ED(RSA)
- 7
- OB Form
- Instructions OMB No. 1820
- 0608 Expiration Date: May 31, 201 4 

# UNITED STATES DEPARTMENT OF

**EDUCATION**

OFFICE OF SPECIAL EDUCATION AND REHABILITATIVE SERVICES REHABILITATION SERVICES ADMINISTRATION

Wa shington D.C. 20202 FISCAL YEA R 

### INDEPENDENT LIVING SERVICES FOR OLDER INDIVIDUALS WHO ARE BLIND ANNUAL REPORT INSTRUCTIONS
**Title VII Chapter 2, of the Rehabilitation A ct, as amended**  **Section 752(I)(2)(A ) of the Rehabilitation A** **ct, 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 informatio n 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 mandatory Sec. 752(i)(2)(A) of the Rehabilitation Act of 1973, as amended /required to obtain or retain benefit Sec. 410, Pub. L. 105
- 220, W orkforce Investment Act of 1998 and voluntary. Send comments regarding the burden es timate 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 ICDocketMg r@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 y ou have comments or concerns regarding**  **the status of y our individual**  **submission of this form, write directly to:**  **Elizabeth A kinola**  , U.S. Department of Education, 400 Maryland Ave , S.W ., PCP Room 5068, Washington, D.C. 20202
- 2800.II 

### TA **BLE OF CONTENTS**

INTRODUCTION

................................ ................................ ................................ ............ III SUBMITTAL INSTRUCTIONS

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

–

INSTRUCTIONS

................................ ................................ ............................. V PART II: STAFFING

– INSTRUCTIONS

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

– INSTRUCTIONS

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

–

INSTRUCTIONS

................................ ................................ ......................... XIV PART V: COMPARISON OF PRIOR YEAR ACTIV ITIES TO CURRENT REPORTED

YEAR

– INSTRUCTIONS

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

– INSTRUCTIONS

................................ ................................ ................................ .................. XVIIIIII



### Introduction The revised ED RSA
- 7
- OB form incorporates revisions to the four established performance measures for the I ndependent Living Services for Older Individuals who are Blind (IL
- OIB) program. Added in 2007, these measures aim to better reflect the program’s impact on individual consumers and the community. Added to capture information that may be required to meet GPRA guidelines, the performance measures can be found under Part VI: Program Outcomes/Performance Measures as follows: Measure 1.1 Of individuals who received AT (assistive technology) services and training, the percentage who regained or improved functional abilities previously lost as a result of vision loss. Measure 1.2 Of individuals who received orientation and mobility (O & M) services, the percentage who experienced functional gains or maintained their ability to travel safely and independently in their home and/or community environment. Measure 1.3 Of individuals who received services or training in alternative non
-visual or low vision techniques, the percentage that experienced functional gains or were able to successfully restore and maintain their functional ability to engage in their customary life activities within their home environment and community. Measure 1.4 Of the total individuals served, the percentage that reported that they are in greater control and are more confident in their ability to maintain their current living situation as a result of services. Revisions to these established program performance measures consists of the following additional five items: E1. Enter the 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) E2. E nter the n umber of individuals served who reported feeling that they ha ve less control and confidence in their ability to maintain their current living situation as a result of services they received (closed/inactive cases only) E3. E nter the n umber of individuals served who reported no change in their feelings of control a nd confidence in their ability to maintain their current living situation as a result of services they received (closed/inactive cases only)IV

E4. Enter the n umber of individuals served who experienced changes in lifestyle for reasons unrelated to vision lo ss. (closed/inactive cases only) E5. Enter the 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)


### Submittal Instructions OIB g rantees are expected to complete and submit the 7
- OB Report online through RSA’s Management Information System (MIS), unless RSA is notified of pertinent circumstances that may impede the online submission. To register with RSA’s MIS, please go to http://www.ed.gov/rschstat/eval/rehab/rsamis/rsamis_help_pg2.html . The Getting Started link provides instructions for obtaining an agency
- specific username and password. Further i nstructions for completing and submitting the 7
- OB Report online will be provided upon completion of the registration process. OIB grantees submitting the 7
- OB Report online are not required to mail signed copies of the 7
- OB Report to RSA, but they must certify in the MIS that the signed and dated 7
- OB Report and lobbying certification forms are retained on file. The Report submittal deadline is no later than December 31 of the reporting year.V

