ࡱ                >  	               8          :          7   s    [	               TM   bjbj                  	 8\  ΐ ΐ                                                                      |      |                                                         8     l   w           ,#  h    2  5     K      K      K                 t   {"     }"      }"      }"      }"      }"      }"      $    6'  @   }"  i                         w                                  w      w      }"                          K              K  4  "                       w  j         K            K      {"                                                                    w      {"                                                                                                                K          Ќ9                                 g"     "  0   ,#            v'          v'                                                                                    v'                      X  w      w            w      w                                      w      w      w      }"      }"                                        ^                                   w      w      w      ,#      w      w      w      w                                                                                          v'      w      w      w      w      w      w                                                              w      w      w      |  	    :     	                                                                                                                                                                                                                                                                                                                                                                                                                                         E M B E D   P r e s e n t a t i o n s . D r a w i n g . 1 0         M I S S O U R I   D E P A R T M E N T   O F   S O C I A L   S E R V I C E S  F A M I L Y   S U P P O R T   D I V I S I O N  O L D E R   B L I N D   G R A N T   D A T A   S H E E T      O B S   2   N A M E   ( L A S T ,   F I R S T ,   M I )       F O R M T E X T               C A S E   N U M B E R       F O R M T E X T            C A S E L O A D   N U M B E R       F O R M T E X T            F E D E R A L   F I S C A L   Y E A R  ( 1 0 - 0 1 - X X   T H R O U G H   9 - 3 0 - X X )      F O R M T E X T             C L O S U R E       F O R M C H E C K B O X         C L O S E D   S T A T U S   2 6   =   S U C C E S S F U L L Y   R E H A B I L I T A T E D .      D A T E   O F   C L O S U R E :      F O R M T E X T             F O R M C H E C K B O X         C L O S E D   S T A T U S   2 8   =   U N S U C C E S S F U L L Y   R E H A B I L I T A T E D    R E A S O N   F O R   C L O S U R E :    F O R M T E X T            D A T E   O F   C L O S U R E   :     F O R M T E X T                F O R M C H E C K B O X         C L O S E D   S T A T U S   0 8   =   I N E L I G I B L E .    D A T E   O F   C L O S U R E :     F O R M T E X T                 F O R M C H E C K B O X         E L I G I B L E   B U T   N O T   C L O S E D .   ( U S E   F O R   Y E A R   E N D   ( 9 / 3 0 )   R E P O R T I N G     O N L Y )    P L A C E A CHECK MARK IN THE BOX NEXT TO EACH SERVICE IN SECTIONS A, B, C, THAT WAS PROVIDED DURING THIS FEDERAL FISCAL YEAR REGARDLESS OF WHETHER THE TRAINING HAS BEEN COMPLETED. A.  CLINICAL /FUNCTIONAL VISION ASSESSMENT AND SERVICES FORMCHECKBOX  (1) VISION SCREENING /VISION EXAMINATION /LOW VISION EVALUATION FORMCHECKBOX  (2) SURGICAL OR THERAPEUTIC TREATMENT TO PREVENT, CORRECT, OR MODIFY                        DISABLING EYE CONDITIONSB.  ASSISTIVE TECHNOLOGY DEVICES AND SERVICES FORMCHECKBOX  (1)  PROVISION OF ASSISTIVE TECHNOLOGY DEVICES AND AIDS FORMCHECKBOX   (2)  PROVISION OF ASSISTIVE TECHNOLOGY SERVICESC.  INDEPENDENT LIVING AND ADJUSTMENT TRAINING AND SERVICES FORMCHECKBOX   (1)  INDEPENDENT LIVING AND ADJUSTMENT  SKILLS TRAINING FORMCHECKBOX   (2)  ORIENTATION AND MOBILITY TRAINING FORMCHECKBOX   (3)  COMMUNICATION SKILLSNAME (LAST, FIRST, MI) FORMTEXT                                                                                                           C A S E   N U M B E R       F O R M T E X T                F O R M C H E C K B O X         ( 4 )     D A I L Y   L I V I N G   S K I L L S      F O R M C H E C K B O X         ( 5 )     S U P P O R T I V E   S E R V I C E S ,   ( R E A D E R   S E R V I C E S ,   T R A N S P O R T A T I O N ,   P E R S O N A L   A T T E N D A N T ,   S U P P O R T   S E R V I C E   P R O V I D E R S ,   I N T E R P R E T E R S ,   E T C )      F O R M C H E C K B O X         ( 6 )    ADVOCACY TRAINING AND SUPPORT NETWORKS FORMCHECKBOX   (7)  COUNSELING (PEER, INDIVIDUAL AND GROUP)   FORMCHECKBOX   (8)  INFORMATION, REFERRAL AND COMMUNITY INTEGRATION FORMCHECKBOX   (9)  OTHER IL SERVICES NOT LISTED ABOVED.  