WIPA STAR System

Attachment F – Master List of all Data Elements

This table provides a comprehensive list of data elements in the three information collections instruments – the form SSA-4565, form SSA-4566 and the WIPA START system. The form SSA-4565 includes 10 data-collection tables. Each table cell is listed in this table on a separate row.

Fields collected on a paper form are noted with a “P”. Following the “P” is the corresponding field number on the paper form. Fields collected electrically in the WIPA STAR system are indicated with an “E”. Following the “E” is a notation of which module within the data system (1 – 4) the field is collected.

	Collected in?
Data Element	SSA-4565	SSA-4566	WIPA STAR System
Date of contact	P (line 1)	P (line 3)	E (module 4)
Servicing WIPA	P (line 2)
Previously referred?	P (line 3a)
If yes, date	P (line 3b)
First name	P (line 4)	P (line 1)1	E (module 1)
Middle name	P (line 4)	P (line 1)	E (module 1)
Last name	P (line 4)	P (line 1)	E (module 1)
Address 1	P (line 5a)		E (module 1)
Address 2	P (line 5a)		E (module 1)
City	P (line 5a)		E (module 1)
State	P (line 5a)		E (module 1)
ZIP code	P (line 5a)		E (module 1)
County	P (line 5b)		E (module 1)
Cell phone	P (line 6a)		E (module 1)
Home phone	P (line 6b)		E (module 1)
Work phone	P (line 6c)		E (module 1)
TTY/Videophone Number/IP address	P (line 6d)		E (module 1)
Email address	P (line 7)		E (module 1)
Best time and number to call	P (line 8)
Beneficiary’s preferred language	P (line 9a)
If “Other”, specify	P (line 9b)
Representative Payee?	P (line 10a)		E (module 1)
Representative Payee first name	P (line 10b)		E (module 1)
Representative Payee middle name	P (line 10b)		E (module 1)
Representative Payee last name	P (line 10b)		E (module 1)
Representative Payee address 1	P (line 10c)		E (module 1)
Representative Payee address 2	P (line 10c)		E (module 1)
Representative Payee city	P (line 10c)		E (module 1)
Representative Payee state	P (line 10c)		E (module 1)
Representative Payee ZIP code	P (line 10c)		E (module 1)
Representative Payee phone	P (line 10d)		E (module 1)
Representative Payee email address	P (line 10e)		E (module 1)
SSN	P (line 11)		E (module 1)
Claim number (if different from beneficiary SSN)	P (line 12)		E (module 1)
Date of birth	P (line 13)		E (module 1)
Is the beneficiary between the ages of 14 and 25 at the time of referral?	P (line 14)		E (module 2)
Is the beneficiary a Veteran of the U.S. Military?	P (line 15)		E (module 2)
Type of benefits received by the beneficiary (wording on SSA-4565) Beneficiary status (wording in WIPA STAR System)	P (line 16)		E (module 1)
Ticket status	P (line 17a)
If assigned / in-use with vocational rehabilitation agency, agency name	P (line 17b)
Employment status at time of referral	P (line 18a)		E (module 2)
If employed, job details	P (line 18b)
Employer health benefits?	P (line 18c)
Reported work to SSA?	P (line 18d)
Other benefits received?	P (line 19a)
If yes, specify	P (line 19b)
Beneficiary concerns/questions	P (line 20)
Date of referral	P (line 21)		E (module 2)
Source of referral	P (line 22)		E (module 2)
Beneficiary unique ID	P (line 23)	P (line 2)	E (module 1)
CWIC	P (line 24)		E (module 1)
Local SSA Field Office	P (line 25)
Primary contact	P (line 26a)
If Other, specify	P (line 26b)
Is the Representative Payee the legal guardian?	P (line 27a)		E (module 1)
Legal guardian first name	P (line 27b)		E (module 1)
Legal guardian middle name	P (line 27b)		E (module 1)
Legal guardian last name	P (line 27b)		E (module 1)
Legal guardian address 1	P (line 27c)		E (module 1)
Legal guardian address 2	P (line 27c)		E (module 1)
Legal guardian city	P (line 27c)		E (module 1)