**PA RT I: FUNDING SOURCES FOR EXPENDITURES A**  **ND ENCUMBRA NC**  **ES –**  **INSTRUCTIONS** PLEASE NOTE : Total expenditures and encumbrances for direct program services in Part I (C) must equal the total funds spent on services in Part IV. Part I C must equal the sum of Part IV A1+B1+C1+D1. TITLE VII
- CHAPTER 2 FEDERAL GRANT AWA RD FOR REPORTED FI SCAL YEAR Enter the total amount of your Title VII
- Chapter 2 Grant Award for the reported Federal Fiscal Year (FY). Other **federal grant award for reported fiscal y ear**  Enter the total amount of any other **federal grant award y ou received**  **for the reported fiscal y** **ear** TITLE VII
- CHAPTER 2 CARRYOVER FROM PREVIOUS YEAR Enter any chapter 2grant carryover amount from the previous FY that was expended or encumbered in the reported FY. Other **federal grant carryover from previous y ear**  Enter any o ther **federal grant carry ov** **er** amount from the previous FY that was expended or encumbered in the reported FY **from previous year** A. FUNDING SOURCES FOR EXPENDITURES AND ENC UMBRANCES IN REPORTED FY A1. Enter the total amount of Title VII
- Chapter 2 funds expen ded or encumbered during the reported FY. Include expenditures or encumbrances made from both carryover funds from the previous FY and from the reported FY grant funds. A2. Enter the total of any other federal funds expended or encumbered in the Title VI I
- Chapter 2 program during the reported FY. Designate the funding sources and amounts in (a) through (e). A3. Enter the total amount of state funds expended or encumbered in the Title VII
- Chapter 2 program. Do not include in
- kind contributions (e.g., documented value of services, materials, equipment, buildings or office space, or land). A4. Enter the total amount of third party contributions including local and community funding, non
- profit or for
- profit agency funding, etc. Do not include in
- kind contributions (e.g., documented value of services, materials, equipment, buildings or office space, or land). A5. Enter the total amount of in
- kind contributions from non
-federal sources. Include value of property or services that benefit the Title VII
- Ch apter 2 program (e.g. theVI

fairly evaluated documented value of services, materials, equipment, buildings or office space or land). A6. Enter the total matching funds (A3 + A4 + A5). Reminder: The required non
federal match for the Title VII
- Chapter 2 program is not less than $1 for each $9 of federal funds provided in the Title VII
- Chapter 2 grant. Funds derived from or provided by the federal government, or services assisted or subsidized to any significant extent by the federal government, may not be included in determining the amount of non
-federal contributions. A7. Enter the total amount of all funds expended and encumbered (A1 + A2 + A6) during the reported fiscal year. B. TOTAL EXPENDITURES A ND ENCUMBRANCES ALLO CATED TO ADMINISTRATIVE, SUPP ORT STAFF, AND GENERAL OVERHEAD COSTS Enter the total amount of expenditures and encumbrances allocated to administrative, support staff, and general overhead costs. Do not include costs for direct services provided by agency staff or the costs of contract o r sub
grantee staff that provide direct services under contracts or sub
- grants. If an administrator spends a portion of his or her time providing administrative services and the remainder providing direct services, include only the expenditures for admini strative services. C. TOTAL EXPENDITURES A ND ENCUMBRANCES FOR DIRECT PROGRAM SERVICES Enter the total amount of expenditures and encumbrances for direct program services by subtracting line B from line A7.VII