OLDER BLIND SERVICES PROGRAM OUTCOMES AND PERFORMANCESPlace a check mark in the box next to the performance outcome that has been achieved in section "D" during this federal fiscal year. Each outcome may be reported only once, throughout the life of the case. FORMCHECKBOX  (1)  AFTER COMPLETION OF O & M SERVICES, CLIENT HAS EXPERIENCED                    FUNCTIONAL GAINS AND IS ABLE TO MAINTAIN THEIR ABILITY TO TRAVEL SAFELY AND INDEPENDENTLY. FORMCHECKBOX   (2)  CLIENT HAS NOT COMPLETED O & M  SERVICES AND THEREFORE HAS NOT YET EXPERIENCED  FUNCTIONAL GAINS         FORMCHECKBOX   (3) AFTER COMPLETION OF SERVICES OR TRAINING IN NON-VISUAL OR LOW VISION TECHNIQUES CLIENT EXPERIENCED FUNCTIONAL GAINS OR HAS SUCCESSFULLY RESTORED OR MAINTAINED THEIR FUNCTIONAL ABILITY TO ENGAGE IN THEIR CUSTOMARY LIFE ACTIVITIES. FORMCHECKBOX   (4)  CLIENT HAS NOT COMPLETED NON-VISUAL  OR LOW VISION TECHNIQUES AND THEREFORE HAS NOT YET EXPERIENCED FUNCTIONAL GAINS. FORMCHECKBOX   (5)  AFTER COMPLETION OF ASSISTIVE TECHNOLOGY SERVICES OR TRAINING, CLIENT HAS REGAINED OR IMPROVED FUNCTIONAL ABILITIES THAT WERE PREVIOUSLY LOST OR DIMINISHED AS A RESULT OF VISION LOSS. FORMCHECKBOX   (6)  CLIENT HAS NOT COMPLETED ASSISTIVE TECHNOLOG                                   D  F  J    	  	   	  F	  H	  J	  ^	  `	  b	  l	  n	  p	  t	  	  	  	  	  	  弭{paVDa                 #j  h  hc OJ QJ Uh  hc OJ QJ  j    h  hc OJ QJ Uh  h@2Z OJ QJ  (j    h  hGB OJ QJ UmH nH u #je  h  hGB OJ QJ Uh  hGB OJ QJ  j    h  hGB OJ QJ Uh  h|H OJ QJ  h  h> 5OJ QJ #jE
h  h> OJ QJ UVh  h> OJ QJ  j    h  h> OJ QJ U    L      	  	  D	  F	  H	  r	                                                  r                                                                                                                                   }  kd  $$If   l             0 * \                 &                
t  0                              P+6                          4   4 
l a  yt     $If   l                	r	  t	  	  	  	  	  	  	  	  
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t  0                              P+6              4   4 
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  Źxm[xmMB             h  h; OJ QJ  h  h; 5>*OJ QJ  #j  h  h>D OJ QJ Uh  h> OJ QJ  (j    h  h>D OJ QJ UmH nH u #j>  h  h>D OJ QJ Uh  h>D OJ QJ  j    h  h>D OJ QJ Uh  hf 5OJ QJ h  h> 5OJ QJ h  hf OJ QJ  j    h  hc OJ QJ U(j    h  hc OJ QJ UmH nH u
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t  0                              P+6                                      4   4 
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  
  
  (  *  L  N  P  d  f  h  j  l  p  r             4  6  8  B  D  ټ٪n\G   (j    h  h; OJ QJ UmH nH u #j  h  h; OJ QJ U#j  h  h OJ QJ Uh  h-@ OJ QJ  j    h  h-@ OJ QJ Uh  h; OJ QJ mH nH u#j  h  h OJ QJ Uh  h/n OJ QJ  #j  h  h; OJ QJ Uh  h; OJ QJ  j    h  h; OJ QJ Uh  h; 5OJ QJ  n  p    F  j                q            q            Z            Z                                                                                                          L$If   ]Lgd  l                  $If   gd T l               {  kd0  $$If   l             0 *                  :                
t  0                              P+6                          4   4 
l a  yt   D  j  l                              2  4  6  @  B  F  H  J  f  h  |jUC#j%  h  h; OJ QJ U(j    h  h; OJ QJ UmH nH u #j  h  h; OJ QJ Uh  h: OJ QJ  #jX  h  h; OJ QJ Uj    h  h; OJ QJ Uh  h; 5OJ QJ (j    h  h-@ OJ QJ UmH nH u #j)  h  h OJ QJ Uh  h-@ OJ QJ  j    h  h-@ OJ QJ Uh  h; OJ QJ         D  F              q            Z            Z            Z                                                                                                          L$If   ]Lgd  l                  $If   gd T l               {  kd  $$If   l             0 *                  :                
t  0                              P+6                          4   4 
l a  yt   F  H                  q            Z                                                                                                                                            L$If   ]Lgd  l                  $If   gd T l               {  kd  $$If   l             0 *                  :                
t  0                              P+6                          4   4 
l a  yt   h  j                      ;  <  J  K  L                  >  ?  M  N  ´¥¥ʹp\p¥J    #jl%  h  hr_ OJ QJ U&j$  h  hr_ 5OJ QJ U  j    h  hr_ 5OJ QJ U #j.#  h  hr_ OJ QJ U#j   h  hr_ OJ QJ Uj    h  hr_ OJ QJ Uh  hr_ 5>*OJ QJ  h  hr_ OJ QJ  h  hr_ 5OJ QJ h  h; 5OJ QJ h  h; OJ QJ  j    h  h; OJ QJ U             :  ;            =              q            q            q            q            q            q            q            q            q            q            q            q                $If   gd T l               {  kd   $$If   l             0 *                  :                
t  0                              P+6                          4   4 
l a  yt   =  >                F  G  t  u                                                                                                                                                                                                                                                                                                                                                                                       $If   gdo&S l                  $If   gd T l                N  O                            G  H  V  W  X  t  u  v  w  |      ˺٦vrf[L                  j    h  hGB OJ QJ Uh  hj OJ QJ  h  hj 5OJ QJ ho&S  h  h5	 5OJ QJ #j'  h  hr_ OJ QJ U#j '  h  hr_ OJ QJ U&j>&  h  hr_ 5OJ QJ U  j    h  hr_ 5OJ QJ U h  hr_ 5>*OJ QJ  h  hr_ 5OJ QJ h  hr_ OJ QJ  j    h  hr_ OJ QJ U u  v  w          &  (  *  R                                                                                                                                                                                                               $If   gdj l                  j  kd(  $$If   l             = * P+              
t  0                              P+6              4   4 
l a  yt   
         
