Form SSA-4290 Development of Participation in a Vocational Rehabilitat

Form Approved
OMB No. 0960-0282

SOCIAL SECURITY ADMINISTRATION

DEVELOPMENT OF PARTICIPATION IN A
VOCATIONAL REHABILITATION OR SIMILAR PROGRAM
Part I - To be completed by the State DDS or SSA Field Office
Section A - Beneficiary Information
1. Beneficiary' s Name (Last, First, MI)

2. Beneficiary’s Date
of Birth

3. Type of claim
DI

4. Beneficiary’s Social Security Number

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SSI

Concurrent

5. Wage Earner’s Social Security Number
(if different from Beneficiary’s)

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6. Beneficiary's address (Number & Street, City, State, Zip Code)

7. Beneficiary reports that he/she is receiving vocational rehabilitation services, employment
services, or other support services from (check one):
An Employment Network under an Individual Work Plan (IWP)

A State Vocational Rehabilitation agency under an Individualized Plan for
Employment (IPE)
Other provider of services under an individualized, written employment plan
similar to an IPE
An educational institution under an Individualized Education Program (IEP)
to beneficiary age 18 through 21 years
8. Name, address and telephone number of a contact person in the organization/agency
identified above:

Section B - DDS/FO Information
9. Signature of Person Who Completed Part I:
10. Title:

11. Date:

12. DDS or FO Code:

13. Telephone number
(include area code):

Form SSA-4290-F4 (07-2005) ef (07-2005)
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Part II - To be completed by provider/coordinator of services as shown below
Section A - Employment Network
Section B - State Vocational Rehabilitation Agency
Section C - Other provider of vocational rehabilitation services, employment services, or other support
services (If not an agency of the Federal Government or not an educational institution administering
a student plan in accordance with the Individuals with Disabilities Act, attach a copy of qualifications to
provide vocational rehabilitation services in State services are provided, i.e., license, certification,
accreditation, or registration.)
Section D - Educational Institution under IDEA

Section A -To be completed by Employment Network
1. Is the beneficiary receiving vocational rehabilitation services, employment services, or
other support services under an Individual Work Plan (IWP)?
Yes
No
If no, sign below and return this document to requester.
If yes, give the date the beneficiary and EN signed the IWP and proceed to next question.
Date IWP signed:
No
2. Is the beneficiary taking part in the activities and services outlined in the IWP? Yes
If no, sign below and return this document to requester. If yes, proceed to next question.

3. What is the employment goal?

4. Describe the education, work skills, and/or work experience that the beneficiary will
acquire by completing the IWP or by continuing to participate in the IWP for a specified
period of time.

5. When is the beneficiary expected to complete the activities and services outlined in the
IWP? (Month and Year) :
Signature:
Title:

Date:
Telephone No.
(include area code):

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Section B - To be completed by the State Vocational Rehabilitation (VR)
1. Is the beneficiary receiving VR services, employment services, or other support under an
Yes
No
Individualized Plan for Employment (IPE)?
If no, sign below and return this document to requester.
If yes, give the date the beneficiary and the VR Counselor signed the IPE and proceed to
next question. Date IPE signed:
Yes
No
2. Is the beneficiary taking part in the activities and services outlined in the IPE?
If no, sign below and return this document to requester. If yes, proceed to next question.

3 What is the employment goal?

Form SSA-4290-F4 (07-2005) ef (07-2005)

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4. Describe the education, work skills, and/or work experience that the beneficiary will
acquire by completing the IPE or by continuing to participate in the IPE for a specified
period of time.

5. When is the beneficiary expected to complete the activities and services outlined in the
IPE? (Month and Year) :
Signature:

Date:

Title:

Telephone No.
(include area code):

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Section C - To be completed by Another Provider of Rehabilitation Services
If you are not an agency of the Federal Government or not an educational institution under the Individuals with
Disabilities Act (IDEA), attach a copy of your qualifications to provide vocational rehabilitation services,
employment services or other support services in the State in which you are providing the services (i.e., license,
certification, accreditation, or registration).

1. Is the beneficiary receiving vocational rehabilitation services, employment services or other
support services under an individualized, written employment plan similar to an Individualized
Plan for Employment used by State Vocational Rehabilitation Agencies?
Yes
No
If no, sign below and return this document to requester.
If yes, give the date the provider and the beneficiary signed the plan and proceed to next
question. Date employment plan signed:
2. Is the beneficiary taking part in the activities and services outlined in the employment plan?
Yes

No

If no, sign below and return this document to requester. If yes, please proceed to next
question.
3. What is the employment goal?

4. Describe the education, work skills, and/or work experience that the beneficiary will
acquire by completing the employment plan or by continuing to participate in the
employment plan for a specified period of time.

5. When is the beneficiary expected to complete the activities and services outlined in the
employment plan? (Month and Year) :
Signature:
Title:

Form SSA-4290-F4 (07-2005) ef (07-2005)

Date:
Telephone No.
(include area code):

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Section D - To be completed by an educational institution under the IDEA
1. Is the beneficiary’s educational program provided under an Individualized Education Plan
(IEP)?
Yes
No
If no, complete Section C above.
If yes, give the date the educational institution implemented the IEP and proceed to next
question. Date IEP implemented:
2. Is the beneficiary taking part in the activities and services outlined in the IEP?
Yes

No

If no, sign below and return this document to requester. If yes, please proceed to
next question.
3. When is the beneficiary expected to complete the IEP? (Month and Year):
Signature:

Date:

Title:

Telephone No.
(include area code):

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Privacy Act Statement
Public Law 106-170 and section 234 of the Social Security Act authorize the collection of
information requested on this form. The information you provide will allow you or a beneficiary
participating in the Ticket-to-Work and Self-Sufficiency Program to have more choices in
receiving employment services. You do not have to give us this information. However, without
this information, employment services, vocational rehabilitation services or other support services
necessary for a participant to achieve a vocational goal may not be available to him or her.
The information you provide may be disclosed to another Federal, State, or local government
agency for determining eligibility for a government benefit or program, to a Congressional office
requesting information on your behalf, to an independent party for the performance of research
and statistical activities, or to the Department of Justice for use in representing the Federal
Government.
We may also use this information when we match records by computer. Matching programs
compare our records with those of other Federal, State or local government agencies. Many
agencies may use matching programs to find or prove that a person qualifies for benefits paid by
the Federal Government. The law allows us to do this even if you do not agree to it.
Explanations about these and other reasons why information you provide may be used or given out
are available in Social Security offices. If you want to learn more about this, contact any Social
Security office.
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. The OMB control number for this form is 0960-0282. We estimate that it will
take about 15 minutes to read the instructions, gather the facts, and answer the questions. You
may send comments on our time estimate above to: SSA, 1338 Annex Building, Baltimore, MD
21235-0001. Send only comments on our time estimate to this address, not the completed form.
Form SSA-4290-F4 (07-2005) ef (07-2005)

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