February 2009 Brief Survey of Title XVI Applicants

Application for Supplemental Security Income (SSI)

2009 brief survey

February 2009 Brief Survey of Title XVI Applicants

OMB: 0960-0229

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OMB No. 0960-0229

2009 Survey Questions


1. Did any organization or company refer you to SSA to file for disability benefits? (Yes/No)


What type of organization referred you:

  • Private disability company

  • Public (state/local) disability program

  • Worker’s compensation agency

  • Department of Veteran’s Affairs

  • State/local public assistance office (TANF, food stamps, general assistance programs)

  • Unemployment office

  • Other (please specify):


2. If yes, were you required to file for Social Security disability benefits as a condition of receiving cash benefits from the referring organization?

  • Yes

  • No

  • Do not receive or expect to receive cash benefits from the organization that referred me.



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