    *  ,  @  B  D  N  P  R  T  V  r  t  v    ԿԳrcXFc;                   h  hF# OJ QJ  #j*  h  h3 OJ QJ Uh  h3 OJ QJ  j    h  h3 OJ QJ U(j    h  hj OJ QJ UmH nH u #j)  h  hj OJ QJ Uh  hj OJ QJ  j    h  hj OJ QJ Uh  hj 5OJ QJ (j    h  hGB OJ QJ UmH nH u j    h  hGB OJ QJ U#j)  h  hGB OJ QJ Uh  hGB OJ QJ R  T          (  )  k  l                q            q            ^            ^            ^            ^            ^            ^            ^                             $If   gdu
` l                  $If   gdF# l               {  kdU*  $$If   l             0 * F                  
                
t  0                                6                          4   4 
l a  yt   
                    )  *  8  9  :  l  m  {  |  }                      厃qfZO         h  h> OJ QJ  h  hj 5OJ QJ h  h*& OJ QJ  #jp/  h  hW OJ QJ Uh  hW OJ QJ  j    h  hW OJ QJ U#j.  h  hu
` OJ QJ U#j-  h  hu
` OJ QJ U#j,  h  hu
` OJ QJ U#j+  h  hu
` OJ QJ Uh  hu
` OJ QJ  j    h  hu
` OJ QJ U           -  .                                              q            ^            ^            ^            ^            ^            ^                             $If   gdIZ l               k  kd40  $$If   l 4             * +            
t  0                                6              4   4 
l a  f4yt     $If   l                  $If   gdu
` l                
  ,  -                            @  A  O  P  Q  >  ?  M  N  O          炔p^S                 h  hIZ OJ QJ  #j?8  h  h<v OJ QJ U#j5  h  h<v OJ QJ U#j3  h  h<v OJ QJ Uj    h  h<v OJ QJ U#j0  h  h-e OJ QJ Uh  h-e OJ QJ  j    h  h-e OJ QJ Uh  h<v >*OJ QJ h  h<v 5OJ QJ h  h<v OJ QJ  h  h<v 5>*OJ QJ   ?  @  =  >          H  H  H  H                                                                                                                          q            o                             h  kd>  $$If   l              * +              
t  0                                6              4   4 
l a  yt     $If   gdj l                  $If   gdIZ l                                       H  H  H  H  H  H  H  H  H  H  H  H  I  I  $I  &I  :I  <I  >I  峧吅s^L   #j?  h  hj OJ QJ U(j    h  hGB OJ QJ UmH nH u #j$?  h  hGB OJ QJ Uh  hGB OJ QJ  j    h  hGB OJ QJ UhW  h<v  h  h<v 5OJ QJ h  hj 5OJ QJ U#j5=  h  hj OJ QJ U#jw:  h  hj OJ QJ Uh  hj OJ QJ  j    h  hj OJ QJ U Y   S E R V I C E S   O R   T R A I N I N G   A N D   T H E R E F O R E   H A S   N O T   Y E T   E X P E R I E N C E D   F U N C T I O N A L   G A I N S .          N A M E   ( L A S T ,   F I R S T ,   M I )       F O R M T E X T            C A S E   N U M B E R       F O R M T E X T             E .     C O M P L E T E     A T   C L O S U R E      F O R M C H E C K B O X         ( 1 )     C L I E N T   R E P O R T S   T H E Y   A R E   I N   G R E A T E R   C O N T ROL AND ARE MORE CONFIDENT IN THEIR ABILITY TO MAINTAIN THEIR CURRENT LIVING SITUATION AS A RESULT OF SERVICES THEY RECEIVED.  FORMCHECKBOX   (2)  CLIENT REPORTS THAT THEY HAVE LESS  CONTROL AND CONFIDENCE IN THEIR ABILITY TO MAINTAIN THEIR CURRENT LIVING SITUATION, AS A RESULT OF SERVICES THEY RECEIVED. FORMCHECKBOX   (3)  CLIENT REPORTS 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. FORMCHECKBOX   (4) CLIENT EXPERIENCED CHANGES IN LIFESTYLE FOR REASONS UNRELATED TO VISION LOSS.MO 886-4004 (10-08)                                                                               PAGE  PAGE 1                                                                                                        OBS-2                                                                                                                                                                            H  H  H  H  H  H  H  H  H  I   I  "I  $I  LI                                                                                                                                                                                                                                                                                                                                                                                                                    $If   gdj l                   >I  HI  JI  LI  NI  I  I  I  I  I  J  J  J  J  J  8K  9K  GK  HK  IK  K  K  	L  ŷq_qqMqq                                        #jF  h  h) OJ QJ U#jD  h  h) OJ QJ Uj    h  h) OJ QJ Uh  h) OJ QJ  #j@  h  h-e OJ QJ Uh  h-e OJ QJ  j    h  h-e OJ QJ Uh  h) 5>*OJ QJ  h  hj OJ QJ  h  hj 5OJ QJ j    h  hj OJ QJ U(j    h  hj OJ QJ UmH nH uLI  NI  I  I  J  J  7K  8K  K  K  _L              q            q            q            q            q            q            q            q            q                                                                   $If   gd) l               {  kdd@  $$If   l             0 * F                  
                
t  0                                6                          4   4 
l a  yt   
	L  
L  L  `L  aL  cL  dL  eL  fL  gL  iL  jL  lL  mL  oL  pL  rL  L  L  L  L  L  L  L  L  L  L  ÿø|k|V                                      (hk 0J CJ OJ QJ aJ mH nH u*  hx[ hKy 0J CJ OJ QJ aJ  )j    hx[ hKy 0J CJ OJ QJ UaJ hKy CJ OJ QJ aJ  h> hKy CJ OJ QJ aJ  h   j    h  Uhf h)  h|H  h)  h  h) 5OJ QJ h  h) OJ QJ  j    h  h) OJ QJ U#jI  h  h) OJ QJ U _L  `L  aL  bL  cL  dL  eL  fL  hL  iL  kL  lL  nL  oL  qL                                                  }            }            }                                                                                                           gd;    h  kdJ  $$If   l              * +            
t  0                                6              4   4 