**PA RT II: STA**  **FFING –**  **INSTRUCTIONS** Base all FTE calculations upon a full
-time 40
- hour workweek or 2080 hours per year. Record all FTE assigned to the Title VII
- Chapter 2 program irrespective of whether salary is paid with Title VII
- Chapter 2 funds. A. FULL
- TIME EQUIVALENT (FTE ) PROGRAM STAFF A1. Un der the “Administrative & Support” column (A1a), enter the full
- time equivalent (FTE) of all administrative and support staff (e.g. management, program directors, supervisors, readers, drivers for staff, etc.) assigned to the Title VII
Chapter 2 program from the State agency. (For example, if 20% or 8 hours per week of a staff person’s time were spent on administrative and support functions related to this program, the FTE for that staff person would be .2). Under the “Direct Services” column (A1b), enter the FTE of all direct service staff (e.g. rehabilitation teacher, IL specialist, orientation and mobility specialist, social worker, drivers for individuals receiving services, etc.) assigned to the Title VII
Chapter 2 program from the State agency. If a dministrative or support staff of the State agency also provide direct services, report the FTE devoted to direct services in the “Direct Services” column (A1b). (For example, if 80% of a staff person’s time were spent in providing direct services, the FT E for that person would be 8). Finally, add across the “Administrative & Support” FTE (A1a) and “Direct Service” FTE (A1b) to enter the total State agency FTE in the TOTAL (A1c) column. A2. Under the “Administrative & Support” column (A2a), enter the ful l
- time equivalent (FTE) of all administrative and support staff (e.g. management, program directors, supervisors, readers, drivers for staff, etc.) assigned to the Title VII
Chapter 2 program from contractors or sub
- grantees. Under the “Direct Services” column (A2b), enter the FTE of all direct service staff (e.g. rehabilitation teacher, IL specialist, orientation and mobility specialist, social worker, driver for individuals receiving services, etc.) assigned to the Title VII
Chapter 2 program from contra ctors and sub
- grantees. If administrative staff of the contractors or sub
- grantees also provides direct services, report the FTE devoted to direct services in the “Direct Services” column (A2b). Finally, add across the “Administrative & Support” FTE (A2a ) and “Direct Service” FTE (A2b) to enter the total contractor or sub
- grantee FTE in the TOTAL (A2c) column. A3. Add each column for A1 and A2 and record totals on line A3. B. EMPLOYED OR ADVANCED IN EMPLOYMENT B1. Enter the total number of employees (a gency and contractor/sub
- grantee staff) with disabilities, including blindness or visual impairment, in B1a. Enter the FTE of employees with disabilities in B1b. (To calculate B1b, add the total number ofVIII

hours worked by all employees with disabilities a nd divide by 2080 to arrive at the FTE) B2. Enter the total number of employees (agency and contractor/sub
- grantee staff) who are blind or visually impaired and age 55 and older in B2a. Enter the FTE of employees who are blind or visually impaired and ag e 55 or older in B2b. (To calculate B2b, add the total number of hours worked by employees who are blind or visually impaired and age 55 and older and divide by 2080 to arrive at the FTE) B3. Enter the total number of employees (agency and contractor/sub
- grantee staff) who are members of racial/ethnic minorities in B3a. Enter the FTE of employees who are members of racial/ethnic minorities in B3b. (To calculate B3b, add the total number of hours worked by employees who are members of racial/ethnic minor ities and divide by 2080 to arrive at the FTE) B4. Enter the total number of employees (agency and contractor/sub
- grantee staff) who are women in B4a. Enter the FTE of employees who are women in B4b. (To calculate B4b, add the total number of hours worked by women and divide by 2080 to arrive at the FTE) B5. Enter the total number of employees (agency and contractor/sub
- grantee staff) who are ages 55 and older, but not blind or visually impaired, in B5a. Enter the FTE of employees who are ages 55 and o lder, but not blind or visually impaired, in B5b. (To calculate B5b, add the total number of hours worked by employees who are ages 55 and older, but not blind or visually impaired, and divide by 2080 to arrive at the FTE) **PA RT III: DA** **TA**

**ON INDIVIDUA LS**  **SERVED –**  **INSTRUCTIONS** Provide data in all categories on program participants who received one or more services during the fiscal year being reported. A. INDIVIDUALS SERVED A1. Enter the number of program participants carried over from the previous federal fiscal year who received services in this reported FY (e.g. someone received services in September (or any other month) of the previous FY and continued to receive additional services in the reported FY). A2. Enter the number of program participants wh o began receiving services during the reported fiscal year irrespective of whether they have completed all services. A3. Enter the total number served during the reported fiscal year (A1 + A2). B. AGEIX

