Invitation and Consent to Join the Ohio Direct Referral

[DATE]
Invitation and Consent to Join the Ohio Direct Referral Demonstration
What is the Ohio Direct Referral Demonstration?
The Social Security Administration (SSA) and Opportunities for Ohioans with Disabilities (OOD) are
conducting a research study called the Ohio Direct Referral Demonstration. We are sending this letter to
ask you to join the demonstration. This letter also explains the study and any possible risks of joining.
OOD is the Ohio agency that houses the state Division of Disability Determination (DDD) and the state’s
Bureau of Vocational Rehabilitation (BVR). DDD makes decisions regarding whether someone meets
SSA’s rules for disability. BVR provides vocational rehabilitation services to help Ohioans with disabilities
go to work. The Ohio Direct Referral Demonstration will test the effect of SSA making referrals to BVR for
some of the people who agree to be part of the demonstration. SSA will make the referral by having DDD
provide participant information to BVR. When SSA sends a person’s information from DDD to BVR, it is a
“direct referral” for vocational rehabilitation services.
We are asking you to join the demonstration because SSA is reviewing your disability record. This is
because you applied for Social Security Disability Insurance (SSDI) or Supplemental Security Income
(SSI) benefits, or because SSA must decide if your SSI benefits can continue under the adult rules for
disability. The adult rules for disability are different from the rules for people under age 18. We call this
review an SSI Age 18 redetermination.
What is a “demonstration”?
A demonstration is a type of research study. Demonstrations allow SSA to change a rule temporarily to
see if the change helps people do something differently. Current law prevents SSA from directly referring
SSDI or SSI applicants or beneficiaries to BVR. In this demonstration, SSA will temporarily change that
rule and will directly refer some applicants and beneficiaries who have joined the demonstration to BVR
for vocational rehabilitation services.
What will I get if I join the demonstration?
If you join this demonstration, you have the chance to be selected to have a direct referral of your
information made to BVR. If a direct referral is made to BVR, it will speed up your application for the
vocational services that BVR has to offer. If you are not selected for a direct referral, you will still receive
information about BVR’s services, for which you may apply directly.
What are vocational rehabilitation services offered by BVR?
BVR can provide a variety of services that can help you reach an employment goal. This can include
training, adaptive equipment, job placement, or other goods or services that you and the rehabilitation
counselor assigned to you agree will help you reach your goal.
What do I need to do to join this demonstration?
To join the demonstration, you need to read, complete, and sign:
(1) The voluntary informed consent at the bottom of this letter, and

(2) Form SSA-3288 Consent for Release of Information, (attached), authorizing SSA to disclose your
complete medical record, date of birth, Social Security number, and contact information to BVR for the
purpose of this demonstration.
Once you complete and sign these two forms, please mail them in the enclosed envelope as soon as
possible. If we don’t hear from you, we may contact you to make sure you received the forms.
Do I have to join the demonstration?
No, it is up to you. You may choose not to be part of this demonstration. If you decide to participate and
later change your mind, you may withdraw at any time by calling DDD at one of the phone numbers listed
below:
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Cyndal Glass, 1-800-282-2695 ext. 8227
Dan Cuda, 1-800-282-2695 ext. 8245
Jill Odenweller, 1-800-282-2695 ext. 8265

What happens after I join the demonstration?
Once you join the demonstration, your name will be placed into one of two groups. We call one group the
usual services group (control group). We call the other group the program services group (test group). We
pick who goes into which group randomly. Once assigned to a group, you will get a letter that tells you
whether you are in the usual services group or the program services group.
What does the demonstration do for members of the usual services group?
If you are in the usual services group, we will send you information about BVR. You may apply for BVR
vocational rehabilitation services on your own.
What does the demonstration do for members of the program services group?
If you are in the program services group, we will send you information about BVR. In addition, a BVR staff
person will contact you to set up an appointment and help you complete the application for vocational
rehabilitation services. After they have the information they need, BVR will decide if you are eligible for
services. If BVR decides you are eligible for vocational rehabilitation services, you can begin to work
towards your employment goal with their help.
Removal from the demonstration
SSA and OOD retain the right to remove any participants from the Ohio Direct Referral Demonstration for
any reason, including participant misconduct.
What should I know about signing the informed consent?
Before you sign the informed consent, you should:
• Read and understand this invitation;
• Understand that joining or not joining this demonstration is your choice, and that you can
withdraw at any time;
• Know that BVR will contact you to help you apply for vocational rehabilitation services if you are
part of the program services group;

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Understand that SSA and OOD will use information about you for research purposes throughout
the demonstration. If you withdraw from the demonstration, SSA, DDD, and BVR will not use your
information for the demonstration or for research purposes.

