Participation Agreement (Informed Consent)

SOCIAL SECURITY ADMINISTRATION
BENEFIT OFFSET NATIONAL DEMONSTRATION
Stage 2 Participation Agreement
We invite you to volunteer to take part in a new research study that we are conducting under the
Social Security Disability Insurance (SSDI) program. The study is called the Benefit Offset
National Demonstration, or the BOND study for short.
What is the BOND generally study all about?
In this study, we are testing special rules for paying disability benefits to certain SSDI
beneficiaries who work. The special rules are meant to help beneficiaries in their efforts to
work.
Specifically, the special rules use a benefit offset based on earnings instead of using the rules
that we now apply to SSDI beneficiaries who work. Under the special rules, we will reduce
SSDI benefits $1 for every $2 that you earn above a set amount for the year (which is explained
in detail below) . The special benefit offset will allow you to receive reduced SSDI benefit
payments when we would ordinarily stop your payments or your entitlement under our usual
work and earnings rules..
Our goal in this study is to find out whether a benefit offset alone, or a benefit offset along with
enhanced counseling services, will help SSDI beneficiaries to return to work or increase their
earnings. We have hired Abt Associates, an independent research company, to help us
manage the study.
What will I get if I join the BOND study?
If you decide to join the BOND study, you may have the chance to return to work and keep more
of your disability benefits than you can now. If you currently work and you decide to join this
study, you may have the chance to increase your earnings while keeping more of your disability
benefits. If you join the study, you may also have the chance to work with a special counselor
who can help you return to work.
Do I have to join in the BOND study?
You do not have to join the BOND study. Your participation is voluntary. If you choose not to
join the study, we will continue to apply the usual SSDI program rules to you. If you decide to
join, you will be one of about 12,600 SSDI beneficiaries whom we expect to be part of the study.
How does working affect my benefits under the usual SSDI rules?

Going to work does not affect your benefits right away. We provide you with a Trial
Work Period (TWP) that allows you to test your ability to work for at least nine months
and still be considered disabled. During the TWP, you continue to receive full SSDI
benefits no matter how much money you earn, as long as you report your work activity
and continue to have a disabling impairment. The TWP ends when you have completed
nine trial work months, not necessarily in a row, within a 60-month period.

If you complete the TWP and continue to have a disabling impairment, we provide you
with a 36-month reentitlement period that begins right after you complete the TWP. We
Participation Agreement

-1-

explain below how working during the reentitlement period may affect the payment of
benefits.

If you work after the TWP, we review your work and earnings to decide if your work is
Substantial Gainful Activity (SGA). Usually, we consider your work to be SGA if your
monthly earnings, after allowable deductions, average more than the monthly SGA
amount. In 2010, the monthly SGA amount was $1,000 a month for a person who is not
blind or $1,640 a month for a person who is blind. These amounts may increase from
year to year.

We will decide that your disability has ended in the first month you do SGA after
completion of the TWP. We pay you benefits for the month disability ended and the
following two months, no matter how much you earn. This three-month period is the
“grace period.”

We will not pay benefits to you or any member of your family entitled on your earnings
record for any month in which you do SGA after the grace period and during the 36month reentitlement period. However, we will pay benefits for any month in which you
do not do SGA during the reentitlement period. We will terminate your entitlement to
SSDI benefits if you do SGA after the reentitlement period ends.

How would working affect my benefits under the special BOND rules?

The special BOND rules offer you the opportunity to work at an SGA level after the grace period
and receive reduced SSDI benefit payments under a benefit offset. We will still apply our usual
rules for the TWP, for deciding whether your disability ended due to the performance of SGA,
and for paying benefits during the grace period. We will not apply the benefit offset before you
have completed the grace period. Under the special benefit offset, you may receive reduced
SSDI benefit payments when you would ordinarily not receive benefit payments under our usual
rules.
To be eligible for the benefit offset, you must:
•
•
•
•
•
•

Agree to participate in the BOND study;
Be selected for one of the Offset Test Groups under a random assignment process
described below;
Complete the TWP by September 30, 2017;
Perform SGA after the TWP so that we decide that your disability has ended due to
SGA;
Complete the grace period before the end of your BOND participation period; and
Continue to have a disabling impairment.