B1
- B10. Enter the total number of program participan ts served in each respective age

category. B11. Enter the sum of B1 through B10. This must agree with A3. C. GENDER C1. Enter the total number of females receiving services. C2. Enter the total number of males receiving services. C3. Enter the sum of C1 and C2. This must agree with A3. D. RACE/ETHNICITY Hispanic or Latino means a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. D1. Enter the number of individuals served who are Hispanic/Latino of any race or Hispanic/Latino only. Hispanic/Latino means a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. D2. Enter the number of individuals served who are American Indian or Alaska Native. American Indian or Alaska Native means a person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment. D3. Enter the number of individuals served who are Asian. Asian means a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia , Pakistan, the Philippine Islands, Thailand, and Vietnam. D4. Enter the number of individuals served who are Black or African American. Black or African American means a person having origins in any of the black racial groups of Africa. Terms such as “ Haitian” may be used. D5. Enter the number of individuals served who are Native Hawaiian or Other Pacific Islander. Native Hawaiian or Other Pacific Islander means a person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pa cific Islands. D6. Enter the number of individuals served who are W hite or Caucasian. W hite means a person having origins in any of the original peoples of Europe, the Middle East, or North Africa.X

D7. Enter the number of individuals served who report two or more races but who are not Hispanic/Latino of any race. D8. Enter “race and ethnicity unknown” only if the consumer refuses to identify race and ethnicity. D9. Enter the total of D1 through D8. This number must agree with A3. E. DEGREE OF VISUAL I MPAIRMENT E1. Enter the number of individuals served who are totally blind (e.g. have light perception only or no light perception). E2. Enter the number of individuals served who are legally blind (excluding those recorded in E1). E3. Enter the number of individuals served who have severe visual impairment. E4. Add E1 + E2 + E3 and enter the total. This number must agree with A3. F. MAJOR CAUSE OF VISUA L IMPAIRMENT (Please note that the primary site for the definitions of diseases is http://www.nia.nih.gov/AboutNIA/StrategicPlan/ResearchGoalA/Subgoal1.htm .) Enter only one major cause of visual impairment for each individual served. F1. Enter the number of indiv iduals served who have macular degeneration as the major cause of visual impairment. Age
- related macular degeneration (AMD) is a progressive disease of the retina wherein the light
- sensing cells in the central area of vision (the macula) stop working and eventually die. The cause of the disease is thought to be a combination of genetic and environmental factors, and It is most common in people who are age 60 and over. AMD is the leading cause of legal blindness in senior citizens. F2. Enter the number of individuals served who have diabetic retinopathy as the major cause of visual impairment. Diabetic retinopathy is the leading cause of new cases of legal blindness among working
- age Americans and is caused by damage to the small blood vessels in the reti na. It is believed that poorly controlled blood sugar levels are related to its progression. Most persons with diabetes have non
- insulin
- dependent diabetes mellitus (NIDDM) or what is commonly called “adult
- onset” or Type II diabetes, and control their b lood sugar with oral medications or diet alone. Others have insulin
- dependent diabetes mellitus (IDDM), also called "younger or juvenile
- onset" or Type I diabetes, and must use insulin injections daily to regulate their blood sugar levels.XI

