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Protection and Advocacy of Beneficiaries of Social Security
(PABSS)
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Welcome to the Social Security Web Report System, (PABSS)
To begin a new report, please select the Create New Report link. To continue on a report that has
been started, select the Edit Report link. To view or print submitted reports, select the View
Completed Report link. To generate reports, select the Report Generator link.
Privacy Act Statement
See Revised
SSA is required to collect this information under section 1150 of the Social Security Act (the
Privacy Act
Act). We use the information to manage the Protection and Advocacy for Beneficiaries of Social
Statement
and
Security programs, with particular emphasis on contract administration,
budgeting,
and
PRA
training.
There are certain situations authorized by Federal law in which SSA may release the
information you give us through this Project. For example, we release the information to a
congressional office in response to an inquiry that office may make at your request.
Explanations about these and other reasons why information you provide us may be used or
given out are available in Social Security Offices. If you want to learn more about this, contact
any Social Security Office.
Paperwork Reduction Act Statement
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 60 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.
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SSA will insert the following revised Privacy Act Statement into the form as soon
as possible:
Collection and Use of Personal Information
Section 1150 of the Social Security Act, as amended, allows us to collect the requested
information. Furnishing this information is voluntary. However, failing to provide all or part of
the information may result in some loss of the beneficiary’s service. We will use the information
you provide to ensure beneficiaries receive appropriate services. Additional information and a
full listing of all our system of records notices is available on our website at
www.socialsecurity.gov/foia/bluebook.
SSA will insert the following revised PRA Statement into the form as soon
as possible:
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. We estimate that it will take about
60 minutes to read the instructions, gather the facts, and answer the questions. Send only
comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.
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Name
Report Period
FY 2016 Annual Report
Grant Award
Number
Report Prepared By
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Part I - Quantitative Statistics
Part II - Narrative Reporting
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Part I - Quantitative Statistics
Section A: Information and Referral
1. How many individuals received Information and Referral under the
PABSS program during the Report Period? (Do not count individuals
more than once for this response.)
Individuals Receiving I&R
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Part I - Quantitative Statistics
Section A: Information and Referral
2. How many Information and Referral requests were made under the
PABSS program during the report period? (Include all I&R requests,
even if more than one for some individuals. This number should equal or
exceed Section A. 1.)
Information and Referral Requests
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Part I - Quantitative Statistics
Section B: Individuals and Issue Area Service Requests/Workload Statistics
1. Individuals
a. How many individuals had open PABSS issue area service requests at the start of
the report period?
b. How many new PABSS individuals were added during the report period?
c. Total number of individuals with all issue area service requests that were closed
during the report period under the PABSS program
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Section B: Individuals and Issue Area Service Requests/Workload Statistics
2. Services
a. Total PABSS issue area service requests open at the start of the report period.
b. Number of new PABSS issue area service requests added during the report period?
c. Total number of issue area service requests closed during the report period?
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Part I - Quantitative Statistics
Section C: Individual Demographics
1. Please provide counts of individuals served by Gender:
a. Male
b. Female
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Section C: Individual Demographics
2. Please provide counts of individuals served by Ethnicity:
a. Alaskan Native
b. American Indian
c. Arab American (Middle Eastern)
d. Asian
e. Black (Not Hispanic/Latino Origin)
f. Hispanic/Latino
g. Multi Racial / Multi Cultural
h. Pacific Islander
i. White (Not Hispanic/Latino Origin)
j. Unknown
Other (IF SELECTED MUST SPECIFY)
Explanations
There are no data records to display.