l a  yt     $If   gd<v l                qL  rL  QM  RM  SM  TM                                                                                                                                                                                                                                                                                                                                                                                                                                                                              gd;    gdcEn     L  L  M  ,M  PM  QM  RM  SM  TM  ƿ                                                                                                                                                                                                                                                                                                                                                  hf h)  h   hKy  hKy CJ OJ QJ aJ  h> hKy CJ OJ QJ aJ  ,j    hx[ hKy 0J CJ OJ QJ UaJ *6 &P 1h:px[ / =!"#$%                                                                                                                                                                                                                                                                                                                                                                                                                                                                            D d       
             6B8@ >                                  0   
      
  #    A              b J  6Qwogz	 &     D       n  6Qwogz	PNG

   IHDR        3]F   gAMA  |Q   	pHYs  Y  Zrv  IDAThޭoIvǫ,L0`q:`8,	/PPf@;6X,IffH{=tX;^_^Ո̻`G0o>y$gٿ\~8U\l>(dwQyvw>Lncf]_GA왲X{zH7mM:sbz!1ϵmSI)M}lb"ʢ8X|Ѿc;A*Ve E/kQvLкH]3	1q\zCH/[f^XUXG1ND!0WsP@N*IxLƉQ4cnuhYAi`gt0G{s;LgA<.ӛfy5^=et#-2Ҭ$]xc
W~&5r)-LȻ($7&^Y@CLXr
@u
:1?n0<S(nN?c2(oL1=0W:6ʚ٦lN$/a?wmO+fM?,g1dvS<ϰ=;EXӹoT*,~-:mk5ugqѱm2bOPYˮ)?n!Q#c曛LOڇo6th)E>lIn - WжSQ[mBCRȋtnkpGOf[HuaOCݺ>nu	SbAy.bL?SΎj])5ptbX%yNǼmAY8Ój_;sCe{gu&7A<
VfFaq5.9ZEc/z>6JLjs9eX1j15"(, eb|NgTPTl­얁FeD(UƋ)ȭg	M^\5S2 fNb@җ_tLI+s`yiQ)YdZRBP*9RFxm\Od<yNψL0/)"$g0Ekzbh[@>S*_"0/I4:-İ\1=1x|5'̠DwZ4?cr`^22+<6wT6IR\L;IR[@S>g5g
(o`=mUD32%ILİ Dl
ܝU)f	d<cݞK9A1]EYi]j<	\f^4
-zIi.[D
ҤPnbvʙXI9&CZ	
*RA<F645LJ2V6Tab8QsiqZ8q"m Oz|U o;0<>)KmL">0*|u)\*xaJ1/E\ߕ1/ǈ]2Y:=EʛA;T9xZ%׆mA;i2ъqְ_k6yeMgyx<G	7}3bT2oSP	a'WTb:ݕeд4C>MGvsb5eɡٹx LUsb$y&Mʞ9C!VX005f s'NDYHf9]'Vr|)QX~JvL-pUE1Nl9<:CuRW}rugy*<7QĨ1_GЗzИlBe<ucK[?$3U?u{Y'ӠF0ckA9	;:ERM`W=0gW}I9٘fᯙFeV>_O~Mv3[A	f4\>FΌČyb̔dH\r)8Oϧ4{&g&y}&lmAcGH$E}*/-jxEzL(Kcn:.0NɭH80;<g#7[Htfx%Zf'jvw}0ܖgA׺S$8ZBz8^`T=Iȑa1矟'STP*x?Ȏ.O*ĘΉ􊗽RQda#GYk?bl<}Wi3)V{02-r|X{eE/~oy@=8߬ikϯrgL@{*Ec,XR(wD^fsLPT)&"Px'H=P+fWtL8by-RO+vFr#R]c/iƮ7Ŧ1Ue-T2.oRycTlau_4+y{
5 u6o[Xj|<g̵[m3SjʦΈm[XC)򵠪cFL=,\(rf<3(쩠}#dO)0jbw@we81`'/8?H(;>^KʒȨI8BT.gQ7dgOC%͐?64F/cP9m0Kn{\1+YSc-P0DL-R#([C3|N~3V"Gs&&Pȉ_mU7|JLsnu2<vn)P#21NaOA=(vĈI\ƥz-v08AD*Gߔ/vrUE1;۳W4}1\|^ DE]fzy$bZNYGʖ]J&ڔf11 Nk-Cѳm޶W=fBeXR|6ű}E9j짴]J[*RO%Y(b|>Vntc7JrjvdP<)%5"H%ubr91AI
-ieF۽J@fa*NxcTPyWߓA`8-v"uY64
sH:#:8/q#Ŗ|#Uzz`%J|_*=+gUY`ϩj~jl,˦ A;(hRt}3TJj5G&Y[#}^s2 xlaQ4{4Ybv%zsft+D7NN7X D|fiae>/Aa9veZ͗|lbAL2ĎE{ =Js5tHgCX)We-j1(g_1FY/ݺU-N"=}Ĕdcײ=?P(̝d(8댦 :yzYN`M9nZdqlD:d4F^ sb'|8A8/R2&`)9n3t5uKAGYb(ľ*O׎!\L:Z㈁r>{T|sH{D%&lKAW|PiKR%v7t\a=/'j)OQkGރQidZaȼ%ҨOw#/RӪ{HH]mU.\^U:X=T]5"WNxYM/gew؜8V                        	   
                                                                      !   "   #   $   %   &   '   (   )   *   +   ,   -   .   0   1   2   3   4   5   6   R   9   Q   q   =   >   ?   @   A   B   C   D   E   F   G   H   I   J   K   L   M   N   O   P   p   S   T   U   V   W   X   Y   Z   [   \   ]   ^   _   `   a   b   c   d   e   f   g   h   i   j   k   l   m   n   o   r   u   v   w   x   y   z   {   |   }   ~         R o o t   E n t r y                                                 	           F            p#9;          D a t a                                                         
                                     /   2K      W o r d D o c u m e n t                                                                                     8\      O b j e c t P o o l                                                                        Ќ9p#9            _ 1 1 7 3 5 2 0 1 5 2                                               PRP '    Ќ9Ќ9             O l e                                                         
                                         7        W P G 2 0                                                                                                <   (       C o m p O b j                                                                                         }                	   
                                     '               F   ! 	   WP 7 [0]           
  PRP '   Corel Presentations 10 Drawing    Embed Source    Presentations.Drawing.10 9q                                                                                F     H                                                 F   H   d                                                                             Oh +'0                                                        	     WPC           (         -.    -. 5   1   3     9 X!      -.    b(   	  0                     	              C             (                                       F F 2~~00_~ <?X?9?ǎǏ|?!Ǐ <w     ?      >    >  6p0Q  8?!~<cx< uc8<?  u8 8| ?0 ??xp~?q ?  ? ?    ??            u?x       <      C??           ?   |?|<?> ?  À?   |?   ??0?  ? x  ??  0 ~  3     !  ` ? #| ?+   ? ?r  ? 	 a ?3  }~p?   ~#     8?! |u >?8    ?Ã ~    χǀ   p? ~?    Ç   ?Ç  ?     xA?C     88D  x   88`  > x  ?? ?  ?l? p >?ǀA0>??  ~ |   xp  x   Ç x     xp  8< A0> ?| ?`  > 0?`   03     L    ? ?  ??A |   >?8   ?p    `   ?1         <
 Ì 8?     |     x  0  @@ |? 8c  |` |?>`>?#`??6ó ?
