Work Incentives Planning and Assistance Community Work I

Point of Service Information
* Participant:

Fake, Test

* Point of Service / Activity:

Provide WIPA Services

* Contact Location / Method:

--Select Location / Method--

* Date of Last Contact:

None

* Date of Contact:

1/29/2013

* Date of Next Contact:

Submit

Submit

Submit

Provide WIPA Services
* Time Spent:
* Value:

--Select--

Trial Work Period (TWP)
Impairment-Related Work
Expenses (IRWE)

* Work Incentives Discussed:

Extended Period of
Eligibility (EPE)
Plan for Achieving Self
Support (PASS)

1619 (a)

1619 (b)

Medicaid Buy-in

Blind Work Expense (BWE)

Student Earned Income
Exclusion
Extended Medicare

Subsidy Development
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)

* 2-Employment Suggestions:

--Select--

* 3-Benefits Suggestions:

--Select--

* 4A-Service Referrals:

Vocational
Rehabilitation

Para-Transit

Protection and
Advocacy

Work-Related Training/Counseling

DOL One-Stop
Career Center

Employment Network

Transitional Youth
Services
SSA

Employer Assistance and Referral
Network (EARN)
Maximus

* 4B-Name of Service Referral
organization(s):
* 5-Follow Up Contact
Suggested?:

--Select--

* BS&A Status:

--Select--

* WIP Status:

--Select--

Provide WIPA Services Notes

* Notes:

Save Effort & Close Save Effort & Record Similar Effort Save Effort & View/Edit Participant

I & R Assessment
WIPA Team Example

Section A. Inquiry Information
A-1. Topic of Inquiry
Benefits
Non-WIPA Services

Work Incentives
Employment

WIPA Services
Education

Public Health Insurance

Subsidized Housing or Other
Rental Subsidies

Food Stamps

Workers Compensation
Unemployment Insurance
Benefits

TANF
Enrollment in State Vocational
Rehabilitation Agency

Veterans Benefits
Ticket to Work

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

Substantial Gainful
Employment (SGA)

Section 301

Expedited Reinstatement
(EXR)

Earned Income Tax Credit
(EITC)

Other Non-WIPA Service

A-2. Specific Benefit(s) Inquiry

Other Benefits
If Other Benefits, please provide details:

A-3. Specific Work Incentives Query

If Other Non-WIPA Service, please provide details:

January 29, 2013

Page 1 of 2

I & R Assessment
WIPA Team Example

A-4. Specific Non-WIPA Services Inquiry
Vocational Rehabilitation
Services

Para Transit

Protection and Advocacy

Work Related
Training/Counseling

DOL One Stop Career Center

Employment Network (EN)

Transitional Youth Services

Employer Assistance and
Referral Network (EARN)
If Other Non-WIPA Services, please provide details:

Other Non-WIPA Services

A-5. Resolution of I & R Contact
Basic Info Needed

Analysis and Advisement
Needed

Work Incentives Assistance
Needed

Vocational Rehabilitation
Work-Related
Training/Counseling

Para-Transit
DOL One-Stop Career Center

Protection and Advocacy
Employment Network

Transitional Youth Services

Employer Assistance and
Referrals

SSA

Referred to Other Services
Agency
A-6. Service Referrals

Maximus
Please provide the referral organization name(s):

A-7. Time Spent (minutes):

January 29, 2013

Page 2 of 2

OMB No. 0960-0629
WIPA 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:

Telephone: (
Fax: (

)
)

Zip Code:

__ -

-

__ -

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 (OMB) control number. The OMB control
number is 0960-0629. OMB approval expires on ____________. We estimate that it
will take about 15 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 1-800-325-0778). 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.

* 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 WIPA 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 Page

changing time to
20 minutes.

WIPA Program Home Page:

change time to 20
minutes

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.

change time to 20
minutes

WIPA Work Incentives Plan (Baseline)
WIPA Team Example

Section A.
Beneficiary Goals

Section B. EMPLOYMENT PLAN
B-1. Did the beneficiary identify employment goals?
Yes

No

B-2. If beneficiary identified work goals, did they identify strategies to meet these
goals?
Yes
No
If Yes, please provide details:

B-3. In what type of work is beneficiary interested? What suggestions did WIPA staff
make regarding type of work?