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Section C: Individual Demographics
3. Please provide counts of individuals receipted by Age Bracket:
a. 14 to 18
b. 19 to 21
c. 22 to 40
d. 41 to 59
e. 60 to 64
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Section C: Individual Demographics
4. Please provide counts of individuals receipted by Beneficiary Status.
a. SSI eligible
b. SSDI eligible
c. Dually eligible
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Section C: Individual Demographics
5. Please provide counts of individuals receipted by Primary Disability:
a. Absence of extremities
b. Autism
c. Auto-immune (lupus, thyroid, ALS, etc.)
d. Blindness (both eyes)
e. Cancer
f. Cerebral palsy
g. Deaf-blind
h. Deafness
i. Diabetes
j. Digestive disorders (chronic pancreatitis, esophageal stricture, fistulae, chronic liver,
etc.)
k. Epilepsy
l. Genitourinary conditions (kidney, prostate, etc.)
m. Hard of Hearing (not deaf)
n. Heart and other circulatory problems including cardiovascular
o. HIV/AIDS
p. Mental illness (diagnosis according to DSM-IV)
q. Mental retardation
r. Multiple sclerosis
s. Muscular dystrophy
t. Muscular / Skeletal impairment (arthritis, fibromyalgia, osteogenesis imperfecta,
osteomyelitis, etc.)
u. Neurological disorders (brain tumors, convulsive disorders, Parkinson, etc.)
v. Other emotional/behavioral (Provide detail)
Explanations
There are no data records to display.
w. Other intellectual such as ADD/ADHD (Provide detail)
Explanations
There are no data records to display.
x. Physical / orthopedic including spinal cord injuries, paraplegia, quadriplegia, back
problems, etc.
y. Respiratory disorders (emphysema, asthma, pulmonary hypertension, cystic
fibrosis, etc.)
z. Specific learning disabilities (SLD)
aa. Speech impairment
bb. Spina bifida
cc. Substance abuse (alcohol or drugs)
dd. Tourette syndrome
ee. Traumatic brain injury (TBI)
ff. Visual Impairment (not blind)
gg. Disability not known/Other than Above (Specify)
Explanations
There are no data records to display.
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Section E: Closed Issue Area Service Requests
1. What was the problem/sub-problem area?
a. [AT] Assistive Technology
b. [Education] Transition school to work
c. [Employment] Discrimination in employment benefits
d. [Employment] Discrimination in hiring
e. [Employment] Unlawful termination / firing
f. [Employment] Other employment discrimination
g. [Employment] Reasonable accommodation – not d, e, or f from above
h. [Employment] Service provider issues – not c-g above
i. [Employment] Wage and hour issues
j. [Financial Entitlements] SSI: Overpayments based on work issues
k. [Financial Entitlements] SSDI: Overpayments based on work issues
l. [Financial Entitlements] (other) – Specify
Explanations
There are no data records to display.
m. [Healthcare] Medicaid only issues
n. [Healthcare] Medicare/Medicaid issues
o. [Healthcare] Medicare only issues
p. [Healthcare] Private Insurance Issues
q. [Housing] Accommodations in housing
r. [Housing] Subsidized housing/Section 8
s. [Housing] Rental termination – not q .
t. [Housing] Other – Specify
Explanations
There are no data records to display.
u. [Childcare]
v. [Rehab Services] Related to State VR
w. [Rehab Services] Related to Employment Network (EN)
x. [Rehab Services] Related to Agencies other than State VR or Employment Network
(EN)
y. [Post-Secondary Ed] Accessibility
z. [Post-Secondary Ed] Funding issues
aa. [Post-Secondary Ed] Grievance Against College – Not y or z above
bb. [Post-Secondary Ed] Other – Specify
Explanations
There are no data records to display.
cc. [Services] Personal assistance – not Employment
dd. [Transportation]
ee. [Benefits Planning] referral / access to BPAO services
ff. [Other] (IF SELECTED MUST SPECIFY)
Explanations
There are no data records to display.
