Form SSA-1370 Ticket to Work Individual Work Plan

Form SSA-1370
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Ticket to Work Program

INDIVIDUAL WORK PLAN (IWP)
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Part One: Employment Network and Ticketholder Contact Information
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1. Employment Network (EN) Name:_______________________________________________________________
DUNS:______________________________________________________________________________________
Address:____________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Telephone:__________________________________________________________________________________
Email:_______________________________________________________________________________________
Business Model (Select one Ticketholder service model):
[ ] Traditional Services [ ] Consumer Directed Services [ ] Employer or Employer Agent
2. Ticketholder’s Name:__________________________________________________________________________
SSN:_______________________________________________________________________________________
Address:____________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Telephone:__________________________________________________________________________________
Email:______________________________________________________________________________________
3. Ticketholder’s Alternate Contact Name:__________________________________________________________
Relationship to Ticketholder:___________________________________________________________________
Address:____________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Telephone:__________________________________________________________________________________
Email:______________________________________________________________________________________

Removed the other 2 Alternate Contact's

_____________________________________________________________________________________________

Added this Part Part Two: Documentation of EN-Ticketholder Discussion
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Section 1: Discussion Arrangement
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1. Date of Discussion:____________________________________________________________
2. Discussion Modality
[ ] Face to Face
[ ] Telephone
[ ] Other (Explain)_____________________________________________________________

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Form SSA-1370
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3. Location:____________________________________________________________________
4. Duration:____________________________________________________________________
5. Name and Position of EN Interviewer:____________________________________________
_____________________________________________________________________________________________

Section 2: Ticketholder’s Recent Work History Moved from Part Three
_____________________________________________________________________________________________
1. Check all that apply
[ ] Currently working
[ ] No earnings in the past 18 months
[ ] Earnings in the month prior to the month Ticket assigned
[ ] Earnings in 3 of the past 6 months
[ ] Earnings in 6 of the past 12 months
[ ] Earnings in 12 of the past 18 months
2. List all work and earnings during the last 18 months (most recent employer first) in the chart below:

Employer

Job Title

Start Date

End Date

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Hourly Wage

Weekly Hours

Form SSA-1370
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Section 3: Ticketholder’s Employment Goals Moved from Part One
_____________________________________________________________________________________________
1. Describe short-term goal (next 3-18 months)
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
2. Describe long-term goal
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
3. Has the Ticketholder’s previous employment provided any experience relative to achievement of the:


Short-term goal above? [ ] Yes [ ] No
If “Yes” please explain:____________________________________________________________
_______________________________________________________________________________



Long-term goal above? [ ] Yes [ ] No
If “Yes” please explain:____________________________________________________________
_______________________________________________________________________________

4. Does the Ticketholder require additional supports and services to achieve the:


Short-term goal above? [ ] Yes [ ] No
If “No” please explain:_____________________________________________________
________________________________________________________________________



Long-term goal above? [ ] Yes [ ] No
If “No” please explain:_____________________________________________________
________________________________________________________________________

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Form SSA-1370
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Section 4: EN Supports and Services Moved from Part Two
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1. Short-term (Initial Job Acquisition)
Check all blocks that apply and explain how the services contribute to achievement of the Ticketholder’s
short-term goal.




Career Planning
[ ] Benefits counseling

______________________________________________________________

[ ] Goal setting

_______________________________________________________________

[ ] Job coaching

_______________________________________________________________

[ ] Job development

_______________________________________________________________

[ ] Training (specify)

________________________________________________________________
________________________________________________________________

[ ] Other (specify)

_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

Job Placement Assistance
[ ] Job search

________________________________________________________________

[ ] Job accommodation

_______________________________________________________________

[ ] Job placement

________________________________________________________________

[ ] Other (specify)

________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

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Form SSA-1370
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2. Long-term (Ongoing Employment Support)
Check all blocks that apply and explain how the services contribute to achievement of the Ticketholder’s longterm goal.
[ X ] Regular follow-up with Ticketholder (mandatory) _____________________________________________
[ ] Job stabilization and retention

_______________________________________________________

[ ] Career advancement counseling

_______________________________________________________

[ ] Other (specify)

________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________

3. Will the EN directly provide the supports and services above? [ ] Yes [ ] No
If “No,” please complete question 4 below.
4. If known, list the names of the provider(s) to whom you will refer the Ticketholder, along with the services
provided.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
5. Will the EN coordinate or arrange for medical and/or related health services to the Ticketholder?
[ ] Yes [ ] No
If “Yes,” please explain:________________________________________________________
____________________________________________________________________________

Part Three: IWP Terms and Conditions

Moved from Part Four

The following terms and conditions apply to the EN and the Ticketholder identified in Part One above:
1. The EN and the Ticketholder shall inform one another immediately of any changes in the contact information
shown in Part One above.
2. The Ticketholder shall report all earnings to the EN and to Social Security.