F3. Enter the nu mber of individuals served who have glaucoma as the major cause of visual impairment. Glaucoma is a group of eye diseases causing optic nerve damage that involves mechanical compression or decreased blood flow. It is permanent and is a leading cause of b lindness in the world, especially in older people. F4. Enter the number of individuals served who have cataracts as the major cause of visual impairment. A cataract is a clouding of the natural lens of the eye resulting in blurred vision, sensitivity to l ight and glare, distortion, and dimming of colors. Cataracts are usually a natural aging process in the eye (although they may be congenital) and may be caused or accelerated by other diseases such as glaucoma and diabetes. F5. Enter the number of indiv iduals served who have any other major cause of visual impairment. F6. Enter the sum of F1 through F5. This number must agree with A3. G. OTHER AGE
- RELATED IMPAIRMENTS Enter the total number of individuals served in each category. Individuals may report one or more non -visual impairments/conditions. The National Institute on Aging (NIA) Strategic Plan identifies age
- related diseases, disorders, and disability including the following categories. G1. Hearing Impairment: Presbycusis is the gradual hearing loss that occurs with aging. An estimated one
- third of Americans over 60 and one
- half of those over 85 have some degree of hearing loss. Hearing impairment occurs when there is a problem with or damage to one or more parts of the ear, and may be a condu ctive hearing loss (outer or middle ear) or a sensorineural hearing loss (inner ear) or a combination. The degree of hearing impairment can vary widely from person to person. Some people have partial hearing loss, meaning that the Ear can pick up some sou nds; others have complete hearing loss, meaning that the ear cannot hear at all. One or both ears may be affected, and the impairment may be worse in one ear than in the other. G2. Diabetes: Diabetes is a disease in which the body does not produce or properly use insulin, a hormone that is needed to convert sugar, starches and other food into energy needed for daily life. Type 2 diabetes, which results from insulin resistance and abnormal insulin action, is most prevalent in the older population. Diabet es complications, such as heart disease and loss of sight, increase dramatically when blood sugar is poorly controlled and often develop before diabetes is diagnosed. G3. Cardiovascular Disease and Strokes: Diseases of the heart and blood vessels are the leading cause of hospitalization and death in older Americans.XII

Congestive heart failure is the most common diagnosis in hospitalized patients aged 65 and older. G4. Cancer: The second leading cause of death among the elderly is cancer, with individuals a ge 65 and over accounting for 70 percent of cancer mortality in the United States. Breast, prostate, and colon cancers, are common in older people. G5. Bone, Muscle, Skin, Joint, and Movement Disorders: Osteoporosis (loss of mass and quality of bones), o steoarthritis (inflammation and deterioration of joints), and sarcopenia (age
- related loss of skeletal muscle mass and strength) contribute to frailty and injury in millions of older people. Also contributing to loss of mobility and independence are chang es in the central nervous system that control movement. Cells may die or become dysfunctional with age, as in Parkinson's disease. Therefore, older people may have difficulty with gross motor behavior, such as moving around in the environment, or with fine motor skills, such as writing. G6. Alzheimer’s Disease/Cognitive Impairment: Alzheimer’s disease is the most common type of dementia (a brain disorder that significantly affects an individual’s ability to carry out daily life activities) in older people. It and other cognitive impairments impact parts of the brain that control thought, memory, and language. G7. Depression is widespread, often undiagnosed, and often under
-treated in the elderly. It is believed to affect more than 6.5 million of the 35 mi llion Americans who are 65 or older. Depression is closely associated with dependency and disability. Symptoms may include: loss of interest in normally pleasurable activities, persistent, vague or unexplained somatic complaints, memory complaints, chang e in weight, sleeping disorder, irritability or demanding behavior, lack of attention to personal care, difficulty with concentration, social withdrawal, change in appetite, confusion, delusions or hallucinations, feeling of worthlessness or hopelessness, and thought about suicide. G8. Other Major Geriatric Concerns: Several conditions can compromise independence and quality of life in older persons including weakness and falls, urinary incontinence, benign prostatic hyperplasia, and co morbidity (co morb idity describes the effect of all other diseases an individual might have on the primary disease). H. TYPE OF RESIDENCE H1. Enter the number of individuals served who live in private residence (house or apartment unrelated to senior living). H2. Enter the number of Individuals served who live in senior living/retirement community ( e.g. housing designed for those age 55 and older).XIII

H3. Enter the number of individuals served who live in assisted living facility ( e.g. housing that provides personal care and s ervices which meet needs beyond basic provision of food, shelter and laundry). H4. Enter the number of individuals served who live in nursing homes/long
-term care facility (e.g. any facility that provides care to one or more persons who require nursing care and related medical services of such complexity to require professional nursing care under the direction of a physician on a 24 hour a day basis). H5. Enter the number of individuals served who are homeless H6. Enter the sum of H1, H2, H3, H4 and H5. This number must agree with A3. I. SOURCE OF REFERRAL I1. Enter the number of individuals served referred by an ophthalmologist or optometrist. I2. Enter the number of individuals served referred by a medical provider other than an ophthalmologist or opt ometrist. I3. Enter the number of individuals served referred by a state vocational rehabilitation agency. I4. Enter the number of individuals served referred by a government or social services agency defined as a public or private agency which provides as sistance to consumers related to eligibility and securing entitlements and benefits, counseling, elder law services, assistance with housing, etc. I5. Enter the number of individuals served referred by the Veterans Administration I6. Enter the number of i ndividuals served referred by a senior program defined as a community
- based educational, recreational, or socialization program operated by a senior center, nutrition site, or senior club. I7. Enter the number of individuals served referred by an assiste d living facility defined as housing that provides personal care and services which meet needs beyond basic provision of food, shelter and laundry. I8. Enter the number of individuals served referred by a nursing home/long
-term care facility defined as an y facility that provides care to one or more persons who require nursing care and related medical services of such complexity to require professional nursing care under the direction of a physician on a 24 hour a day basis.XIV