What information about me will be used for research purposes and how will my information be
protected?
The information SSA will use to find the results of the demonstration include:
• Identifying information, including your name, address, Social Security number, and date of birth;
• The dates you participated in the demonstration;
• Records from BVR about the services they provided; and
• The work and earnings information you report.
SSA will use information about your participation in this demonstration, including records obtained from
BVR, only for research and reporting purposes, and not for other purposes. SSA will safeguard your
information from unauthorized access, in accordance with Federal law. SSA will look at data from all of
the people who joined the demonstration to see if sending information directly to BVR and having BVR
help people apply for vocational rehabilitation services makes a difference in the number of people who
successfully go to work. SSA will write about these findings so that others can learn about the effects of
the direct referral. Any research reports will not identify you.
What are the possible risks of being in this demonstration?
The researchers designed the demonstration in a way that limits risk. If you join, risks could include the
possibility that earnings from a job you get through BVR services could affect your eligibility or the amount
you get from public benefit programs like Supplemental Nutrition Assistance Programs (Food Stamps),
housing assistance, or other programs. Also, if you are successful in going to work, earnings might affect
SSI or Social Security benefits. BVR staff will provide counseling about these matters during the
application for vocational rehabilitation services.
Are there any costs if I am part of this demonstration?
No, you do not have to pay anything to be part of this demonstration or to apply for vocational
rehabilitation services from BVR.
If you have questions
If you have questions regarding the demonstration or decide you do not want to continue participation
after you have joined the demonstration, please contact:
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Derek Willer, 1-800-282-2695 ext. 1712
Cyndal Glass 1-800-282-2695 ext. 8227
Dan Cuda, 1-800-282-2695 ext. 8245
Jill Odenweller, 1-800-282-2695 ext. 8265

If you have any questions about your rights if you join this demonstration, you may call Derek Willer at the
Ohio DDD toll-free at 800-282-2695 ext. 1712.

Consent to join the demonstration
By signing this form, I confirm that:
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I have read and understand the information.
I voluntarily agree to take part in the Ohio Direct Referral Demonstration and be assigned to a
group by random assignment.
I voluntarily agree to participate in the demonstration testing the effect of directly referring people
for BVR services on future employment.
I understand that my participation in this demonstration is voluntary.
I understand that I can withdraw from the demonstration at any time without penalty.
I understand that SSA and OOD retain the right to remove any participants from the Ohio Direct
Referral Demonstration for any reason.
I understand that I will be given a signed copy of this informed consent to keep.
I will submit a completed Form SSA-3288 authorizing SSA to disclose complete medical record,
date of birth, Social Security number, and contact information to BVR for the purpose of the Ohio
Direct Referral Demonstration.
I agree to participate, and if I am randomly selected to be in the program services group, I
understand that BVR will contact me to help me apply for vocational rehabilitation services.

_______________________________________________
Participant’s Name –PLEASE PRINT
_______________________________________________ ________________
Participant’s Signature
Date
_______________________________________________
Street Address
_______________________________________________ ________________
City, State, Zip
Telephone

Legal Guardian signature (if applicable).
________________ Date_________
PLEASE RETURN THIS FORM IN THE ENCLOSED ENVELOPE WITHIN 10 DAYS OF the date of the
form.
Use the following Impartial Witness Confirmation only if applicable.

Impartial Witness Confirmation
If someone read this consent form to the participant because the participant is unable to read the form, an
impartial witness not affiliated with the researcher or investigator must be present for the consent and sign
the following statement:
I confirm that I accurately explained the information in the consent form and any other written information
to the participant. I also confirm that the participant apparently understands the information. The participant
freely consented to participate in the demonstration.

Signature of Impartial Witness

Date

Note: No one can use this signature block for translations into another language. A translated consent form
is necessary for enrolling participants who do not speak English.

Privacy Act Statement
Collection and Use of Personal Information
Sections 234 and 1110 of the Social Security Act, as amended, allow us to collect this
information. Furnishing us this information is voluntary. However, failing to provide the
information will prevent you from participating in the Ohio Direct Referral Demonstration
(ODRD).
We will use the information to manage your participation in the ODRD project and for research
and statistics purposes. We may also share your information for the following purposes, called
routine uses:
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With respect to any records, including those collected by means of survey or interview to
be used solely for research and statistical purposes, disclosure may be made: (a) To a
congressional office in response to an inquiry from that office made at the request of the
subject of a record. (b) To a contractor under contract to the Social Security
Administration, subject to any restrictions imposed by 26 U.S.C. 6103 of the Internal
Revenue Code, for the performance of research and statistical activities directly related to
this system of records in conducting the demonstrations and experiments and to provide a
statistical data base for research studies; and

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With respect only to records that are not collected by means of surveys or interviews for
use solely for research and statistical purposes, disclosure may be made subject to any
restrictions imposed by 26 U.S.C. 6103 of the Internal Revenue Code: (a) To a third party
organization under contract to SSA for the performance of project management activities
directly related to this system of records. (b) To a State vocational rehabilitation agency
in the State in which the disabled individual resides, for the purpose of assisting the

agency in providing rehabilitation counseling and service to the individual that are
necessary in carrying out the demonstrations and experiments.
In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice
(SORN) 60-0218, entitled Disability Insurance and Supplemental Security Income
Demonstration Projects and Experiments System, as published in the Federal Register (FR) on
January 11, 2006, at 71 FR 1836. Additional information, and a full listing of all of our SORNs,
is available on our website at www.ssa.gov/privacy/.