WIPA Beneficiary/Recipient Application

Intake for WIPA Team Example
WIPA Initial Contact and Demographics
*First Name
Middle Initial
*Last Name
Suffix
I

II

III

IV

Jr.

Sr.

Address 1
Apt./Suite
ZipCode
E-Mail
Home Phone
Cell Phone
Ext
Work Phone
TTY??
No

Yes

SSN
DOB
Gender
Marital Status
Common Law

Divorced

Domestic Partner

Married

Separated

Single

Widowed

Case Number
Benefits received at intake
Private Disability Insurance

SSDI

SSI

Veterans benefits

Workers Compensation

TTY/Videophone number/IP address
How did customer hear about the WIPA?
Community Rehabilitation Provider

Developmental Disability Agency

DOL One-Stop Center

Employment Network

Housing Agency

Internet

* A demographic with an asterisk is a required field.

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Intake for WIPA Team Example
Medicaid

Mental Health Agency

Newspaper

Other

Other WIPA Outreach

Receipt of a Ticket

SSA Field Office

Television

Veteran Service Organization

Vocational Rehabilitation

Walk-In

WIIRC

WISE

Employment status at intake
Considering employment

Currently working

Job offer pending

Looking for employment

Self employed

Self-Reported Primary Disability
Blind or Visual Impairment

Cancer/Neoplasm

Cognitive/Developmental Disability

Hearing, Speech, and Other Sensory
Impairment

Infectious Disease

Injury

Mental and Emotional Disorders

Non-Spinal Cord Orthopedic
Impairment

Other

Spinal Cord Injury

System Disease

Traumatic Brain Injury

If OTHER primary disability, please specify:
Self-Reported Secondary Disability
Blind or Visual Impairment

Cancer/Neoplasm

Cognitive/Developmental Disability

Hearing, Speech, and Other Sensory
Impairment

Infectious Disease

Injury

Mental and Emotional Disorders

Non-Spinal Cord Orthopedic
Impairment

Other

Spinal Cord Injury

System Disease

Traumatic Brain Injury

If OTHER secondary disability, please specify:
Is beneficiary his her own payee?
No

Yes

Name of Representative Payee
Representative Payee Address
Telephone number of Payee
Special Language Consideration
English as a second language

Other special language needs

Sign language interpreter

English Proficiency
Understand neither written nor verbal
communication

Understand written English
communication

Understands both verbal and written
English communication

Understands verbal English
communication

* A demographic with an asterisk is a required field.

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Intake for WIPA Team Example
Level of Education at Intake
Associate/2 year degree

Bachelor's degree

Doctorate degree

HS diploma or equivalent

Less than HS diploma

Master's degree

Other degree or certification

Some college

Health Status at Intake (self-identified)
Fair

Good

Poor

Very Good

Beneficiary services funding source
Other funds

State funds

WIPA funds

AssignedStaffID
Priority Level
Basic

High

Low

Medium

Alert

* A demographic with an asterisk is a required field.

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* 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. *TIME SPENT ON CONTACT (MINUTES):

6. CASE NOTES (CALLED “NOTES IN ETO”) (TEXT BOX):

Paperwork Reduction Act References
WIPA I&R Program Home Page

change to 30
minutes

WIPA Program Home Page:

change to 30
minutes

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.