I9. Enter the number of individ uals served referred by a faith
- based (religious affiliated) organization. I10. Enter the number of individuals served referred by an independent living center (ILC) defined as a consumer
- controlled, community
- based, cross
- disability, nonresidential priva te nonprofit agency that is designed and operated within a local community by individuals with disabilities, and provides an array of independent living services. I11. Enter the number of individuals referred by a family member or friend. I12. Enter the number of individuals who were self
- referred. I13. Enter the number of individuals referred from all other sources aside from those listed above. I14. Enter the sum of I1, I2, I3, I4, I5, I6, I7, I8, I9, I10, I11, I12, and I13. This number must agree w ith A3
**PA RT IV: TYPES OF SERVICES PROVIDED A**  **ND RESOURCES A LLOCA** **TED –** 

**INSTRUCTIONS** PLEASE NOTE : Total expenditures and encumbrances for direct program services in Part I C must equal the total funds spent on services in Part IV. Part I C must equal the sum of Part IV A1+B1+C1+D1. In addition, salary or costs associated with direct service staff or contractors providing direct services should be included in the cost of services provided in A, B, C, and D. A. CLINICAL / FUNCTIONAL VISION ASSESSMENTS A ND SERVICES A1. Enter the total cost from Title VII
- Chapter 2 federal grant funds (A1a) and the total cost from all other sources of program funding (A1b) for clinical and/or functional vision assessments and services, whether purchased or provided directly. A2. Enter the total number of program participants who received clinical vision screening or vision examinations from qualified or certified professionals such as ophthalmologists or optometrists, and who received functional vision assessments or low vision evaluations to identify strategies for enhancing visual performance both without and with optical and low vision devices and equipment. Assessment areas may include functional visual acuity and fields, efficiency of vision in the performance of e veryday tasks, and evaluation for low vision aids or equipment. These assessments are typically provided by skilled professionals or those who are certified or have a master’s degree in low vision rehabilitation. DoXV

not include evaluations for orientatio n and mobility. These should be included in C3. A3. Enter the total number of program participants who received surgical or therapeutic treatment to prevent, correct, or modify disabling eye conditions; and, hospitalizations related to such services. I nclude prescription optics in this service category. Nonprescription optics should be reported in B2. B. ASSISTIVE TECHNOLOGY DEVICES, AIDS , SERVICES and TRAINING B1. Enter the total cost from Title VII
- Chapter 2 federal grant funds (B1a) and the tota l cost from all other sources of program funding (B1b) for the provision of assistive technology devices, aids, services and training. B2. Enter the total number of program participants who received one or more assistive technology devices and aids. As d efined in Section 3(4) of the Assistive Technology Act of 2004 (P ub