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Section E: Closed Issue Area Service Requests
2. What was the reason for closing the individual's issue area service
request?
a. Issue Resolved in Individual’s Favor
b. Issue Partially Resolved in Individual’s Favor
c. Issue Lacked Legal Merit
d. Individual decided not to pursue resolution or Individual Withdrew Complaint (Not
e-g below)
e. Other Representation Obtained (Individual found other representation)
f. Individual Not Responsive to Agency / Individual refused to cooperate with P&A
g. Services Not Needed Due to lost contact, Death, Relocation, etc.
h. Advocacy efforts/appeals were unsuccessful (Issue not resolved in Individual’s
Favor)
i. Other (IF SELECTED MUST SPECIFY)
Explanations
There are no data records to display.
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Section E: Closed Issue Area Service Requests
3. What was the highest intervention strategy used?
a. Short Term/Technical assistance
b. Informal Resolution
c. Investigation/Monitoring
d. Negotiation
e. Mediation / Alternative Dispute Resolution
f. Administrative Remedies
g. Legal remedy / Litigation
h. Class Action Suits
i. Systemic / Policy activities
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Section E: Closed Issue Area Service Requests
4. As a result of P&A intervention, the following major outcome was
achieved:
a. Individual gained / maintained access to services including those of VR, EN or other
agency
b. Individual obtained employment
c. Individual regained employment
d. Individual maintained employment
e. Individual advanced in employment
f. Individual’s employment opportunities increased
g. Individual obtained an increase in salary and/or benefits
h. Validity of discrimination complaint was upheld
i. Overpayment situation addressed (it doesn’t matter if it was waived or the efforts
weren’t successful)
j. Individual acquired knowledge concerning his/her rights
k. Outcome information is not available
l. Other outcome (IF SELECTED MUST SPECIFY)
Explanations
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Section A: Description of Progress and Status Update
Please provide a brief overview of overall project status, staff changes,
staff training or other major developments with regard to the PABSS
program. This could include information about boards and committees
where decisions are made concerning disability service delivery and
local policy.
Progress and Status Update
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Section B: Detail of Actions Taken on the Project
1. Issue Area Service Requests Summaries: [Please provide summaries
of three Issues/Service Requests undertaken as part of the PABSS
project. Indicate clearly the issue or problem, the PABSS intervention,
and the results if known]
Issue Area Service Requests Summaries
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Section B: Detail of Actions Taken on the Project
2. Outreach Statistics:
Total Number of Outreach/Presentations
Total Number of Persons Reached by Outreach/ Presentation Events
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Section B: Detail of Actions Taken on the Project
3. Other Information Dissemination Activities: (Number of Instances)
1. Radio/TV appearances by PABSS staff
2. Newspaper/Magazine/Journal articles prepared by staff
3. PSAs/videos/films aired by the Agency
4. Reports disseminated
5. Publications/Booklets/Brochures disseminated
6. Number of Website hits
7. Other media activities (IF SELECTED MUST SPECIFY)
Explanations
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Section B: Detail of Actions Taken on the Project
4. Outreach Narrative: [Describe the agency's outreach efforts. Describe
the trainings presented by the staff including information about the
topics covered, the purpose of the training, and a description of the
attendees. Describe media events, informational materials developed or
other activities undertaken as part of the PABSS project.]
Outreach Narrative
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Section C: Problems Encountered and Steps Taken to Resolve Problems
Problems encountered and steps taken to resolve problems: [Please
provide detail information about problems encountered in implementing
or administering the PABSS program and actions you have taken to
resolve the problems you encountered.]
Problems encountered and steps taken to resolve problems
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Section D: Planned Future Activities
Planned activities: [Please provide activities you plan to undertake to
further the objectives of the PABSS project.]
Planned activities
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Section E: Diversification Activities
Diversification activities: [Please provide a description of activities
undertaken to address the needs of individuals with disabilities from
diverse ethnic and racial communities.]
