RSA Annual Payback Report

RSA Payback Grantee Form: Sample Instrument

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. Public reporting burden for this collection of information is estimated to average one hour 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 a benefit (Section 13 of the Rehabilitation Act, 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, Washington, DC 20210-4537 or email ICDocketMgr@ed.gov and reference the OMB Control Number 1820-0617. Note: Please do not return the completed RSA Payback Grantee Form to this address.

The RSA Payback form is submitted electronically using the RSA MIS system. This sample form provides an overview of the information grantees are required to submit each fiscal year until every scholar under a specific grant successfully fulfills their payback obligation. Detailed instructions for grantees are included in the Payback MIS User Guide and Instructions manual. Cells that are shaded gray indicate the information either rolls over from a previous screen or the information cannot be inputted by grantees because the data self-populates based on information entered into other areas of the form.

	Screen 1: General Information
Grantee:		Project Director:		Name of Person Completing Form:	Grant Number:
Address:		Phone:		Phone:	FY Grant Amount
Rehab Field of Training		Email:		Email:	Reporting Period (last Fiscal Year completed)

The data fields are self explanatory for this screen. Grantees will type in the information requested. The Rehab Field of Training field displays a drop down box that asks grantees to select the correct field of training the grant they are reporting on supports.

					Screen 2: Add/Edit Scholars
Name of RSA Scholar	Status	Scholar start date		Date of initial disbursement		Initial disbursement amount	Scholarship prior amount	Total support all years	Payback agreement signed and on file?	Current address on file?
Text field	Drop down box	Text field		Text field		Text field	Text field	Text field	Select Yes/No	Select Yes/No

The second screen of the RSA payback form asks for information about the students receiving aid under the grant. Grantees type in or choose the correct option from the drop down menu or checkbox for the information requested. Under “status” the grantee will note whether the student is currently enrolled in the program or has exited. The last two fields on Screen 2 require grantees to check a box certifying that the required payback agreement has been signed and is on file and that the scholar’s address information is up to date.

Screen 3: RSA Current Scholars
Name of RSA Scholar	Academic degree sought	Student Status	Alias of Scholar (Former name of scholar)
Text field	Drop down box	Drop down box	Text field

Screen three asks for information on scholars currently enrolled in the grantee’s academic program. This information will carry over year to year until the student’s status is changed from “current” to “exited” on screen 2.

		Screen 4: RSA Exited Scholars
Name of RSA Scholar	Why did this scholar exit the program?		Date exited the program	Date work must begin (including 2 years grace)	Number of work years owed	Date by which work must be completed (including 2 years grace)
Text field	Drop down box		Text field	Automatically populates: no data entry required	Text field	Automatically populates: no data entry required

Screen four collects information on scholars who have graduated or otherwise exited the grantee’s program and are now in payback status. Grantees need to specify why a scholar exited the program. Once the grantee enters the date the system will automatically generate the date work must begin, the date by which work must be completed, and the scholar’s commitment time completed and remaining obligation to date.

		Screen 5: RSA Exited Scholars (continued)
Name of RSA Scholar	Employment Status		If deferment or waiver or non qualifying employment, explain	Number of work years owed	Work years completed to date	Commitment (years/money) completed to date	Commitment (years/money) Remaining obligation	Payback complete?
Text field	Drop down box		Text field	Text field	Automatically populates: no data entry required	Automatically populates: no data entry required	Automatically populates: no data entry required	Automatically populates: no data entry required

Screen five collects additional information on RSA exited scholars, specifically information about employment. Grantees are required to update the information each year until each scholar fulfills their payback obligation. When the fields in “number of work years owed” equals “work years completed to date,” the system will automatically default to “Yes” in the “payback complete” field and the scholars’ information will not appear on future payback forms. Grantees cannot manually change the payback complete field.

Screen 6: Summary and Signatures
Total support all years to date
Total scholarship amount current year
Average number of work years owed
Total number of scholars on this report
Total number of current scholars
Total number of full time scholars
Total number of part time scholars
Total number of graduated scholars
Total number who exited without graduating
Total for whom payback is complete
Total for whom payback is not complete
Total number of scholars in unqualified employment
Total number of deferments (table in guide says temporary deferments)
Total number of waivers
Name of individual submitting this form	Automatically populates: no data entry required
Title of individual submitting this form	Automatically populates: no data entry required
Date	Text field

The last screen provides a summary of grantee activity based on data entered into the prior five screens. Grantees must fill out the last three text boxes on this form: the name of the individual submitting the current form, their title and the date. RSA will use all of the grantee summary screens for analysis. Any fields with questionable data will be noted by RSA project officers who will then contact the grantees for additional information or to provide technical assistance.

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