B-4. Did the beneficiary use employment services in the past year for the purpose of
getting a job or increasing earnings?
Yes
No
If Yes, please provide details:

B-5. Did the beneficiary look for work in the past four weeks?
Yes

No

Section C. EDUCATION PLAN
C-1. Did the beneficiary identify education goals?
Yes

No

January 28, 2013

Page 1 of 14

WIPA Work Incentives Plan (Baseline)
WIPA Team Example

C-2. Is the beneficiary pursuing education?
Beneficiary pursuing education
at intake

Beneficiary not pursuing
education at intake

Beneficiary not pursuing
education at intake; WIPA staff
suggested beneficiary pursue
education

Beneficiary pursued education
C-3. If beneficiary is pursuing education (Post secondary, continuing adult education,
special education, GED, vocational, etc.), are they taking classes or have they applied for
classes?
Applied for classes
Taking classes
Not applying for or taking
classes

Section D. BENEFITS/WORK INCENTIVES/SERVICES PLAN
D-1. Does the beneficiary want to earn enough to reduce benefits?
No, beneficiary made no
decision
No, they decided against this
after receiving WIPA services

No, this is not their initial plan

Yes, this is their initial plan

Yes, this became their plan
after receiving WIPA services

D-2. Does the beneficiary want to earn enough to stop receiving benefits? (SSI or
SSDI)?
No, this is not their initial plan
Yes, this is their initial plan
No, beneficiary made no
decision
No, they decided against this
Yes, this became their plan
after receiving WIPA services
after receiving WIPA services
D-3. Benefits - Private Health Insurance?
Yes

No

D-4. Benefits - Public Health Insurance
Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

Not utilizing at intake but
suggested

D-5. If Yes to Public Health Insurance, what type?
Medicaid

Medicare

Medicare and Medicaid

D-6. If receiving Medicaid, has beneficiary participated in Medicaid Buy-In?
Yes

No

D-7. Benefits - Subsidized Housing or Other Rental Subsidies
Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

Not utilizing at intake but
suggested

Utilizing at intake

Not utilizing at intake but
suggested

D-8. Benefits - Food Stamps
Not utilizing at intake not
suggested

January 28, 2013

Utilizing after receiving WIPA
services

Page 2 of 14

WIPA Work Incentives Plan (Baseline)
WIPA Team Example

D-9. Benefits - Workers Compensation
Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

Not utilizing at intake but
suggested

Utilizing at intake

Not utilizing at intake but
suggested

Utilizing at intake

Not utilizing at intake but
suggested

D-10. Benefits - TANF
Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services
D-11. Benefits - Veterans Benefits
Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

D-12. Benefits - Unemployment Insurance Benefits
Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

Not utilizing at intake but
suggested

D-13. Benefits - Enrolled in State Vocational Rehabilitation Agency (SVRA)
Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

Not utilizing at intake but
suggested

Utilizing at intake

Not utilizing at intake but
suggested

D-14. Benefits - Tickets
Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

D-15. To whom has the beneficiary assigned his/her ticket?
SVRA

Employment Network

D-16. If the beneficiary assigned his/her ticket to an EN, what is the name of the EN?

January 28, 2013

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WIPA Work Incentives Plan (Baseline)
WIPA Team Example

D-17. Benefits - Other Benefit(s)
Utilizing at intake
Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services
Please provide details on the Other Benefit(s):

Not utilizing at intake but
suggested

D-18. Work Incentives - Trial Work Period (TWP)
Knowledge of incentive at
intake
Not utilizing at intake but
suggested

Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

D-19. Work Incentives - Extended Period of Eligibility (EPE)
Knowledge of incentive at
intake
Not utilizing at intake but
suggested

Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

D-20. Work Incentives - Impairment Related Work Expenses (IRWE)
Knowledge of incentive at
intake
Not utilizing at intake but
suggested

Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

D-21. Work Incentives - Plan for Achieving Self Support (PASS)
Knowledge of incentive at
intake
Not utilizing at intake but
suggested

Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

D-22. Work Incentives - 1619 (a)
Knowledge of incentive at
intake
Not utilizing at intake but
suggested
D-23. Work Incentives - 1619 (b)
Knowledge of incentive at
intake
Not utilizing at intake but
suggested

January 28, 2013

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WIPA Work Incentives Plan (Baseline)
WIPA Team Example

D-24. Work Incentives - Medicaid Buy In
Knowledge of incentive at
intake
Not utilizing at intake but
suggested

Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

D-25. Work Incentives - Blind Work Expense (BWE)
Knowledge of incentive at
intake
Not utilizing at intake but
suggested

Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

D-26. Work Incentives - Student Earned Income Exclusion
Knowledge of incentive at
intake
Not utilizing at intake but
suggested

Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

D-27. Work Incentives - Subsidy Development
Knowledge of incentive at
intake
Not utilizing at intake but
suggested

Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

D-28. Work Incentives - Extended Medicare
Knowledge of incentive at
intake
Not utilizing at intake but
suggested

Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

D-29. Work Incentives - Property Essential to Self Support
Knowledge of incentive at
intake
Not utilizing at intake but
suggested

Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

D-30. Work Incentives - Substantial Gainful Employment (SGA)
Knowledge of incentive at
intake
Not utilizing at intake but
suggested

Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

D-31. Work Incentives - Section 301
Knowledge of incentive at
intake
Not utilizing at intake but
suggested

D-32. Work Incentives - Expedited Reinstatement (EXR)
Knowledge of incentive at
intake
Not utilizing at intake but
suggested

January 28, 2013

Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

Page 5 of 14

WIPA Work Incentives Plan (Baseline)
WIPA Team Example

D-33. Work Incentives - Earned Income Tax Credit (EITC)
Knowledge of incentive at
intake
Not utilizing at intake but
suggested

Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

D-34. Services - Vocational Rehabilitation Services
Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

Not utilizing at intake but
suggested

Utilizing at intake

Not utilizing at intake but
suggested

D-35. Services - Para Transit
Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

D-36. Services - Protection and Advocacy
Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

Not utilizing at intake but
suggested

D-37. Services - Work Related Training/Counseling
Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

Not utilizing at intake but
suggested

D-38. Services - DOL One Stop Career Center
Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

Not utilizing at intake but
suggested

D-39. Services - Employment Network (EN)
Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

Not utilizing at intake but
suggested

D-40. Services - Transitional Youth Services
Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

Not utilizing at intake but
suggested

D-41. Services - Employer Assistance and Referral Network (EARN)
Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

January 28, 2013

Utilizing at intake

Not utilizing at intake but
suggested

Page 6 of 14

WIPA Work Incentives Plan (Baseline)
WIPA Team Example

Beneficiary

Section E. EMPLOYMENT INFORMATION (UPDATE FOR EACH NEW EMPLOYMENT)
E-1. Is beneficiary currently employed?
Yes

No

E-2. Is beneficiary employed full time or part time?
Full time

Part time

E-3. Name and address of employer or potential employer.

E-4. What is the type of work?

E-5. Number of hours per week

E-6. Hourly wage.
$
E-7. Does beneficiary receive benefits through your employment?
Yes

No

E-8. Date of hire
__/__/____
E-9. Is beneficiary self employed?
Yes

No

OPTIONAL-Benefit

Section F. INTAKE INFORMATION
F-1. Do we have a signed release of information?
Yes

No

F-2. Permission granted to CC report to the following person.

F-3. Did beneficiary attend a WISE presentation?
Yes

No

Section G. BENEFIT PLANNING QUERY (BPQY)
G-1. What is beneficiary's Supplemental Security Income (SSI) amount on the BPQY?
$

January 28, 2013

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WIPA Work Incentives Plan (Baseline)
WIPA Team Example

G-2. What is the beneficiary’s date of entitlement for SSI?
__/__/____
G-3. What is beneficiary's SSDI Amount on BPQY?
$
G-4. What is the beneficiary’s date of entitlement for SSDI?
__/__/____
G-5. Has beneficiary started beneficiary's TWP?
Yes

No

G-6. What date did beneficiary start beneficiary's TWP?
__/__/____
G-7. How many TWP months are remaining?

G-8. What is the date beneficiary's TWP ended?
__/__/____
G-9. Are there any earnings reflected in the BPQY that should have triggered TWP
months?
Yes

No

Section H. SOCIAL SECURITY CASH BENEFITS - SSDI
H-1. Did beneficiary receive Social Security Disability Insurance (SSDI)?
Yes

No

H-2. What type of SSDI benefits is beneficiary receiving?
Against your own record

Childhood disability
beneficiary (formerly DAC)

Widow/Widower

Other
H-3. Are there minor children receiving cash benefits on beneficiary's record under this
Social Security number?
Yes

No

H-4. What is the date the EPE began?
__/__/____
H-5. What is the date the 36 month EPE ended?
__/__/____

Section I. SOCIAL SECURITY CASH BENEFITS - SSI
I-1. What is the amount of beneficiary's gross monthly unearned income?
$

January 28, 2013

Page 8 of 14

WIPA Work Incentives Plan (Baseline)
WIPA Team Example

I-2. What is the amount of beneficiary's gross monthly earned income?
$
I-3. If beneficiary is married, does beneficiary's spouse have any income?
Yes

No

I-4. If so, how much?
$

Section J. RESOURCES
J-1. Does beneficiary own beneficiary's own home?
Yes

No

J-2. How much money does beneficiary have in a savings account?
$
J-3. How much money does beneficiary have in a checking account?
$
J-4. List any other assets

J-5. Does beneficiary have an Individual Retirement Account (IRA)?
Yes

No

J-6. If so, how much does beneficiary have saved in a retirement account?
$
J-7. Does beneficiary own more than one vehicle?
Yes