? < pL?     ?? |        ?-?         ?8? x    4? 8    ? <8x?   &8<,@  >  <<$@O> 
| > ~  ?~ ?   ?<?<AO x?  N  ?     | ?      |? ?      ~s? ?      ~q 8 <     ~!u8    0 8  0? | x?<ar?? |~a? >?< ?r?  8   0     	`?   	`|  `  ?   >` `??   | `??   >?`??? ??
? g?? ??  |`Ã?  8`x? `? x<x? 08 ?~ |  c? x <   c?? p    C^? q H` 0? x 0? | 0<x?|π00????L@?? ` ?|??   ~X     Á    ? ?  qCxG3?<<G??  $8>s? <  ??< <0  ?|  | < @< ???<  ?p<?  x ?<?  >  8   ?   ?   C?   Ã ?~=      a ?  a ?u? ?0?? ?0q??  89?t ???>?x?V? ? ? ? ? ???  @ > ?? |   ?  a  ?   ??        ?          ?   ???   ?     ?  ? ? < V    ?  |?  x??   x?_? |??$  ?V?>?R? ? ? ?  8                      `   ?  ?? ?& ??|c < <?~|>     ??  u ?  s 8?? ?  ?    p Ç  >     ? ??up?u0Çp up ? >0 F 0? 0  >aa `Ï?`  ?a  p~ 0?q~  0~ ,?  ~   ???S ?  
  ?A0?v0?  ~ 3   &U3@tEV                                                                                                                                                                                                                                                                                                                O b j I n f o                                                      	                                                  B O l e P a r t                                                
                                                  W P G E x t e n t s                                                                                    
       1 T a b l e                                                                                                 t   v'       8m%ֳ~kxUAɱ&`8_RPX2܍O@\3w|BnOm;4{{[K0ҝ}cO7Sdu-i}yLEtB7oGoES,^gFX>ê#§lN1a[Ōp˅/r=a_L3e>+h)|0||qӝ-6lTгM.1I4_s'/b_HM'`7N5J&Yg_N@i)	<1Vm[=SP.8N?îTzjWwRx!iWFk 8ĚUbRsV<&e
;KsmoA)(^zj9i[/#:42;n0Tty{IaCUPQ͖!?kZ!z,ޟgXw{E'=TE#ҎAЖtx)(nVw[CiwQrtn\!7WVLj!Cw)}6gfcKg0^p FϥSy5;2@Ԛޠ*ޑ<,?!YN=ğ^=V	xKJ~?P,U7W(O<]Ҷe*Qn71
#0S-ȵؿ=6ajco_!O6^\ng7'j6cemg	FQo>jmtkO7tQ0j;vnk{)̨h?wY2,g}.Vûirz;L̽.6=+tzY.s|Zǟd|s313?\ w-    IENDB` $$If     !v h5 \5&#v \#v&:V l 
t  0                              P+65 \5&yt     D                                                                     T e x t 1               . O   B   S   2 .   P a g e   1 .   C l i e n t   n a m e   ( l a s t ,   f i r s t ,   M I .           { $$If     !v h5 P+#v P+:V l 
t  0                              P+65 P+yt     D                                                                     T e x t 2                C A S E   N U M B E R .              D                                                                    T e x t 3                C a s e l o a d   n u m b e r .              D                                                                    T e x t 4               9 F E D E R A L   F I S C A L   Y E A R     E X A M P L E     1 0 / 1 / Y E A R   T H R O U G H   9 / 3 0 / Y E A R            $$If     !v h5 X5X5#v X#v:V l 
t  0                              P+65 X5/      yt  { $$If     !v h5 P+#v P+:V l 
t  0                              P+65 P+yt     D                                                               e                 - C L O S E D   S T A T U S   2 6   =   S U C C E S S F U L L Y   R E H A B I L I T A T E D              D                                                                                      D a t e   o f   2 6   c l o s u r e            $$If     !v h5 5:#v #v::V l 
t  0                              P+65 5:yt     D                                                               e                 0 C L O S E D   S T A T U S   2 8   =   U n s u c c e s s f u l l y   r e h a b i l i t a t e d .              D                                                                     T e x t 6                R E A S O N   F O R   2 8   C L O S U R E              D                                                                     T e x t 1 0                D a t e   o f   2 8   c l o s u r e .            $$If     !v h5 5:#v #v::V l 
t  0                              P+65 5:yt     D                                                               e                  C L O S E D   S T A T U S   0 8   =   I N E L I G I B L E              D                                                                     T e x t 8                D a t e   o f   0 8   c l o s u r e            $$If     !v h5 5:#v #v::V l 
t  0                              P+65 5:yt     D                                                               e                 A E L I G I B L E   B U T   N O T   C L O S E D .   ( U S E   F O R   Y E A R   E N D   ( 9 / 3 0 )   R E P O R T I N G   O N L Y )            $$If     !v h5 5:#v #v::V l 
t  0                              P+65 5:yt    D                                                                   C h e c k 1          P L A C E   A   C H E C K   M A R K   I N   T H E   B O X   N E X T   T O   E A C H   S E R V I C E   I N   S E C T I O N S   A ,   B ,   C ,   T H A T   W A S   P R O V I D E D   D U R I N G   T H I S   F E D E R A L   F I S C A L   Y E A R   R E G A R D L E S S   O F   W H E T H E R   T H E   T R A I N I N G   H A S   B E E N   C O M P L E T E D .     [ A 1 .   V I S I O N   S C R E E N I N G   / V I S I O N   E X A M I N A T I O N   / L O W   V I S I O N   E V A L U A T I O N .   P r e s s   F 1   f o r   i n s t r u c t i o n s .           \  D                                                                   C h e c k 2             t A 2 .   S U R G I C A L   O R   T H E R A P E U T I C   T R E A T M E N T   T O   P R E V E N T ,   C O R R E C T ,   O R   M O D I F Y                                                 D I S A B L I N G   E Y E   C O N D I T I O N S              D                                                               e    C h e c k 2 3             6 B 1 .   