ETO System Fields

Attachment B. Screenshots for the Existing ETO System Fields
I&R Assessment Form- Initial Contact and Demographics

Demographics Page (Add a Beneficiary)- Initial Contact and Demographics

Beneficiary Effort- Initial Contact and Demographics
Track Initial Contact Notes

Beneficiary Effort- WIPA Work Incentives Planning and Assistance
Provide WIPA Services

Baseline and Follow-up Assessment- WIPA Work Incentives Planning and Assistance
Beneficiary Goals

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.