CRPs $ C. Business Enterprise Program $ D. Transition Consultation and Technical Assistance $ E
. All other services to groups $ **4 .**  **Total Agency Expenditures** A. Total SE Program Expenditures included in Sections 1, 2 and 3 above $ B. Total Innovation and Expansion Activity Costs included in 1, 2 and 3 above $Page 2 of 3 **Form RSA -**  **2 OMB Number: 1820**  **- 001**  **7 SCHEDULE II:**  **Labor Hours Staff Function Category**  **Labor Hours** 1. Administrative Staff 2. Counselor Staff 3. Staff Supporting Counselor Activities 4. Other Staff 5. Number of hour s per week considered full time in state. **SCHEDULE III: Number of Individuals Served and Purchased Service Expenditures**  **by Service**

**Category Service Category**  **Number of Individuals**  **Am ount**  1. Assessment $ 2. Diagnosis and Treatment of Impairments $ 3. Vocational Rehabilitation Counseling and Guidance $ 4. Graduate College or University Training $ 5. Four
- Year College or University Training $ 6. Junior or Community College Training $ 7. Occupational or Vocational Training $ 8. On
- the

-

job Training $ 9. Apprenticeship Training $ 10. Basic Academic Remedial or Literacy Training $ 11. Job Readiness Training $ 12. Disa bility Related Skills Training $ 13. Miscellaneous Training $ 14. Job Search Assistance $ 15. Job Placement Assistance $ 16. On
- the

-

job Supports

– Time

- limited $ 17. On
- the

-

job Supports

– Supported Employ ment $ 18. Transportation $ 19. Maintenance $ 20. Rehabilitation Technology $ 21. Reader $ 22. Interpreter $ 23. Personal Attendant $ 24. Technical Assistance $ 25. In formation and Referral $ 26. Benefits Counseling $ 27. Customized Employ

ment $ 28. Other $Page 3 of 3 **Form RSA -**  **2 OMB Number: 1820**  **- 0017**  **S CHEDULE III:**  **Number of Individuals Served and Purchased Service Expenditures by Service**

**Category -**  **Continued 29. Total Purchased Services Expenditures**  A. Total SE P rogram Service E xpenditures included in Schedule III above $ **3 0**  **. Certification:**  By

s igning this report, I certify that it is true, complete, and accurate to the best of my knowledge. I am aware that any f alse, fictitious, or fraudulent information may s ubject me to criminal, civil, or administrative penalties. (U.S. Code, Title 18, S ection 1001) A. Ty ped or Printed Name and Title of Authorized Certifying Official B. Telephone (Area code, number and extension): C. Email Address: D. Signature of Authorized Certifying Official E. Date Report Submitted (Month, Day , Year): **Public Burden Statement:** According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection display s a valid OMB control number. Public reporting burden for this collection of information is estimated to average 4 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 (Rehabilitation Act of 1973, as amended) . 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, W ashington, DC 20210

- 4537 or email ICDocketMgr@ed.gov and reference the OMB Control Number 1820
- 0017 . Note: Please do not return the completed RSA
- 2 Form to this address.