P R O V I S I O N   O F   A S S I S T I V E   T E C H N O L O G Y   D E V I C E S   A N D   A I D S              D                                                               e    C h e c k 2 4             . B 2 .   P R O V I S I O N   O F   A S S I S T I V E   T E C H N O L O G Y   S E R V I C E S              D                                                               e    C h e c k 2 5             6 C 1 .   I N D E P E N D E N T   L I V I N G   A N D   A D J U S T M E N T     S K I L L S   T R A I N I N G              D                                                               e    C h e c k 2 6             % C 2 .   O R I E N T A T I O N   A N D   M O B I L I T Y   T R A I N I N G              D                                                               e    C h e c k 2 7              C 3 .   C O M M U N I C A T I O N   S K I L L S            $$If     !v h5 P+#v P+:V l =
t  0                              P+65 P+/      yt     D                                                                                    % P a g e   2 .   C l i e n t   n a m e   ( l a s t ,   f i r s t ,   M I .              D                                                                     T e x t 2                C A S E   N U M B E R .            $$If     !v h5 F 5
#v F #v
:V l 
t  0                                65 F 5
yt     D                                                               e    C h e c k 2 8              C 4 .   D A I L Y   L I V I N G   S K I L L S           n  D                                                               e    C h e c k 2 9             | C 5 .   S U P P O R T I V E   S E R V I C E S ,   ( R E A D E R   S E R V I C E S ,   T R A N S P O R T A T I O N ,   P E R S O N A L   A T T E N D A N T ,   S U P P O R T   S E R V I C E   P R O V I D E R S ,   I N T E R P R E T E R S ,   E T C )              D                                                               e    C h e c k 3 0             * C 6 .   A D V O C A C Y   T R A I N I N G   A N D   S U P P O R T   N E T W O R K S              D                                                               e    C h e c k 3 1             - C 7 .   C O U N S E L I N G   ( P E E R ,   I N D I V I D U A L   A N D   G R O U P )                  D                                                               e    C h e c k 3 2             3 C 8 .   I N F O R M A T I O N ,   R E F E R R A L   A N D   C O M M U N I T Y   I N T E G R A T I O N              D                                                               e    C h e c k 3 3             ' C 9 .   O T H E R   I L   S E R V I C E S   N O T   L I S T E D   A B O V E .            $$If     !v h5 +#v +:V l 4
t  0                                65 +/      f4yt    D                                                                   C h e c k 3 5          I n   s e c t i o n   D ,   r e p o r t   e a c h   o u t c o m e   o n l y   o n c e   d u r i n g   t h e   l i f e   o f   t h e   c a s e .  
 D 1 .   A F T E R   C O M P L E T I O N   O F   O   &   M   S E R V I C E S ,   C L I E N T   H A S   E X P E R I E N C E D                                         F U N C T I O N A L   G A I N S   A N D   I S   A B L E   T O   M A I N T A I N   T H E I R   A B I L I T Y   T O   T R A V E L   S A F E L Y   A N D   I N D E P E N D E N T L Y .   N D 1 .   A F T E R   C O M P L E T I O N   O F   O   &   M   S E R V I C E S ,   . . .   p r e s s   F 1   f o r   c o m p l e t e   e x p l a n a t i o n .           @  D                                                               e                 l D 2 .   C L I E N T   H A S   N O T   C O M P L E T E D   O   &   M     S E R V I C E S   A N D   T H E R E F O R E   H A S   N O T   Y E T   E X P E R I E N C E D     F U N C T I O N A L   G A I N S                           <  D                                                                   C h e c k 3 7          D 3 .   A F T E R   C O M P L E T I O N   O F   S E R V I C E S   O R   T R A I N I N G   I N   N O N - V I S U A L   O R   L O W   V I S I O N   T E C H N I Q U E S   C L I E N T   E X P E R I E N C E D   F U N C T I O N A L   G A I N S   O R   H A S   S U C C E S S F U L L Y   R E S T O R E D   O R   M A I N T A I N E D   T H E I R   F U N C T I O N A L   A B I L I T Y   T O   E N G A G E   I N   T H E I R   C U S T O M A R Y   L I F E   A C T I V I T I E S .   z D 3 .   A F T E R   C O M P L E T I O N   O F   S E R V I C E S   O R   T R A I N I N G   I N   N O N - V I S U A L   O R   L O W   V I S I O N   T E C H N I Q U E S   . . .   p r e s s   F 1   f o r   c o m p l e t e   e x p l a n a t i o n .           8  D                                                                   C h e c k 3 8         y D 4 .   C L I E N T   H A S   N O T   C O M P L E T E D   N O N - V I S U A L     O R   L O W   V I S I O N   T E C H N I Q U E S   A N D   T H E R E F O R E   H A S   N O T   Y E T   E X P E R I E N C E D   F U N C T I O N A L   G A I N S .   h D 4 .   C L I E N T   H A S   N O T   C O M P L E T E D   N O N - V I S U A L     O R   L O W   V I S I O N   T E C H N I Q U E S   . . .   p r e s s   F 1   f o r   c o m p l e t e   e x p l a n a t i o n .             D                                                                   C h e c k 3 9          D 5 .   A F T E R   C O M P L E T I O N   O F   A S S I S T I V E   T E C H N O L O G Y   S E R V I C E S   O R   T R A I N I N G ,   C L I E N T   H A S   R E G A I N E D   O R   I M P R O V E D   F U N C T I O N A L   A B I L I T I E S   T H A T   W E R E   P R E V I O U S L Y   L O S T   O R   D I M I N I S H E D   A S   A   R E S U L T   O F   V I S I O N   L O S S .   i D 5 .   A F T E R   C O M P L E T I O N   O F   A S S I S T I V E   T E C H N O L O G Y   S E R V I C E S   O R   T R A I N I N G ,   . . .   p r e s s   F 1   f o r   c o m p l e t e   e x p l a n a t i o n .           d  D                                                               e                 ~ D 6 .   C L I E N T   H A S   N O T   C O M P L E T E D   A S S I S T I V E   T E C H N O L O G Y   S E R V I C E S   O R   T R A I N I N G   A N D   T H E R E F O R E   H A S   N O T   Y E T   E X P E R I E N C E D   F U N C T I O N A L   G A I N S .            $$If     !v h5 +#v +:V l 
