Work Incentives Planning and Assistance Community Work I

OMB No. 0960-0629
Work Incentives Planning and Assistance Project Site
Application
1. Project Name (SSA grantee name): ________________________________
2. Project Site (provider agency name): ________________________________
3. Primary contact person for data:
Last Name: ________________________ First Name: _________________
Email: _______________________________________
4. Date Site began operation (MM/DD/YY): __ __ /__ __ / __ __
5. Site Contact Information:
Full Address:
City: _______________________State: ___ ___ Zip Code: __ __ __ __ __ - __ __ __ __
Telephone: (__ __ __) __ __ __ - __ __ __ __
Fax: (__ __ __) __ __ __ - __ __ __ __
Site ID: This identifier is assigned when the site Information is entered, and is required
to review or enter either benefit specialist information or beneficiary/recipient
information.
Write it down here when the computer gives it to you: ___ ___ ___ ___ ___ ___
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 2
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.
See Revised
Paperwork
Reduction Act and
Privacy Act below.

CWIC Form

* Indicates a required field.
1. *PARTICIPANT NAME:
2. *CONTACT LOCATION/METHOD (SELECT ONE)
• Follow-up contact
• Initial Contact
3. *DATE OF CONTACT (MM/DD/YYYY)
4. DATE OF NEXT CONTACT (MM/DD/YYYY)
5. WORK INCENTIVES DISCUSSED (SELECT AS MANY THAT
APPLY)
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

Trial Work Period (TWP)
Extended Period of Eligibility (EPE)
Impairment-Related Work Expenses (IRWE)
Plan for Achieving Self Support (PASS)
1619 (a)
1619 (b)
Medicaid Buy-in
Blind Work Expense (BWE)
Student Earned Income Exclusion
Subsidy Development
Extended Medicare
Property Essential to Self Support
Expedited Reinstatement (EXR)
Ticket to Work Program
Continuing Disability Review Protections
Section 301
Unsuccessful Work Attempt
Medicare Modernization Act (MMA)

6. EMPLOYMENT RECOMMENDATIONS (SELECT ONE):

• Beneficiary Unemployed – Recommended looking for job
• Beneficiary Unemployed – Did not recommend looking for a job

•
•
•
•
•
•
•

Beneficiary Unemployed – Recommended if offered Job to accept
Beneficiary Unemployed – Recommended if offered Job to decline
Beneficiary Employed – Recommended quitting job
Beneficiary Employed – Recommended increasing hours
Beneficiary Employed – Recommended maintaining hours
Beneficiary Employed – Recommended decreasing hours
Beneficiary Employed – Recommended seeking promotion

7. BENEFITS RECOMMENDATIONS (SELECT ONE):

•
•
•
•

Recommended earning enough to exit program
Recommended staying on the program
Recommended staying on the program with lower benefit (if SSI)
No recommendation

8. SERVICE REFERRALS (SELECT AS MANY THAT APPLY):

•
•
•
•
•
•
•
•

Vocational Rehabilitation
Para-Transit
Protection and Advocacy
Work-Related Training/Counseling
DOL One-Stop Career Center
Employment Network
Transitional Youth Services
Employer Assistance and Referral Network (EARN)

9. NAME OF SERVICE REFERRAL ORGANIZATION(S): (TEXT BOX)

10. FOLLOW UP CONTACT RECOMMENDED?

• Yes
• No
11. BS&A STATUS

• Completed BS&A
• Updated BS&A

12. WIP STATUS

• Completed WIP
• Updated WIP
13. *TIME SPENT ON CONTACT (MINUTES):

14. TYPE OF SERVICES PROVIDED (CALLED “NEW VALUE” IN ETO. SEE
INFORMATION AT END OF DOCUMENT.) (SELECT ONE);

• Provided Problem Solving and Advocacy Services
• Provided Work Incentives Analysis Services
• Provided Long term Support Services
15. CASE NOTES (CALLED “NOTES IN ETO”) (TEXT BOX):

Point of Service Element: Provide WIPA Services
This tracks the point of service work of CWICs in three core service
types.
1. Problem Solving and Advocacy Services
-Referrals to employment related support services including VR, OneStop Centers, ENs
-Referrals to other types of service providers
-Assisting beneficiaries in resolving problems related to return-to-work
or higher education efforts
2. Work Incentives Analysis Services
-Obtaining and recording comprehensive benefits information
-Assessing potential impacts of employment and other changes on state,
local, and federal benefits eligibility and overall economic well-being
-Producing written benefits analysis plans
3. Long Term Support Services
-Long term work incentives monitoring, management, and assistance
-Updating work incentives and related information
-Periodic reassessment

There are additional fields in the ETO point of service page that allow
the CWICs to capture the details of each type of service interaction.
IF BENEFITS, WORK INCENTIVES, SERVICES, OR
EMPLOYMENT CHANGE, RECORD CHANGE(S) IN A NEW
WORK INCENTIVES PLAN FOLLOW UP ASSESSEMENT.

Paperwork Reduction Act References
I&R Program Home Program

See revised Privacy Act and Paperwork
Reduction Act Statements below.

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WIPA Program Home Page:

See revised Privacy Act and Paperwork
Reduction Act Statements below.

DRAFT

C:\Documents

and

Files\Content.Outlook\AJKEM7X9\Paperwork

Settings\013319\Local

Settings\Temporary

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SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
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 (OMB) control number. The OMB control number is 09600629. OMB approval expires on ____________. We estimate that it will take about 5
minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. You can find your local Social Security office through SSA’s website at
www.socialsecurity.gov. Offices are also listed under U. S. Government agencies in
your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1800-325-0778). 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.

SOCIAL SECURITY

WORK INCENTIVES PLANNING AND ASSISTANCES (WIPA)
Privacy Act Notice
The Work Incentives Planning and Assistances (WIPA) program is established by the Social
Security Administration (SSA) under a law called the Ticket to Work and Work Incentives
Improvement Act of 1999. Under the WIPA program, SSA gives money to organizations so
they can provide SSA beneficiaries with accurate information about work incentives and benefits
planning. SSA will be collecting information from these organizations, including the names and
Social Security numbers of the SSA beneficiaries that the organizations serve, so SSA can
evaluate how the WIPA program is working.
The information you provide is voluntary. However, failure to provide the requested information
may limit your ability to participate in the WIPA program.
Any information reported as part of the WIPA program will not become part of your Social
Security record. The information will not be reported to the SSA office that makes eligibility
determinations. You are responsible for reporting income or changes in status to the SSA office.
Explanations about these and other reasons why information you provide us may be used or
given out are available in Systems of Records Notice 60-0218 (Disability Insurance and
Supplemental Security Income Demonstration Projects and Experiments System). The Notice,
additional information about this form, and any other information regarding our systems and
programs, are available on-line at www.socialsecurity.gov or at your local Social Security office.

SOCIAL SECURITY ADMINISTRATION

BALTIMORE MD 21235-0001