Diversification activities
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Existing Report
Sample FY16 PPR
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Edit Sample FY16 PPR
Name
Reporting Period
FY 2016 Annual Report
Grant Award
Number
Report Prepared By
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Period Type
Reports
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OMB Number: 0960-0768
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PROTECTION and ADVOCACY for BENEFICIARIES of SOCIAL SECURITY (PABSS)
ANNUAL PROGRAM PERFORMANCE REPORT
REPORTING PERIOD:
From 10/1/2015 To 9/30/2016
GRANT AWARD NUMBER: 123456789
STATE: DC
AGENCY NAME: NDRN
AGENCY ADDRESS: 820 1ST ST NE
STE 740
Washington, DC 20002
REPORT PREPARED BY: Sample User
TELEPHONE NUMBER: 2024089514
FAX NUMBER: 2024089520
E-MAIL ADDRESS: [email protected]
DATE SUBMITTED: 7/12/2016
1
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Part I - Quantitative Statistics
Section A: Information and Referral
1. How many individuals received Information and Referral under the PABSS program
during the Report Period? (Do not count individuals more than once for this response.)
Individuals Receiving I&R
1
2. How many Information and Referral requests were made under the PABSS program
during the report period? (Include all I&R requests, even if more than one for some
individuals. This number should equal or exceed Section A. 1.)
Information and Referral Requests
1
Section B: Individuals and Issue Area Service Requests/Workload Statistics
1. Individuals
a. How many individuals had open PABSS issue area service requests at the
start of the report period?
b. How many new PABSS individuals were added during the report period?
Total Individuals Served
c. Total number of individuals with all issue area service requests that were
closed during the report period under the PABSS program
Total Individuals Still Being Served
1
1
2
1
1
2. Services
a. Total PABSS issue area service requests open at the start of the report
period.
b. Number of new PABSS issue area service requests added during the
report period?
Total Services
c. Total number of issue area service requests closed during the report
period?
Total Services Still Open
1
1
2
1
1
Section C: Individual Demographics
1. Please provide counts of individuals served by Gender:
a. Male
b. Female
Total individuals receipted
1
0
1
2
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2. Please provide counts of individuals served by Ethnicity:
a. Alaskan Native
b. American Indian
c. Arab American (Middle Eastern)
d. Asian
e. Black (Not Hispanic/Latino Origin)
f. Hispanic/Latino
g. Multi Racial / Multi Cultural
h. Pacific Islander
i. White (Not Hispanic/Latino Origin)
j. Unknown
Other (IF SELECTED MUST SPECIFY)
Sample selection of Other
Total individuals receipted
0
0
0
0
0
0
0
0
0
0
1
1
1
3. Please provide counts of individuals receipted by Age Bracket:
a. 14 to 18
b. 19 to 21
c. 22 to 40
d. 41 to 59
e. 60 to 64
Total individuals receipted
1
0
0
0
0
1
4. Please provide counts of individuals receipted by Beneficiary Status.
a. SSI eligible
b. SSDI eligible
c. Dually eligible
Total individuals receipted
1
0
0
1
5. Please provide counts of individuals receipted by Primary Disability:
a. Absence of extremities
b. Autism
c. Auto-immune (lupus, thyroid, ALS, etc.)
d. Blindness (both eyes)
e. Cancer
f. Cerebral palsy
g. Deaf-blind
0
0
0
0
0
0
0
3
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h. Deafness
i. Diabetes
j. Digestive disorders (chronic pancreatitis, esophageal stricture, fistulae,
chronic liver, etc.)
k. Epilepsy
l. Genitourinary conditions (kidney, prostate, etc.)
m. Hard of Hearing (not deaf)
n. Heart and other circulatory problems including cardiovascular
o. HIV/AIDS
p. Mental illness (diagnosis according to DSM-IV)
q. Mental retardation
r. Multiple sclerosis
s. Muscular dystrophy
t. Muscular / Skeletal impairment (arthritis, fibromyalgia, osteogenesis
imperfecta, osteomyelitis, etc.)
u. Neurological disorders (brain tumors, convulsive disorders, Parkinson,
etc.)