t  0                                65 +/      yt     D                                                                                    % P a g e   3 .   C l i e n t   n a m e   ( l a s t ,   f i r s t ,   M I .              D                                                                     T e x t 2                C A S E   N U M B E R .            $$If     !v h5 F 5
#v F #v
:V l 
t  0                                65 F 5
yt    D                                                                   C h e c k 4 0          S e c t i o n   E , C O M P L E T E     A T   C L O S U R E  
 E 1 .   C L I E N T   R E P O R T S   T H E Y   A R E   I N   G R E A T E R   C O N T R O L   A N D   A R E   M O R E   C O N F I D E N T   I N   T H E I R   A B I L I T Y   T O   M A I N T A I N   T H E I R   C U R R E N T   L I V I N G   S I T U A T I O N   A S   A   R E S U L T   O F   S E R V I C E S   T H E Y   R E C E I V E D .      E 1 .   C L I E N T   R E P O R T S   T H E Y   A R E   I N   G R E A T E R   C O N T R O L   A N D   A R E   M O R E   C O N F I D E N T   I N   T H E I R   A B I L I T Y   T O   M A I N T A I N   . . .   p r e s s   F 1   f o r   c o m p l e t e   e x p l a n a t i o n .             D                                                                   C h e c k 4 1          E 2 .   C L I E N T   R E P O R T S   T H A T   T H E Y   H A V E   L E S S     C O N T R O L   A N D   C O N F I D E N C E   I N   T H E I R   A B I L I T Y   T O   M A I N T A I N   T H E I R   C U R R E N T   L I V I N G   S I T U A T I O N ,   A S   A   R E S U L T   O F   S E R V I C E S   T H E Y   R E C E I V E D .    E 2 .   C L I E N T   R E P O R T S   T H A T   T H E Y   H A V E   L E S S     C O N T R O L   A N D   C O N F I D E N C E   I N   T H E I R   A B I L I T Y   T O   M A I N T A I N   . . .   p r e s s   F 1   f o r   c o m p l e t e   e x p l a n a t i o n .             D                                                                   C h e c k 4 2          E 3 .   C L I E N T   R E P O R T S   N O   C H A N G E   I N   T H E I R   F E E L I N G S   O F   C O N T R O L   A N D   C O N F I D E N C E   I N   T H E I R   A B I L I T Y   T O     M A I N T A I N   T H E I R   C U R R E N T   L I V I N G   S I T U A T I O N   A S   A   R E S U L T   O F   S E R V I C E S   T H E Y   R E C E I V E D .    E 3 .   C L I E N T   R E P O R T S   N O   C H A N G E   I N   T H E I R   F E E L I N G S   O F   C O N T R O L   A N D   C O N F I D E N C E   I N   T H E I R   A B I L I T Y   . . .   p r e s s   F 1   f o r   c o m p l e t e   e x p l a n a t i o n .           
  D                                                               e                 Q E 4 .   C L I E N T   E X P E R I E N C E D   C H A N G E S   I N   L I F E S T Y L E   F O R   R E A S O N S   U N R E L A T E D   T O   V I S I O N   L O S S .            $$If     !v h5 +#v +:V l 
t  0                                65 +/      yt                                                                                                                                                                                                                 S u m m a r y I n f o r m a t i o n                           (                                                     D o c u m e n t S u m m a r y I n f o r m a t i o n           8                                        <       C o m p O b j                                                                                          y                                                                                                                                
   <     H     T     `     l     t     |                                      DSS                           OBS 2 fill in template.dot        WOJCHYV       2         Microsoft Office Word   @    F#    @    :@    #@    #              `                                  ՜. +,0           h      p                                                                       (   Missouri Department of Social Services                                                                          Title            
  	           F'   Microsoft Office Word 97-2003 Document 
   MSWordDoc    Word.Document.8 9q                                                                                                                                                                                                                                                                                                        ^                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               2                     0  @  P  `  p                   2  (         0  @  P  `  p                      0  @  P  `  p                      0  @  P  `  p                      0  @  P  `  p                      0  @  P  `  p                      0  @  P  `  p      8  X        V  ~     _HmH	nH	sH	tH	    L  ` L          N o r m a l      $ CJ OJ QJ ^J _HaJ mH	sH	tH	                  D A` D          D e f a u l t   P a r a g r a p h   F o n t     R i@ R          T a b l e   N o r m a l      4 