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3. The Ticketholder shall authorize the EN to contact employers on the Ticketholder’s behalf, as necessary, to
verify or obtain evidence of the Ticketholder’s work and earnings.
4. The EN may not request or accept compensation from the Ticketholder for the costs of services and supports
provided the Ticketholder under the IWP.
5. The EN shall use only qualified employees and/or providers to provide supports and services to the
Ticketholder.
6. The EN shall establish and explain to the Ticketholder a process to resolve any disputes that arise under this
IWP, including the process for escalating an unresolved dispute to Social Security.
7. The EN shall inform the Ticketholder of the availability of, and contact information for, free protection and
advocacy services under the Protection and Advocacy for Beneficiaries of Social Security program.
8. The EN shall inform the Ticketholder of annual Timely Progress Reviews (TPR) performed by Social Security to
assess the Ticketholder’s work progress, and explain to the Ticketholder the TPR guidelines.
9. The EN shall keep private and confidential the Ticketholder’s personal information, including his or her Social
Security Number and disability, and shall maintain all private and confidential information in a secure area.
10. The EN shall provide the Ticketholder with a copy of the completed IWP, as well as any subsequent changes
to the IWP, in the Ticketholder’s preferred format.
11. Both the Ticketholder and the EN must agree to any change to the IWP. All changes to the IWP must be in
writing and supported by evidence of mutual consent.
12. The EN shall provide the Ticketholder with a copy of his or her EN file upon request.
13. Either the Ticketholder or the EN may choose unilaterally to un-assign the Ticket at any time by notifying the
other in writing, thereby terminating the Ticketholder-EN relationship established by the IWP.
14. Upon approval of the IWP by both the Ticketholder and the EN, the Ticketholder acknowledges assignment
of his or her Ticket to the EN and the EN acknowledges acceptance of that Ticket.
15. Are there any other terms and conditions relating to the implementation and administration of this IWP?
[ ] Yes [ ] No
If “Yes,” list additional terms and conditions:_______________________________________
___________________________________________________________________________

Moved from beginning to here
_____________________________________________________________________________________________
to accompany signature.

I choose to participate in the Ticket to Work Program with the Employment Network (EN) named below. I
understand that my EN will provide me employment support to help me find a job, increase my earnings, and
reduce my reliance on cash benefits. I have read and understand the requirements, obligations, terms, and
conditions expressed in this IWP. I declare under penalty of perjury that I have examined all the information on
this form, and on any accompanying statements or forms, and it is true and correct to the best of my knowledge.
Ticketholder’s Signature:__________________________________________Date:___________
EN Representative’s Signature:_____________________________________Date:___________

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EN Name:

Privacy Act Statement
Collection and Use of Personal Information
Section 1148 of the Social Security Act authorizes us to collect this information. We will use the
information to verify the service provider’s eligibility for payment.
Furnishing us this information is voluntary; however, failing to provide all or part of the
information could prevent the provider from receiving payment.
We rarely use the information you supply for any purpose other than what we state above,
however, we may use the information for the administration of our programs including sharing
information:
1. To comply with Federal laws requiring the release of information from our records
(e.g., to the Government Accountability Office and Department of Veterans Affairs);
and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure
the integrity and improvement of our programs (e.g., to the Bureau of the Census
and to private entities under contract with us).
A list of when we may share your information with others, called routine uses, is available in our
Privacy Act System of Records Notice, 60-0295, entitled Ticket-to-Work and Self-Sufficiency
Program Payment Database, and 60-0300, entitled Ticket-to-Work Program Manager (PM)
Management Information System. Additional information about this and other system of records
notices and our programs are available from our Internet website at www.socialsecurity.gov or
at your local Social Security office.
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, State, or local government
agencies. Information from these matching programs can be used to establish or verify a
person’s eligibility for federally funded or administered benefit programs and for repayment of
incorrect payments or delinquent debts under these programs.

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