. L. 108
- 364), “assistive technology device means any item, piece of equipment, or product system whether acquired commercially, modified, or customized that is used to increase, maintain, or improve functional capabilities of individuals with disabilities.” Assistive technology devices may include such items as canes, slates, insulin gauges, CCTVs, computers, adaptive software, magnifiers, adaptive cooking items, adaptive recreational item s, handwriting guides, Braillers, large button telephones, etc. B3. Enter the total number of program participants who received one or more assistive technology services and training. As defined in Section 3(5) of the Assistive Technology Act of 2004 (PL 108
- 364), “assistive technology service means any service that directly assists an individual with a disability in the selection, acquisition, or use of an assistive technology device.” Services may include the evaluation of assistive technology needs of an individual, services related to acquisition of technology, costs of loan programs, maintenance and repair of assistive technology, training or technical assistance for the individual or professionals related to the use of assistive technology, programs to expand the availability of assistive technology, low vision therapy services related to the use of optical aids and devices, and other services related to the selection, acquisition, or use of an assistive technology device. C. INDEPENDENT LIVING AND ADJUSTMENT TRAINING AND SERVICES C1. Enter the total cost from Title VII
- Chapter 2 federal grant funds (C1a) and the total cost from all other sources of program funding (C1b) for the provision of services and adjustment training leading to independent li ving. Evaluation and assessment services (excluding those included in A2 or B3) leading to the planning and implementation of services and training should be included in these costs.XVI

C2. Enter the total number of individuals who received orientation and mobility (O & M) services or travel training (i.e. learning to access public or private transportation and to travel safely and as independently as possible in the home and community with or without the use of mobility aids and devices). C3. Enter the total number of individuals who received communication skills training (e.g. reading and writing Braille, keyboarding and computer literacy, computer skills training, using the telephone, handwriting guides, telling time, using readers, use of audio and tacti le technologies for home, recreational or educational use; etc.). Training in the use of newspaper reading services and radio services should be included. C4. Enter the total number of individuals who received personal management and daily living skills training (e.g. training in the use of adaptive aids and assistive technology devices for personal management and daily living, blindness and low vision alternative techniques for food preparation, grooming and dress, household chores, medical management, s hopping, recreational activities, etc.) C5. Enter the total number of individuals who received supportive services (e.g. reader services, transportation, personal attendant services, support service providers, interpreters, etc.) while actively participat ing in the program or attaining independent living goals. C6. Enter the total number of program participants who participated in advocacy training or support network activities such as consumer organization meetings, peer support groups, etc. C7. Enter t he total number of individuals who received counseling (peer, individual or group) to assist them in adjusting to visual impairment and blindness. C8. Enter the total number of program participants that received information and referral to other service p roviders, programs, and agencies (e.g. senior programs, public and private social service programs, faith
- based organizations, consumer groups, etc.) to enhance adjustment, independent living, and integration into the community. Do not include individuals who received only information and referral and for whom no other services were provided. C9. Enter the total number of individuals served who were provided any other service not listed above. D. COMMUNITY AW ARENESS ACTIVITIES / INFORMATION AND REFERRAL D1. Enter the total cost from Title VII
- Chapter 2 federal grant funds (D1a) and the total cost from all other sources of program funding (D1b) for providing information and referral services and community awareness activities/events toXVII

individuals for whom this was the only service provided (i.e. training for other professionals, telephone inquiries, general inquiries, etc.). D2. Enter the number of individuals receiving information and referral services for whom this is the only service provided. (optiona l) D3. Enter the number of community awareness events/activities in which the Chapter 2 program participated during the reported year (D3a) and the number or estimated number of individuals who benefited from these activities (D3b).
**PA RT V: COMPA**  **RISON O F PRIOR YEA**  **R A CTIVITIES TO CURRENT REPORTED** 

**YE AR**  **– INSTRUCTIONS**  A1. Program Expenditures and Encumbrances (all sources) Enter the total cost of the program for the prior fiscal year (A1a), and the fiscal year being reported (A1b). The total cost of the p rogram can be found in Part I A7. Calculate the change (plus or minus) from the prior year to the reported year (A1c). A2. Number of Individuals Served Enter the total number of eligible individuals served in the prior year (A2a), and in the current re ported year (A2b). The total number of individuals served can be found in Part III A3. Calculate the change (plus or minus) in the numbers served from the prior year to the reported year (A2c). A3. Number of Minority Individuals Served Enter the total number of minority individuals served in the prior year (A3a), and in the fiscal year currently being reported (A3b). The total number of minority individuals served is the total of Part III D1+D2+D3+D4+D5 +D7. Calculate the change (plus or minus) in the numbers served from the prior year to the reported year (A3c). A4. Number of Community Awareness Activities Enter the number of community awareness activities or events in which the Chapter 2 program participated during the prior year (A4a), and in the fiscal year currently being reported (A4b). The number of community awareness activities is found in Part IV D3a. Calculate the change (plus or minus) in the number of events from the prior year to the year being reported (A4c). A5. Number of Collabora ting Agencies and Organizations Enter the number of collaborating organizations or agencies (formal agreements or informal activity) other than Chapter 2 paid sub
- grantees or contractors in the prior year (A5a), and in the fiscal year currently being reported (A5b). Calculate the change (plus or minus) from the prior year to the year being reported (A5c). A6. Number of Sub
- grantees/Contractors If you provide services through sub
- grantee agencies or contract, enter the number of sub
- grantees or contracts i n the priorXVIII