No

J-8. If yes, what is the value?
$

Section K. OTHER MONTHLY INCOME AMOUNTS
K-1. How much does beneficiary receive in: Unemployment Cash Benefits
$
K-2. How much does beneficiary receive in: Workers Compensation
$
K-3. How much does beneficiary receive in: Railroad Reirement Pension
$

January 28, 2013

Page 9 of 14

WIPA Work Incentives Plan (Baseline)
WIPA Team Example

K-4. How much does beneficiary receive in: Veterans Cash Benefits
$
K-5. How much does beneficiary receive in: Child support
$
K-6. How much does beneficiary receive in: Alimony/Palimony
$
K-7. How much does beneficiary receive in: Private Disability Insurance
$
K-8. How much does beneficiary receive in: Other Incomes
$

Section L. FINANCIAL NEEDS BASED ASSISTANCE
L-1. How much does beneficiary receive in TANF?
$
L-2. How much does beneficiary receive in a PELL grant?
$
L-3. How much does beneficiary receive in Food Stamps?
$
L-4. Does beneficiary receive Subsidized housing?
Yes

No

L-5. If beneficiary receives Subsidized housing- what type does beneficiary receive?
Section 8 Voucher

rent is based on 30% of
beneficiary income (property
based)

Does not apply

Section M. LIVING ARRANGEMENTS
M-1. Does beneficiary live alone?
Yes

No

M-2. If no, how many people live in beneficiary's household?

M-3. How much does beneficiary pay for rent each month?
$

Section N. HEALTH COVERAGE (PUBLIC INSURANCE)

January 28, 2013

Page 10 of 14

WIPA Work Incentives Plan (Baseline)
WIPA Team Example

N-1. Does beneficiary receive public health insurance?
Yes

No

N-2. If beneficiary receives public health insurance, what type?
Medicare
Medicare and Medicaid
Champus/VA/TRICARE
SCHIP
If Other public insurance, please provide details:

Medicaid
Other

Section O. HEALTH BENEFITS (MEDICAID)
O-1. Does beneficiary receive Medicaid
Yes

No

O-2. If so, does beneficiary have a spenddown?
Yes

No

O-3. Does beneficiary meet beneficiary's spenddown each month?
Yes

No

Section P. Section 1619
P-1. If beneficiary is not receiving SSI now, did beneficiary receive it in the past?
Yes

No

P-2. Did beneficiary lose SSI due to wages?
Yes

No

P-3. Did beneficiary lose beneficiary's SSI due to the receipt of some form of Social
Security cash benefit (Pickle Amendment)?
Yes

No

Section Q. HEALTH BENEFITS (HEALTH BENEFITS FOR WORKERS WITH DISABILITIES)
Q-1. Is beneficiary currently working?
Yes

No

Q-2. Is beneficiary currently receiving Health Benefits for Workers with Disabilities?
Yes

No

Q-3. Is beneficiary's current net income (not counting SSI) less than $1702 (single) or
$2282 (couple)?
Yes

No

Section R. HEALTH BENEFITS (MEDICARE)

January 28, 2013

Page 11 of 14

WIPA Work Incentives Plan (Baseline)
WIPa Team Example

R-1. Did beneficiary receive Medicare coverage?
Yes

No

R-2. If so, what parts of Medicare coverage did beneficiary recieve?
Medicare Part A
(Hospitalization)

Medicare Part B (Outpatient)

Medicare Part D (Prescription
coverage)

R-3. Who pays beneficiary's Medicare Part B premium?
I pay it myself.

The state pays my premium
(QMB/SLMB).

R-4. Does beneficiary receive a Subsidy or Extra Help through Social Security for
beneficiary's Medicare Part D prescription coverage?
Yes

No

Section S. HEALTH COVERAGE (PRIVATE INSURANCE)
S-1. Does beneficiary have private health insurance coverage?
Yes

No

S-2. If beneficiary has private health insurance, what type does beneficiary have?
Employer
Employer of family member
Private disability insurance
Other
If Other private health insurance, please provide details:

Workers Compensation

S-3. If so, how much does beneficiary pay in a monthly premium for beneficiary's
private health insurance coverage?
$

Section T. ANALYSIS OF IRWE
T-1. Does beneficiary have out of pocket expenses each month for items or services that
allow beneficiary to work?
Yes

No

T-2. If there are potential IRWES list items/services and their monthly costs.