l 4   a      ( k  (           N o   L i s t         : %   :   =    E n v e l o p e   R e t u r n       d $  d   rT    E n v e l o p e   A d d r e s s   !  @&+D/ ^@  CJ  aJ  j @ j   >   
 T a b l e   G r i d   7 :V 0                                   4   "4   cEn    H e a d e r      !   4    24   cEn    F o o t e r      !   . )@ A.   cEn    P a g e   N u m b e r     H   RH   ,	    B a l l o o n   T e x t      CJ OJ QJ ^J aJ PK     !         [Content_Types].xmlj0Eжr(΢Iw},-j4	wP-t#bΙ{UTU^hd}㨫)*1P'	^W0)T9<l#$yi};~@(Hu*Dנz/0ǰ$X3aZ,D0j~3߶b~i>3\`?/[G\!-Rk.sԻ..a濭?   PK     ! ֧   6     _rels/.relsj0}Q%v/C/} (h"O
= C?hv=Ʌ%[xp{۵_Pѣ<1H0ORBdJE4b$q_6LR7`0̞O,En7Lib/Seе   PK     ! ky         theme/theme/themeManager.xmlM
 @}w7c(Ebˮ CAǠҟ7՛KY,e.|,H,lxɴIsQ}#Ր ֵ+!,^$j=GW)E+&
8   PK     !   P     theme/theme/theme1.xmlYOo6w toc'vuر-MniP@I}úama[إ4:lЯGRX^6؊>$!)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu	gZo~ٺlAplxpT0+[}`jzA V2Fi@qv֬5\|ʜ̭NleXdsjcs7fW+Ն7`gȘJj|h(KD- dXiJ؇(x$(:;˹!I_TS1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ
x}rxwr:\TZaG*y8IjbRc|XŻǿI
u3KGnD1NIBs
RuK>V.EL+M2#'fi~Vvl{u8zH
*:(W☕~JTe\O*tHGHY }KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4=3ڗP
1Pm\\9Mؓ2aD];Yt\[x]}Wr|]g-
eW)6-rCSjid	DЇAΜIqbJ#x꺃6k#ASh&ʌt(Q%p%m&]caSl=X\P1Mh9MVdDAaVB[݈fJíP|8քAV^fHn-"d>znǊ	ة>b&2vKyϼD:,AGm\nziÙ.uχYC6OMf3or$5NHT[XF64T,ќM0E)`#5XY`פ ;%1U٥m;R>QDDcpU'&LE/pm%]8firS4d7y\`JnίIR3U~7+׸#mqBiDi*L69mY&iHE=(K&N!V.KeLDĕ{D	vEꦚdeNƟe(MN9ߜR6&3(a/DUz<{ˊYȳV)9Z[4^n5!J?Q3eBoCMm<.vpIYfZY_p[=al-Y}Nc͙ŋ4vfavl'SA8|*u{-ߟ0%M07%<ҍ    PK     ! ѐ     '   theme/theme/_rels/themeManager.xml.relsM
0wooӺ&݈Э56?$Q,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{ P8g/]QAsم(#L[    PK-      !                       [Content_Types].xmlPK-      ! ֧   6               +  _rels/.relsPK-      ! ky                     theme/theme/themeManager.xmlPK-      !   P                 theme/theme/theme1.xmlPK-      ! ѐ     '             	  theme/theme/_rels/themeManager.xml.relsPK      ]  
    <?xml version="1.0" encoding="UTF-8" standalone="yes"?>
<a:clrMap xmlns:a="http://schemas.openxmlformats.org/drawingml/2006/main" bg1="lt1" tx1="dk1" bg2="lt2" tx2="dk2" accent1="accent1" accent2="accent2" accent3="accent3" accent4="accent4" accent5="accent5" accent6="accent6" hlink="hlink" folHlink="folHlink"/>        \                 	                                 	  
  D  h  N          >I  	L  L  TM                          !   #   (   *   -      r	  
  
  n    F    =  u  R      H  LI  _L  qL  TM                                       "   '   )   +   ,       "   $                              2  >  D  Q  a                !  5  A  G  J  Z                ;  K      >  N          G  W                              	    R  b  	  	  [
  k
  
  
      j  z  ;  K            #  @  P          y      :FFFFG$FG FFG$FG$G G$G$G$G$G$G$FFG G$G$G$G$G G G$G$G$G$G$FFG G$G$G$s   z   |      !  @                                @             H               0    (    	                    
                        0    (    	                    
          B    
        S              	   ?              T e x t 1  T e x t 2  T e x t 3  T e x t 4  T e x t 5  T e x t 6  T e x t 7  T e x t 1 0  T e x t 8  C h e c k 1  C h e c k 2  C h e c k 2 3  C h e c k 2 4  C h e c k 2 5  C h e c k 2 6  C h e c k 2 7  C h e c k 2 8  C h e c k 2 9  C h e c k 3 0  C h e c k 3 1  C h e c k 3 2  C h e c k 3 3  C h e c k 3 5  C h e c k 3 7  C h e c k 3 8  C h e c k 4 0  C h e c k 4 1  C h e c k 4 2          2      3  5      ;    >      G          	  R  	  
    @                                    	   
                                                              E    "  5  H      L    O      X            c  	  
    Q                                      X  b                           A  H  	  	  ]	  l	  	  Y
  
          ,  5  B  %  1                               3  3  3  3  3  3  3  3  3                                                      2  E  G    R  c  {                                        W  X  b                                                                                                                        J  -q   z  c ] u 4	 \
 kW ;  e i" rT d ?  > df x _ : ' ) " F# y# $ nn$ W& *& X+ |Q- o. ,/ ,:/  B/ 1 ?w4 v8 x9 U\: ; D;  < Z< \< K= m= > -@ >@ 2B ZB E F 7F e.G >H |H EI J K M !P o&S  T VoV W f#W JX @2Z IZ ~] u
` j]` Ba kb c =c vKd kd e -e "[l fl Fm /n cEn h o Po Eo j;r s ~~t xu <v Nv >rw }by o} O} } I 5  ; x[  K = r_ E 	   j9 R l` - z D: t K l    ; j v 
> _D ( n# 3 J  0 ! 	 [ ,K   ; = R NF   5	 "  c p  9. + (s jR l % 4 E b  6k |  >D Z  B IO d <X GB a | W $  ;- k DN  f ^m 1\ ] \G } 
 6% ,	 ! = w $ OH   ! _ # 8 R  > Ky )                @d                          X      X  
    X      X   @  X      X  ( @  X  H    X   @      U n k n o w n                                   G  *                  T i m e s   N e w   R o m a n   5                       S y m b o l   3.  *                  A r i a l   9                       G a r a m o n d   5.  * a               T a h o m a   A                         C a m b r i a   M a t h   "  1   h    Kc֦Kc֦ʆ      `             `             !                                                                                                                                                                                                                                                                                                                           4    d                                                                               2Q                           HP    	?    X+    2                    !                             x   x                              D S S  W O J C H Y V                                                                                                                                                               