Participation Agreement

-2-

Comment [ 1]: The SGA amounts for 2011
should be available in late October of this year.
We will revise this sentence above to reflect the
SGA amounts for 2011.

You will be eligible for the benefit offset only during your BOND participation period. Your
BOND participation period begins the month after you complete the TWP or, if you have already
completed the TWP, the month after you are randomly assigned to an Offset Test Group. It
continues for a period of up to 60 months. If you perform SGA after the BOND participation
period ends, we will terminate your entitlement to SSDI benefits. This termination of entitlement
is similar to what happens under our usual rules when you perform SGA after the 36-month
reentitlement period.
Briefly, here is how the benefit offset works.
If you are eligible for the offset throughout a calendar year, we will ask you to give us an
estimate of your earnings, after allowable deductions, for the calendar year. The counselors at
Abt Associates can help you give us this estimate. Under the offset, we will reduce your total
SSDI benefits by $1 for every $2 that your estimated yearly earnings are above the BOND
yearly amount. If your estimated earnings for the year are not above the BOND yearly amount,
we will not reduce your current benefit payments for any month in that year under the offset.
The BOND yearly amount is equal to twelve times the applicable monthly SGA amount. For
example, in 2010, the BOND yearly amount would be $12,000 for a person who is not blind.
If you are eligible for the offset for only part of the calendar year, we will adjust the BOND
amount based on the number of months for which you are eligible for the offset in that year. We
will only use your earnings and benefits for those months when we apply the offset.
If members of your family are entitled to benefits on your earnings record, we will pay them their
benefits even if you receive reduced SSDI benefit payments under the offset. However, we will
not pay benefits to them for any month for which your SSDI benefit is reduced to zero under the
offset.
After the year is over, we will determine the actual amount of your earnings for the year (or the
part of the year for which you were eligible for the offset) to decide whether we paid more or
less in benefits than was due under the offset. We will make appropriate adjustments to future
benefit payments if we determine that we paid you (or members of your family) too much or too
little in benefits..
What do I need to do to join the BOND study?
To join the BOND study, you need to read and sign this Participation Agreement. Signing and
returning this form to a member of the BOND staff at Abt Associates means you agree to be
part of the research project known as the BOND study.
What happens once I agree to take part in the BOND study?
Once you agree to take part in the BOND study, a professional interviewer from Abt Associates
will meet with you. The interviewer will ask you questions about your work experiences, health,
ability to do certain activities, and health insurance coverage. The interviewer will also ask you
about any benefits you receive, your income, and the people that live with you. The interview
session will take about 60 minutes. You will be given $40 as a way of thanking you for the time
needed to complete the interview.
After you finish the interview, your name will be placed into one of three BOND study groups,
through a process called random assignment. The random assignment process is like a lottery.
A special computer program will randomly place you into one of the BOND study groups. Every
beneficiary who agrees to participate in the study has an equal chance of being selected for one
of the BOND study groups.
What are the three BOND study groups?
Participation Agreement

-3-

Comment [ 2]: We anticipate that the nonblind SGA amount for 2011 will become
available before this form is distributed for use
and we will revise the preceding sentence to
reflect the 2011 BOND yearly amount for a
person who is not blind.

1. Control Group. We will assign approximately 4,800 beneficiaries to this group. If you are
randomly placed in this group, you will continue to be subject to our usual SSDI program rules.
You will not receive the special BOND rules. You will have access to the work incentives
available under the usual SSDI rules outlined above. You will also have access to Work
Incentives Planning and Assistance (WIPA) services available from the WIPA program in your
area. A Work Incentives Coordinator at the WIPA program can help you understand how
working will affect your benefits under the usual SSDI rules and can assist you in getting
employment help. If you return to work, you need to report your work activity and earnings to us
right away.