Section U. ANALYSIS OF SUBSIDIES

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U-1. Is government agency paying part of wage?
Yes

No

U-2. Does beneficiary get special assistance on the job?
Yes

No

U-3. Does beneficiary perform fewer duties than others?
Yes

No

U-4. Does employer accept less productivity than from others?
Yes

No

U-5. Does beneficiary receive extra rest periods/breaks?
Yes

No

U-6. Is beneficiary frequently absent or working irregular hours because of disability?
Yes

No

U-7. Does beneficiary receive job coach assistance?
Yes

No

U-8. If receiving job coach assistance, how many hours per week does beneficiary
receive *(on site)* assistance?

Section V. BLIND WORK EXPENSES ANALYSIS
V-1. Is beneficiary legally blind?
Yes

No

V-2. Is beneficiary receiving SSI benefits?
Yes

No

V-3. List potential BWE items/services and their montly costs

Section W. PASS ANALYSIS
W-1. Does beneficiary have an approved PASS?
Yes

No

W-2. Does beneficiary have goods or services that would help him or her reach a
vocational goal, that he or she would purchase if extra money were available?
Yes

No

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W-3. If yes list goods or services, there expected purpose, and approximate cost.

W-4. *NOTES*

Section X. VOCATIONAL
X-1. Is beneficiary enrolled in State Vocational Rehabilitation Agency?
Yes

No

X-2. Has beneficiary assigned beneficiary's Ticket to Work?
Yes

No

X-3. Who did beneficiary assign beneficiary's Ticket to?

X-4. Name and agency of referral source.

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Section A.
Beneficiary Goals

Section B. EMPLOYMENT PLAN
B-1. Did the beneficiary identify employment goals?
Yes

No

B-2. If beneficiary identified work goals, did they identify strategies to meet these
goals?
Yes
No
If Yes, please provide details:

B-3. In what type of work is beneficiary interested? What suggestions did WIPA staff
make regarding type of work?

B-4. Did the beneficiary use employment services in the past year for the purpose of
getting a job or increasing earnings?
Yes
No
If Yes, please provide details:

B-5. Did the beneficiary look for work in the past four weeks?
Yes

No

Section C. EDUCATION PLAN
C-1. Did the beneficiary identify education goals?
Yes

No

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C-2. Is the beneficiary pursuing education?
Beneficiary pursuing education
at intake

Beneficiary not pursuing
education at intake

Beneficiary not pursuing
education at intake; WIPA staff
suggested beneficiary pursue
education

Beneficiary pursued education
C-3. If beneficiary is pursuing education (Post secondary, continuing adult education,
special education, GED, vocational, etc.), are they taking classes or have they applied for
classes?
Applied for classes
Taking classes
Not applying for or taking
classes

Section D. BENEFITS/WORK INCENTIVES/SERVICES PLAN
D-1. Does the beneficiary want to earn enough to reduce benefits?
No, beneficiary made no
decision
No, they decided against this
after receiving WIPA services

No, this is not their initial plan

Yes, this is their initial plan

Yes, this became their plan
after receiving WIPA services

D-2. Does the beneficiary want to earn enough to stop receiving benefits? (SSI or
SSDI)?
No, beneficiary made no
decision
D-3. Did the beneficiary eventually earn enough to reduce benefits?
Yes
D-4. Does the beneficiary want to earn enough to stop receiving benefits? (SSI or
SSDI)?
No, this is not their initial plan
D-5. Did the beneficiary eventually earn enough to reduce benefits?
No
D-6. Does the beneficiary want to earn enough to stop receiving benefits? (SSI or
SSDI)?
Yes, this is their initial plan
No, they decided against this
Yes, this became their plan
after receiving WIPA services
after receiving WIPA services
D-7. Benefits - Private Health Insurance?
Yes

No

D-8. Benefits - Public Health Insurance
Not utilizing at intake not
suggested

Utilizing at intake

Not utilizing at intake but
suggested

D-9. Did the beneficiary eventually earn enough to stop receiving benefits? (SSI or
SSDI)
Yes

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D-10. Benefits - Public Health Insurance
Utilizing after receiving WIPA
services
D-11. Did the beneficiary eventually earn enough to stop receiving benefits? (SSI or
SSDI)
No
D-12. If Yes to Public Health Insurance, what type?
Medicaid

Medicare

Medicare and Medicaid

D-13. If receiving Medicaid, has beneficiary participated in Medicaid Buy-In?
Yes

No

D-14. Benefits - Subsidized Housing or Other Rental Subsidies
Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

Not utilizing at intake but
suggested

Utilizing at intake

Not utilizing at intake but
suggested

D-15. Benefits - Food Stamps
Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

D-16. Benefits - Workers Compensation
Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

Not utilizing at intake but
suggested

Utilizing at intake

Not utilizing at intake but
suggested

Utilizing at intake

Not utilizing at intake but
suggested

D-17. Benefits - TANF
Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services
D-18. Benefits - Veterans Benefits
Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

D-19. Benefits - Unemployment Insurance Benefits
Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

January 28, 2013

Utilizing at intake

Not utilizing at intake but
suggested

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D-20. Benefits - Enrolled in State Vocational Rehabilitation Agency (SVRA)
Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

Not utilizing at intake but
suggested

Utilizing at intake

Not utilizing at intake but
suggested

D-21. Benefits - Tickets
Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

D-22. To whom has the beneficiary assigned his/her ticket?
SVRA

Employment Network

D-23. If the beneficiary assigned his/her ticket to an EN, what is the name of the EN?

