ED(RSA)-7-OB Form - Instructions

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

INDEPENDENT LIVING SERVICES FOR

OLDER INDIVIDUALS WHO ARE BLIND

ANNUAL REPORT INSTRUCTIONS

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 /required to obtain or retain benefit Sec. 410, Pub. L. 105-220, Workforce Investment Act 

of 1998 and voluntary. 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.

II

TABLE 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 ACTIVITIES TO CURRENT REPORTED 

YEAR – INSTRUCTIONS........................................................................... XVII

PART VI: PROGRAM OUTCOMES/PERFORMANCE MEASURES – INSTRUCTIONS

.................................................................................................................. XVIII
III

Introduction

The revised ED RSA-7-OB form incorporates revisions to the four established 

performance measures for the Independent 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. Enter the 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)

E3. Enter the 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)
IV

E4. Enter the number of individuals served who experienced changes in lifestyle for 

reasons unrelated to vision loss. (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 grantees 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 instructions 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

PART I: FUNDING SOURCES FOR EXPENDITURES AND ENCUMBRANCES –

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 AWARD FOR REPORTED FISCAL 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 year

Enter the total amount of any other federal grant award you received for the 

reported fiscal year

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 year

Enter any other federal grant carryover amount from the previous FY that was 

expended or encumbered in the reported FY from previous year

A. FUNDING SOURCES FOR EXPENDITURES AND ENCUMBRANCES IN

REPORTED FY 

A1. Enter the total amount of Title VII-Chapter 2 funds expended 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 

VII-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-Chapter 2 program (e.g. the 
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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 nonfederal 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 AND ENCUMBRANCES ALLOCATED TO

ADMINISTRATIVE, SUPPORT 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 or subgrantee 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 

administrative services.

C. TOTAL EXPENDITURES AND 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

PART II: STAFFING – 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. Under 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 VIIChapter 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 VIIChapter 2 program from the State agency. If administrative 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 FTE 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 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 VIIChapter 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 VIIChapter 2 program from contractors 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 (agency 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 of 
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hours worked by all employees with disabilities and 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 age 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 

minorities 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 older, 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) 

PART III: DATA ON INDIVIDUALS 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 who 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. AGE
IX

B1-B10. Enter the total number of program participants 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 Pacific 

Islands.

D6. Enter the number of individuals served who are White or Caucasian. White 

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 IMPAIRMENT

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 VISUAL 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 individuals 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 retina. 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 blood 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 number 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 blindness 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 light 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 individuals 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 

conductive 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 sounds; 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. 

Diabetes 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 age 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), osteoarthritis (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 changes 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 million 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, change 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 morbidity 

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 services 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 optometrist.

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 assistance 

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 individuals 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 assisted 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 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.
XIV

I9. Enter the number of individuals 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 private 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 with A3

PART IV: TYPES OF SERVICES PROVIDED AND RESOURCES ALLOCATED –

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 AND 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 everyday 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. Do 
XV

not include evaluations for orientation 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. Include 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 

total 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 defined in Section 3(4) of the Assistive 

Technology Act of 2004 (Pub. 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 items, 

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 living. 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 tactile 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, shopping, 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 participating 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 the 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 providers, 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 AWARENESS 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 to 
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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. (optional)

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).

PART V: COMPARISON OF PRIOR YEAR ACTIVITIES TO CURRENT REPORTED 

YEAR – 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 program 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 reported 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 Collaborating 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 in the prior 
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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.

PART VI: PROGRAM OUTCOMES/PERFORMANCE MEASURES – INSTRUCTIONS

A. Enter the number from Part IV B3 in A1. From available program data and 

evaluations, enter the 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 in A2. (closed/inactive 

cases only).

In A3, 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 longer receiving services and who either did not make functional gains or 

maintain functional ability before case closure or inactivity).

B. Enter the number 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 independently 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 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).

C. Enter the number from 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 longer 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 living 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 activities 
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as a result of services or training in personal management 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 confident in their ability to maintain their current 

living situation as a result of services they received (Closed/inactive cases only).

E2. Enter the 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).

E3. Enter the 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).

E4. Enter the number of individuals served who experienced changes in lifestyle for 

reasons unrelated to vision loss (Closed/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 include 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 

(Closed/inactive cases only).