2. Offset Only Test Group. We will assign approximately 4,800 beneficiaries to this
group. If you are randomly placed in this group, you will have the opportunity for the
benefit offset under the special BOND rules discussed above. A Work Incentives
Coordinator at the WIPA program in your area can help you understand how your work
and earnings will affect your SSDI benefits under the special BOND rules and can assist
you in getting employment help.
If you return to work, you need to report your work activity and earnings to us right away. The
counselors at Abt Associates can help you do this. Also, if you become eligible for the benefit
offset, you will need to give us estimates of your earnings. The counselors at Abt can help you
provide this estimate to us.
3. Offset and Enhanced Counseling Test Group. We will assign approximately 3,000
beneficiaries to this group. If you are randomly assigned to this group, you will have the
opportunity for the benefit offset under the special BOND rules discussed above. You
will also receive enhanced counseling services from counselors in your area. These
counselors can help you understand how work and earnings will affect your SSDI
benefits under the special BOND rules. They can also assist you in getting employment
help. These counselors will contact you to offer counseling you may need to help you
get back to work or to make your work experience better.
If you return to work, you need to report your work activity and earnings to us right away. The
counselors at Abt Associates can help you do this. Also, if you become eligible for the benefit
offset, you will need to give us estimates of your earnings. The counselors at Abt can help you
provide this estimate to us.

If I sign the Participation Agreement, what am I agreeing to do or allow?
By signing this agreement to participate in the BOND study, you agree to be randomly assigned
to any one of the three BOND study groups. You also agree to take part in at least three
surveys that Abt Associates is conducting for us.. You will complete the first survey today after
you sign this Participation Agreement. Abt will send the second survey to you for completion
approximately 12 months from now. It will send the third survey to you for completion
approximately two years after the second survey. If needed, Abt Associates may contact you
for additional interviews or surveys for the BOND study.
Participating in the study also means that you give the BOND study staff and researchers
permission to access other information about you. This information is limited to the information
Participation Agreement

-4-

Comment [ 3]: We will include the following
two sentences only if the Congress enacts
legislation to authorize funding for the WIPA
program for fiscal year (FY) 2011. See section
1149(d) of the Social Security Act, as amended
by Public Law 111-63 (authorizing an
appropriation of funds for the WIPA program
only through FY 2010).

Comment [ 4]: We will include the following
sentence only if the Congress enacts legislation
to authorize funding for the WIPA program for
FY 2011.

described below. As a condition of, and while you are part of the BOND study in any of the
three study groups, you are giving permission to us for the following information to be obtained
by the BOND study staff, researchers at Abt Associates, and the Social Security Administration
(SSA). This permission lasts from the date of your enrollment in the BOND study until
September 2022. The information collected includes:

•
•
•
•
•
•

identifying information, including your name, address, Social Security number, and
date of birth;
the dates of your participation in the BOND study as well as participation in the SSDI
program;
Vocational Rehabilitation Program administrative records;
SSA administrative records;
Health and Human Services administrative records; and
Self-reported employment and earnings data.

Who will see the information I provide and how will it be used?
All information you provide is confidential. Information you provide will be protected to the
greatest extent allowed by law. We will use the information you provide in the BOND study only
for research and demonstration program purposes. If you are assigned to one of the Offset
Test Groups, we will use the information that you provide about your work and earnings to
administer your benefits (and the benefits of family members entitled on your earnings record)
for purposes of the BOND study. Otherwise, your answers to research study questions will not
affect any benefits you receive now or in the future. Four groups of people will see the
information you provide in the BOND study: the interviewer, the researchers doing the study,
the office staff working on the study, and our BOND support staff and researchers at SSA. Your
name will never appear in any research report. Research reports will only present summary
information. The researchers will not use names or individual identifying information in any
research report.
What are the potential risks of joining the BOND study?
The risks of joining this study are minimal. However, if you join, there are a few potential risks,
including the possibility that:
• Additional earnings or income could affect your eligibility for public benefit programs
other than SSDI (such as Food Stamps, housing assistance, or other programs).
• Additional earnings or income could affect the benefit amount you receive from benefit
programs other than SSDI.
• Either an overpayment or underpayment of your SSDI benefits could result if your actual,
end-of-year earnings do not match the estimate of your anticipated monthly earnings.
• While there are strict procedures in place to ensure that your confidentiality is protected,
there is a remote risk of a breach of confidentiality. We would inform you if such a
breach were to occur.
• The intent of the benefit offset is to make beneficiaries financially better off. The benefit
offset provides for a longer period of time when you may have earnings and a cash
benefit, and a gradual reduction of those benefits as your earnings increase. However,
there may be instances where a combination of earnings and reduced benefits under the
benefit offset is not the best choice for you, depending on your specific situation. The
BOND study staff will help provide you with the information needed for you to decide
whether the benefit offset could help you financially.