D-24. Benefits - Other Benefit(s)
Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

Not utilizing at intake but
suggested

Please provide details on the Other Benefit(s):

D-25. Work Incentives - Trial Work Period (TWP)
Knowledge of incentive at
intake
Not utilizing at intake but
suggested

Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

D-26. Work Incentives - Extended Period of Eligibility (EPE)
Knowledge of incentive at
intake
Not utilizing at intake but
suggested

Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

D-27. Work Incentives - Impairment Related Work Expenses (IRWE)
Knowledge of incentive at
intake
Not utilizing at intake but
suggested

January 28, 2013

Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

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D-28. Work Incentives - Plan for Achieving Self Support (PASS)
Knowledge of incentive at
intake
Not utilizing at intake but
suggested

Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

D-29. Work Incentives - 1619 (a)
Knowledge of incentive at
intake
Not utilizing at intake but
suggested
D-30. Work Incentives - 1619 (b)
Knowledge of incentive at
intake
Not utilizing at intake but
suggested

D-31. Work Incentives - Medicaid Buy In
Knowledge of incentive at
intake
Not utilizing at intake but
suggested

Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

D-32. Work Incentives - Blind Work Expense (BWE)
Knowledge of incentive at
intake
Not utilizing at intake but
suggested

Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

D-33. Work Incentives - Student Earned Income Exclusion
Knowledge of incentive at
intake
Not utilizing at intake but
suggested

Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

D-34. Work Incentives - Subsidy Development
Knowledge of incentive at
intake
Not utilizing at intake but
suggested

Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

D-35. Work Incentives - Extended Medicare
Knowledge of incentive at
intake
Not utilizing at intake but
suggested

Not utilizing at intake not
suggested
Utilizing after receiving WIPa
services

Utilizing at intake

D-36. Work Incentives - Property Essential to Self Support
Knowledge of incentive at
intake
Not utilizing at intake but
suggested

January 28, 2013

Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

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D-37. Work Incentives - Substantial Gainful Employment (SGA)
Knowledge of incentive at
intake
Not utilizing at intake but
suggested

Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

D-38. Work Incentives - Section 301
Knowledge of incentive at
intake
Not utilizing at intake but
suggested

D-39. Work Incentives - Expedited Reinstatement (EXR)
Knowledge of incentive at
intake
Not utilizing at intake but
suggested

Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

D-40. Work Incentives - Earned Income Tax Credit (EITC)
Knowledge of incentive at
intake
Not utilizing at intake but
suggested

Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

D-41. Services - Vocational Rehabilitation Services
Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

Not utilizing at intake but
suggested

Utilizing at intake

Not utilizing at intake but
suggested

D-42. Services - Para Transit
Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

D-43. Services - Protection and Advocacy
Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

Not utilizing at intake but
suggested

D-44. Services - Work Related Training/Counseling
Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

Not utilizing at intake but
suggested

D-45. Services - DOL One Stop Career Center
Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

January 28, 2013

Utilizing at intake

Not utilizing at intake but
suggested

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D-46. Services - Employment Network (EN)
Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

Not utilizing at intake but
suggested

D-47. Services - Transitional Youth Services
Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

Not utilizing at intake but
suggested

D-48. Services - Employer Assistance and Referral Network (EARN)
Not utilizing at intake not
suggested
Utilizing after receiving WIPA
services

Utilizing at intake

Not utilizing at intake but
suggested

Beneficiary

Section E. EMPLOYMENT INFORMATION (UPDATE FOR EACH NEW EMPLOYMENT)
E-1. Is beneficiary currently employed?
Yes

No

E-2. Is beneficiary employed full time or part time?
Full time

Part time

E-3. Name and address of employer or potential employer.

E-4. What is the type of work?

E-5. Number of hours per week

E-6. Hourly wage.
$
E-7. Does beneficiary receive benefits through your employment?
Yes

No

E-8. Date of hire
__/__/____
E-9. Is beneficiary self employed?
Yes

No

OPTIONAL-Benefit

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Section F. INTAKE INFORMATION
F-1. Do we have a signed release of information?
Yes

No

F-2. Permission granted to CC report to the following person.

