WIPA Beneficiary/Recipient Application (OMB No. 0960-0629)
WIPA Program Identification Code: _________ Benefit Specialist Code: ___________
Community Work Incentives Coordinator Name: _________________________
Date of Intake (mm/dd/yyyy) Date of Update (mm/dd/yyyy)
Demographic Information:
Last Name First Name Middle Inital
SSN - -
Address
Zip Code
Phone ( ) -
Date of Birth (mm/dd/yyyy) / /
Is the Date of Birth an Estimated Date? Yes No
1. Gender Female Male
2. Primary Disability at Intake
(1) Blind or Visual Impairment
(2) Hearing, Speech, and other Sensory Impairments
(3) Spinal Cord Injury
(4) Non-Spinal Cord Orthopedic Disabilities/Amputations/Motor Impairments
(5) Mental and Emotional Disorders
(6) Cognitive/Developmental Disabilities
(7) System Diseases (e.g. nervous, endocrine, cardiac, etc.)
(8) Traumatic Brain Injury
(9) Infectious Disease
Injury
(11) Cancer/Neoplasm
(12) Other ( Must specify: )
3. Special Language or Other Considerations at Intake (Check all that apply)
Sign Language
English as a Second Language
Other
4. Current Benefit(s) at Intake (Check all that apply)
SSI
SSDI
Concurrent SSI/SSDI
Medicare
Medicaid
Private Health Insurance
Subsidized Housing
Food Stamps
TANF
Workers Compensation
Unemployment Insurance
Veterans Benefit
Other
5. Current Employment Status at Intake
(1) Employed Full-Time
(2) Employed Part-Time
(3) Not Employed, Seeking Employment
(4) Not Employed, Not Seeking Employment
Service Related Questions:
6. Reason for service request (Check all that apply)
Responded to outreach from WIPA program
Communication from SSA
Responded to Ticket to Work Communication from SSA
Not working, but considering going to work
Working, and considering/anticipating change in employment status
Contacted Program as a result of actual change experienced in employment status
(1) lost job (2) starting new job (3) increase/decrease in salary
Anticipated
or actual change experienced in other financial or life
factors
(including other benefits, health care coverage, living arrangement,
marital status...)
Other
7. Service(s) delivered (Check all that apply)
Information and Referral
Problem Solving and Advocacy
Benefits Analysis and Advisement
Benefits Support Planning
Benefits Management
8. Recommended Incentives to be Used (Check all that apply)
TWP
EPE
PASS
IRWE
1619 (a)
1619 (b)
Medicaid Buy-In
Blind Work Expense
Student Earned Income Exclusion
Subsidy Development
Extended Medicare
9. Recommended Provisions to be Used (Check all that apply)
Property Essential to Self Support
Expedited Reinstatement of Benefits
Ticket to Work Program
Continuing Disability Review (CDR) Protections
Section 301
Unsuccessful Work Attempt
10. Anticipated Employment Status Change
(1) Does not intend to change current employment status
(2) Intends to seek new job or supplemental job
(3) Intends to increase work hours in current job
(4) Intends to decrease work hours in current job
(5) Intends to cease employment
(6) Made no decision
10a. Intends to use Ticket to Work to seek new or supplemental job (check if Yes)
10b. Intends to pursue education or training (check if Yes)
11. What is the approximate TOTAL amount of time spent working with or for the participant thus far
(1) Less than 1 hour
(2) One hour or more ( Specify TOTAL in whole hours: )
Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take about 5 minutes to read the instructions, gather the facts, and answer the questions. You may send comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.
File Type | application/msword |
Author | Susan Evans |
Last Modified By | 177717 |
File Modified | 2007-03-27 |
File Created | 2007-03-16 |