year (A6a), and in the fiscal year currently being reported (A6b). Calculate the change (plus or minus) from the prior year to the year being reported (A6c). If you do not use sub
- grantees, enter 0 in A6a, A6b, and A6c.
**PA RT VI: PROGRA**  **M OUTC OMES/PERFORMA**  **NCE ME AS**  **URES –**  **INSTRUCTIONS** A. Enter the number from Part IV B3 in A1. From available program data and evaluations, enter the n umber of individuals receiving AT (assistive technology) services and training who maintained or improved function al abilities that were previously lost or diminished as a result of vision loss in A2. (closed/inactive cases only)

. In A3, from available program data and evaluations, enter the n umber of individuals for whom functional gains have not yet been determine d at the close of the reporting period (This number would not include those individuals who are no longer receiving services and who either did not make functional gains or maintain functional ability before case closure or inactivity)

. B. Enter the numbe r from Part IV C2 in B1. From available program data and evaluations, of those receiving orientation and mobility (O & M) services, enter the number of individuals who experienced functional gains or maintained their ability to travel safely and independe ntly in their residence and/or community environment as a result of services in B2 (closed/inactive cases only). In B3, from available program data and evaluations, enter the n umber of individuals for whom functional gains have not yet been determined at the close of the reporting period (This number would not include those individuals who are no longer receiving services and who either did not make functional gains or maintain functional ability before case closure or inactivity)

. C. Enter the number fro m Part IV C3 in C1. From available program data and evaluations, of those receiving communication skills training, enter the number of individuals who gained or maintained their functional abilities as a result of services they received in C2 (Closed/inactive cases only)

. In C3, from available program data and evaluations, enter the number of individuals for whom functional gains have not yet been determined at the close of the reporting period (This number would not include those individuals who are no l onger receiving services and who either did not make functional gains or maintain functional ability before case closure or inactivity)

. D. Enter the number from Part IV C4 in D1. From available program data and evaluations, of those receiving daily livi ng skills training, enter the number of individuals that experienced functional gains or successfully restored or maintained their functional ability to engage in their customary daily life activitiesXIX

as a result of services or training in personal managem ent and daily living skills In D2 (Closed/inactive cases only)

. In D3, enter the Number of individuals for whom functional gains have not yet been determined at the close of the reporting period (This number would not include those individuals who are no longer receiving services and who either did not make functional gains or maintain functional ability before case closure or inactivity)

. E1. Enter the Number of individuals served who reported feeling that they are in greater control and are more confid ent in their ability to maintain their current living situation as a result of services they received (Closed/inactive cases only)

. E2. E nter the n umber 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 ( C losed/inactive cases only)

. E3. E nter the n umber of individuals served who reported no change in their feelings of control and confidence in their ability to maintain the ir current living situation as a result of services they received ( C losed/inactive cases only)

. E4. Enter the n umber of individuals served who experienced changes in lifestyle for reasons unrelated to vision loss ( C losed/inactive cases only) . “Change in lifestyle” is defined as any non
-vision related event that results in the consumer’s reduced independence, such as moving from a private residence (house or apartment) to another type of residence e.g. living with family, senior living community, assisted living facility, nursing home/long
-term facility, etc. Reduced independence could also result in employing a caregiver to enable the consumer continue to live in his/her home. Examples of events that could result in reduced independence of the consumer i nclude loss of spouse and onset or worsening of other health conditions such as diabetes, cancer, heart disease, etc. E5. Enter the number of individuals served who died before achieving functional gain or experiencing changes in lifestyle as a result of services they received ( C losed/inactive cases only)

.