v. Other emotional/behavioral (Provide detail)
w. Other intellectual such as ADD/ADHD (Provide detail)
x. Physical / orthopedic including spinal cord injuries, paraplegia,
quadriplegia, back problems, etc.
y. Respiratory disorders (emphysema, asthma, pulmonary hypertension,
cystic fibrosis, etc.)
z. Specific learning disabilities (SLD)
aa. Speech impairment
bb. Spina bifida
cc. Substance abuse (alcohol or drugs)
dd. Tourette syndrome
ee. Traumatic brain injury (TBI)
ff. Visual Impairment (not blind)
gg. Disability not known/Other than Above (Specify)
Sample selection of Other
Total individuals receipted
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
1
1
Section D: Major Source of Concern
Please Provide counts of all PABSS issue are service request receipts by major source
of individual's concern for the current report period:
1. State Vocational Rehab Agency (public VR program)
4
0
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2. Employment Networks (SSA contractor)
3. Agencies other than 1. or 2. above
4. Employment discrimination – hire, fire, promotion
5. Employment wages and benefits
6. Housing
7. Healthcare (not 5 above)
8. Insufficient/improper benefits planning
9. Transition services (Student beneficiary between 14-18 (or under age 22)
engaging/needing a transition plan)
10. Post Secondary accommodation
11. Transportation
12. Social Security benefits cessation based on SGA (including CDR’s) – not
Overpayment
13. Benefits Questions/Work Incentives – Not 12 or 14
14. Work Related Overpayment
15. Other (IF SELECTED MUST SPECIFY)
Sample selection of Other
Total issues/service requests of individuals receipted.
0
0
0
0
0
0
0
0
0
0
0
0
0
1
1
1
Section E: Closed Issue Area Service Requests
1. What was the problem/sub-problem area?
a. [AT] Assistive Technology
b. [Education] Transition school to work
c. [Employment] Discrimination in employment benefits
d. [Employment] Discrimination in hiring
e. [Employment] Unlawful termination / firing
f. [Employment] Other employment discrimination
g. [Employment] Reasonable accommodation – not d, e, or f from above
h. [Employment] Service provider issues – not c-g above
i. [Employment] Wage and hour issues
j. [Financial Entitlements] SSI: Overpayments based on work issues
k. [Financial Entitlements] SSDI: Overpayments based on work issues
l. [Financial Entitlements] (other) – Specify
m. [Healthcare] Medicaid only issues
n. [Healthcare] Medicare/Medicaid issues
o. [Healthcare] Medicare only issues
p. [Healthcare] Private Insurance Issues
q. [Housing] Accommodations in housing
5
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
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r. [Housing] Subsidized housing/Section 8
s. [Housing] Rental termination – not q .
t. [Housing] Other – Specify
u. [Childcare]
v. [Rehab Services] Related to State VR
w. [Rehab Services] Related to Employment Network (EN)
x. [Rehab Services] Related to Agencies other than State VR or Employment
Network (EN)
y. [Post-Secondary Ed] Accessibility
z. [Post-Secondary Ed] Funding issues
aa. [Post-Secondary Ed] Grievance Against College – Not y or z above
bb. [Post-Secondary Ed] Other – Specify
cc. [Services] Personal assistance – not Employment
dd. [Transportation]
ee. [Benefits Planning] referral / access to BPAO services
ff. [Other] (IF SELECTED MUST SPECIFY)
Sample selection of Other
Total closed issue area service requests.
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
1
1
2. What was the reason for closing the individual's issue area service request?
a. Issue Resolved in Individual’s Favor
b. Issue Partially Resolved in Individual’s Favor
c. Issue Lacked Legal Merit
d. Individual decided not to pursue resolution or Individual Withdrew
Complaint (Not e-g below)
e. Other Representation Obtained (Individual found other representation)
f. Individual Not Responsive to Agency / Individual refused to cooperate with
P&A
g. Services Not Needed Due to lost contact, Death, Relocation, etc.
h. Advocacy efforts/appeals were unsuccessful (Issue not resolved in
Individual’s Favor)
i. Other (IF SELECTED MUST SPECIFY)
Sample selection of Other
Total closed issue area service requests.