F-3. Did beneficiary attend a WISE presentation?
Yes

No

Section G. BENEFIT PLANNING QUERY (BPQY)
G-1. What is beneficiary's Supplemental Security Income (SSI) amount on the BPQY?
$
G-2. What is the beneficiary’s date of entitlement for SSI?
__/__/____
G-3. What is beneficiary's SSDI Amount on BPQY?
$
G-4. What is the beneficiary’s date of entitlement for SSDI?
__/__/____
G-5. Has beneficiary started beneficiary's TWP?
Yes

No

G-6. What date did beneficiary start beneficiary's TWP?
__/__/____
G-7. How many TWP months are remaining?

G-8. What is the date beneficiary's TWP ended?
__/__/____
G-9. Are there any earnings reflected in the BPQY that should have triggered TWP
months?
Yes

No

Section H. SOCIAL SECURITY CASH BENEFITS - SSDI
H-1. Did beneficiary receive Social Security Disability Insurance (SSDI)?
Yes

No

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H-2. What type of SSDI benefits is beneficiary receiving?
Against your own record

Childhood disability
beneficiary (formerly DAC)

Widow/Widower

Other
H-3. Are there minor children receiving cash benefits on beneficiary's record under this
Social Security number?
Yes

No

H-4. What is the date the EPE began?
__/__/____
H-5. What is the date the 36 month EPE ended?
__/__/____

Section I. SOCIAL SECURITY CASH BENEFITS - SSI
I-1. What is the amount of beneficiary's gross monthly unearned income?
$
I-2. What is the amount of beneficiary's gross monthly earned income?
$
I-3. If beneficiary is married, does beneficiary's spouse have any income?
Yes

No

I-4. If so, how much?
$

Section J. RESOURCES
J-1. Does beneficiary own beneficiary's own home?
Yes

No

J-2. How much money does beneficiary have in a savings account?
$
J-3. How much money does beneficiary have in a checking account?
$
J-4. List any other assets

J-5. Does beneficiary have an Individual Retirement Account (IRA)?
Yes

No

J-6. If so, how much does beneficiary have saved in a retirement account?
$

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J-7. Does beneficiary own more than one vehicle?
Yes

No

J-8. If yes, what is the value?
$

Section K. OTHER MONTHLY INCOME AMOUNTS
K-1. How much does beneficiary receive in: Unemployment Cash Benefits
$
K-2. How much does beneficiary receive in: Workers Compensation
$
K-3. How much does beneficiary receive in: Railroad Reirement Pension
$
K-4. How much does beneficiary receive in: Veterans Cash Benefits
$
K-5. How much does beneficiary receive in: Child support
$
K-6. How much does beneficiary receive in: Alimony/Palimony
$
K-7. How much does beneficiary receive in: Private Disability Insurance
$
K-8. How much does beneficiary receive in: Other Incomes
$

Section L. FINANCIAL NEEDS BASED ASSISTANCE
L-1. How much does beneficiary receive in TANF?
$
L-2. How much does beneficiary receive in a PELL grant?
$
L-3. How much does beneficiary receive in Food Stamps?
$
L-4. Does beneficiary receive Subsidized housing?
Yes

No

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L-5. If beneficiary receives Subsidized housing- what type does beneficiary receive?
Section 8 Voucher

rent is based on 30% of
beneficiary income (property
based)

Does not apply

Section M. LIVING ARRANGEMENTS
M-1. Does beneficiary live alone?
Yes

No

M-2. If no, how many people live in beneficiary's household?

M-3. How much does beneficiary pay for rent each month?
$

Section N. HEALTH COVERAGE (PUBLIC INSURANCE)
N-1. Does beneficiary receive public health insurance?
Yes

No

N-2. If beneficiary receives public health insurance, what type?
Medicare
Medicare and Medicaid
Champus/VA/TRICARE
SCHIP
If Other public insurance, please provide details:

Medicaid
Other

Section O. HEALTH BENEFITS (MEDICAID)
O-1. Does beneficiary receive Medicaid
Yes

No

O-2. If so, does beneficiary have a spenddown?
Yes

No

O-3. Does beneficiary meet beneficiary's spenddown each month?
Yes

No

Section P. Section 1619
P-1. If beneficiary is not receiving SSI now, did beneficiary receive it in the past?
Yes

No

P-2. Did beneficiary lose SSI due to wages?
Yes

No

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P-3. Did beneficiary lose beneficiary's SSI due to the receipt of some form of Social
Security cash benefit (Pickle Amendment)?
Yes