Participation Agreement

-5-

Depending on your BOND study group, you will have access to the services of either Work
Incentives Coordinators or Enhanced Work Incentives Counselors, who can help you review
and avoid any risks resulting from your participation.
Are there any costs to me to take part in the BOND study?
NO, you do not have to pay anything to take part in the BOND study. Any services you receive
from the BOND study will be provided to you at no cost.
What if I decide that I do not want to be part of the BOND study after I have agreed to
join?
If you decide to join the BOND study and are assigned to one of the Offset Test Groups, you
may withdraw in writing from the study at any time without penalty. We will apply our usual SSDI
program rules to you beginning with the month your withdrawal becomes effective. If you are
assigned to an Offset Test Group and later want to withdraw from the study, please contact Ms.
Michelle Wood, the Abt Associates Project Director, at 301-634-1777.
Whom do I contact if I have questions about taking part in the BOND study?
If you have questions regarding the BOND study, please contact Michelle Wood, Project
Director, at 301-634-1777.
If you have any questions about your rights as a participant in the BOND study, you can call
Ms. Teresa Doksum, the IRB Administrator at Abt Associates toll-free at 877-520-6835.
Consent by Participant
By signing this Participation Agreement, I confirm that:
• I have read the information presented in it.
• I understand the information presented in it.
• The information in it was explained to me.
• I have had the opportunity to ask questions about the BOND study.
• I understand my participation in the BOND study is voluntary.
• If I am assigned to an Offset Test Group, I can withdraw from the BOND study at any
time in writing without penalty.
• I understand that I will be given a signed copy of this Participation Agreement for my
records.
• I voluntarily agree to take part in the BOND study and be randomly assigned to any one
of the BOND study groups.
• I voluntarily agree to participate in the research component of the BOND study, the
purpose of which is to determine whether the special BOND rules for paying disability
benefits to certain working SSDI beneficiaries and the amount of counseling provided to
such beneficiaries were successful.

_______________________________________________
Participant’s Name –PLEASE PRINT

_______________________________________________
Participant’s Signature
Date

________________

_______________________________________________
Street, City, State, Zip Code

(___)____-_______
Telephone

Participation Agreement

-6-

Benefit Offset National Demonstration - Participation Agreement
Privacy Act Statement
Collection and Use of Personal Information
Section 234 of the Social Security Act (42 U.S.C. § 434) authorizes us to collect this information. We will
use the information you provide in this agreement to determine whether you are interested in participating
in the Benefit Offset National Demonstration (BOND) study. If you agree to participate in the BOND
study, we will also use the information you provide for a professional interviewer from Abt Associates to
contact you to arrange to meet with you. Your participation in the BOND study is voluntary. However, if
you do not sign this agreement, you will not be able to be a participant in the BOND study. Your current
benefits will not be affected if you choose not to participate.
We rarely use the information you provide on this consent form for any purpose other than for the
purposes explained above. We also may disclose information to another person or to another agency in
accordance with approved routine uses, which include but are not limited to the following:
1. To a congressional office in response to an inquiry from that office made at the request of the
subject of a record;
2. To enable a third party or an agency to assist Social Security in establishing rights to Social Security
benefits or coverage; and
3. To comply with Federal laws requiring the release of information from Social Security records to
other agencies (e.g., to the Government Accountability Office, General Services Administration,
National Archives Records Administration, and the Department of Veterans Affairs).
A complete list of routine uses for this information is available in our System of Records Notice entitled,
Disability Insurance and Supplemental Security Income Demonstration Projects and Experiments System,
60-0218. This notice, additional information regarding this agreement, and information regarding our
programs and systems, are available on-line at www.socialsecurity.gov or at 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 (OMB) control number. The OMB control number for this information
collection is [INSERT NUMBER], expiring [INSERT EXPIRATION DATE]. We estimate that it will take
about 20 minutes to review this form, learn the facts about this new program, and ask any questions you
may have. You may send comments on our time estimate above to: Social Security Administration,
6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate
to this address, not the completed form.

Participation Agreement

-7-