0
0
0
0
0
0
0
0
1
1
1
3. What was the highest intervention strategy used?
a. Short Term/Technical assistance
b. Informal Resolution
c. Investigation/Monitoring
1
0
0
6
OMB Number: 0960-0768
Expiration Date: 1/31/2017
d. Negotiation
e. Mediation / Alternative Dispute Resolution
f. Administrative Remedies
g. Legal remedy / Litigation
h. Class Action Suits
i. Systemic / Policy activities
Total closed issue area service requests.
0
0
0
0
0
0
1
4. As a result of P&A intervention, the following major outcome was achieved:
a. Individual gained / maintained access to services including those of VR,
EN or other agency
b. Individual obtained employment
c. Individual regained employment
d. Individual maintained employment
e. Individual advanced in employment
f. Individual’s employment opportunities increased
g. Individual obtained an increase in salary and/or benefits
h. Validity of discrimination complaint was upheld
i. Overpayment situation addressed (it doesn’t matter if it was waived or the
efforts weren’t successful)
j. Individual acquired knowledge concerning his/her rights
k. Outcome information is not available
l. Other outcome (IF SELECTED MUST SPECIFY)
Sample selection of Other
Total outcomes of closed issue area service requests.
0
0
0
0
0
0
0
0
0
0
0
1
1
1
Part II - Narrative Reporting
Section A: Description of Progress and Status Update
Please provide a brief overview of overall project status, staff changes, staff training or
other major developments with regard to the PABSS program. This could include
information about boards and committees where decisions are made concerning
disability service delivery and local policy.
Sample Text Response
7
OMB Number: 0960-0768
Expiration Date: 1/31/2017
Section B: Detail of Actions Taken on the Project
1. Issue Area Service Requests Summaries: [Please provide summaries of three
Issues/Service Requests undertaken as part of the PABSS project. Indicate clearly the
issue or problem, the PABSS intervention, and the results if known]
Sample Text Response
2. Outreach Statistics:
Total Number of Outreach/Presentations
Total Number of Persons Reached by Outreach/ Presentation Events
1
1
3. Other Information Dissemination Activities: (Number of Instances)
1. Radio/TV appearances by PABSS staff
2. Newspaper/Magazine/Journal articles prepared by staff
3. PSAs/videos/films aired by the Agency
4. Reports disseminated
5. Publications/Booklets/Brochures disseminated
6. Number of Website hits
7. Other media activities (IF SELECTED MUST SPECIFY)
Sample selection of Other
1
1
1
1
1
1
1
1
4. Outreach Narrative: [Describe the agency's outreach efforts. Describe the trainings
presented by the staff including information about the topics covered, the purpose of
the training, and a description of the attendees. Describe media events, informational
materials developed or other activities undertaken as part of the PABSS project.]
Sample Text Response
Section C: Problems Encountered and Steps Taken to Resolve Problems
Problems encountered and steps taken to resolve problems: [Please provide detail
information about problems encountered in implementing or administering the PABSS
program and actions you have taken to resolve the problems you encountered.]
Sample Text Response
Section D: Planned Future Activities
Planned activities: [Please provide activities you plan to undertake to further the
objectives of the PABSS project.]
Sample Text Response
8
OMB Number: 0960-0768
Expiration Date: 1/31/2017
Section E: Diversification Activities
Diversification activities: [Please provide a description of activities undertaken to
address the needs of individuals with disabilities from diverse ethnic and racial
communities.]
Sample Text Response
9
| File Type | application/pdf |
| Author | matt.hayden |
| File Modified | 2016-11-08 |
| File Created | 2016-07-12 |