No

Section Q. HEALTH BENEFITS (HEALTH BENEFITS FOR WORKERS WITH DISABILITIES)
Q-1. Is beneficiary currently working?
Yes

No

Q-2. Is beneficiary currently receiving Health Benefits for Workers with Disabilities?
Yes

No

Q-3. Is beneficiary's current net income (not counting SSI) less than $1702 (single) or
$2282 (couple)?
Yes

No

Section R. HEALTH BENEFITS (MEDICARE)
R-1. Did beneficiary receive Medicare coverage?
Yes

No

R-2. If so, what parts of Medicare coverage did beneficiary recieve?
Medicare Part A
(Hospitalization)

Medicare Part B (Outpatient)

Medicare Part D (Prescription
coverage)

R-3. Who pays beneficiary's Medicare Part B premium?
I pay it myself.

The state pays my premium
(QMB/SLMB).

R-4. Does beneficiary receive a Subsidy or Extra Help through Social Security for
beneficiary's Medicare Part D prescription coverage?
Yes

No

Section S. HEALTH COVERAGE (PRIVATE INSURANCE)
S-1. Does beneficiary have private health insurance coverage?
Yes

No

S-2. If beneficiary has private health insurance, what type does beneficiary have?
Employer
Employer of family member
Private disability insurance
Other
If Other private health insurance, please provide details:

January 28, 2013

Workers Compensation

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S-3. If so, how much does beneficiary pay in a monthly premium for beneficiary's
private health insurance coverage?
$

Section T. ANALYSIS OF IRWE
T-1. Does beneficiary have out of pocket expenses each month for items or services that
allow beneficiary to work?
Yes

No

T-2. If there are potential IRWES list items/services and their monthly costs.

Section U. ANALYSIS OF SUBSIDIES
U-1. Is government agency paying part of wage?
Yes

No

U-2. Does beneficiary get special assistance on the job?
Yes

No

U-3. Does beneficiary perform fewer duties than others?
Yes

No

U-4. Does employer accept less productivity than from others?
Yes

No

U-5. Does beneficiary receive extra rest periods/breaks?
Yes

No

U-6. Is beneficiary frequently absent or working irregular hours because of disability?
Yes

No

U-7. Does beneficiary receive job coach assistance?
Yes

No

U-8. If receiving job coach assistance, how many hours per week does beneficiary
receive *(on site)* assistance?

Section V. BLIND WORK EXPENSES ANALYSIS
V-1. Is beneficiary legally blind?
Yes

No

V-2. Is beneficiary receiving SSI benefits?
Yes

No
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V-3. List potential BWE items/services and their montly costs

Section W. PASS ANALYSIS
W-1. Does beneficiary have an approved PASS?
Yes

No

W-2. Does beneficiary have goods or services that would help him or her reach a
vocational goal, that he or she would purchase if extra money were available?
Yes

No

W-3. If yes list goods or services, there expected purpose, and approximate cost.

W-4. *NOTES*

Section X. VOCATIONAL
X-1. Is beneficiary enrolled in State Vocational Rehabilitation Agency?
Yes

No

X-2. Has beneficiary assigned beneficiary's Ticket to Work?
Yes

No

X-3. Who did beneficiary assign beneficiary's Ticket to?

X-4. Name and agency of referral source.

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Revised Privacy
Act Statement
WORK INCENTIVE PLANNING and ASSISTANCE (WIPA)
Privacy Act Statement
Collection and Use of Personal Information

Section 1148 of the Social Security Act, as amended, authorizes us to collect this information to
support the WIPA program. We will use the information you provide to determine if you qualify
for the WIPA program. We will also share the information with a certified Community Work
Incentive Coordinator, working for the WIPA program.
Furnishing us this information is voluntary. However, failing to provide us with all or part the
requested information may limit your ability to participate in the WIPA program.
Social Security will be collecting information from the WIPA program including the names and
Social Security Numbers of the beneficiaries they serve, so Social Security can evaluate the
success of the WIPA program and can determine how to best meet beneficiaries’ needs.
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 Social Security office that makes
eligibility determinations. You are responsible for reporting income or changes in your status to
the Social Security office.
We rarely use the information for any other purpose other than the WIPA program. However,
we may use it for the administration and integrity of our programs. We may disclose the
information to another person or to another agency in accordance with approved routine uses,
including but not limited to the following:
•

To comply with Federal laws requiring the release of the information from our records
(e.g., to the Government Accountability Office);

•

To facilitate statistical research, audit, and investigatory activities necessary to assure the
integrity and improvement of our programs (e.g., to the Bureau of the Census and to
private entities under contract with us).

A complete list of routine uses for the information you provide us 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 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.