Legal guardian state	P (line 27c)		E (module 1)
Legal guardian ZIP code	P (line 27c)		E (module 1)
Legal guardian phone	P (line 27d)		E (module 1)
Legal guardian email address	P (line 27e)		E (module 1)
Preferred method of contact	P (line 28a)
If Other, specify	P (line 28b)
Alternate contact	P (line 29a)
If Other, specify relationship	P (line 29b)
Alternate contact name	P (line 29c)
Alternate contact address	P (line 29d)
Alternate contact phone	P (line 29e)
Alternate contact email	P (line 29f)
Preferred method of contact for alternate contact	P (line 30a)
If Other, specify	P (line 30b)
Describe any language or accommodation needs	P (line 31)
If over age 18 and receiving SSI, has SSA conducted the age 18 redetermination?	P (line 32)
When did the disability begin?	P (line 33)
Does the beneficiary have a my Social Security account?	P (line 34)
List the primary disability	P (line 35)
Statutorily blind?	P (line 36)
Marital status	P (line 37)
Race	P (line 38)		E (module 1)
Ethnicity	P (line 39)		E (module 1)
Sex	P (line 40)		E (module 1)
List other people in household table	P (line 41)
If any household member (spouse or children) receives any type of means-tested benefits describe	P (line 42)
For SSI and Medicaid recipients only, describe all income or in-kind support received table	P (line 43)
Health insurance	P (line 44a)		E (module 2)
Health insurance notes	P (line 44b)		E (module 2)
SSA benefits table	P (line 45)
Medicaid number	P (line 46a)
Medicaid benefits table	P (line 46b)
Medicare number	P (line 47a)
Medicare benefits table	P (line 47b)
Other Benefits table	P (line 48)
Excluded savings table	P (line 49)
Additional benefits or assets table	P (line 50)
Eligible for WIPA services?	P (line 51)		E (module 2)
Highest grade completed	P (line 52)
If under age 22, is the beneficiary regularly attending school?	P (line 53a)
If “Yes”, is the Student Earned Income Exclusion applicable?	P (line 53b)
Describe any educational goal(s)	P (line 54)
Does the beneficiary want to work more to	P (line 55a)		E (module 3)
Comments on work goals	P (line 55b)		E (module 3)
Earnings goal 1	P (line 56)
Type of position or field of work	P (line 56a)
Number of hours anticipated per week	P (line 56b)
Hourly wage or salary	P (line 56c)
Estimated monthly earning goal	P (line 56d)
Earnings goal 2	P (line 57)
Type of position or field of work	P (line 57a)
Number of hours anticipated per week	P (line 57b)
Hourly wage or salary	P (line 57c)
Estimated monthly earning goal	P (line 57d)
Employment services the beneficiary receives table	P (line 58)
List the services the beneficiary needs to reach his or her employment goal	P (line 59)
Does the beneficiary want you to share the BS&A or other information about benefits counseling with any employment support agency or other person?	P (line 60)
Benefits Summary & Analysis (BS&A) delivery - Beneficiary	P (line 61a)
If Other, specify	P (line 61b)
Benefits Summary & Analysis (BS&A) delivery – Alternate contact	P (line 61c)
If Other, specify	P (line 61d)
Employment status at the time the CWIC begins providing individualized services	P (line 62a)
Start date of current employment or self-employment	P (line 62b)
If employed, name of employer	P (line 62c)
If employed, weekday or dates employer issues paychecks	P (line 62d)
If employed, the amount of gross wages	P (line 62e)
If self-employed, nature of the business	P (line 62f)
If self-employed, estimated net profit	P (line 62g)
Has the beneficiary reported these earnings to Social Security?	P (line 62h)
If “Yes”, give the date(s) of the report and the manner used to report the earnings	P (line 62i)
Prior work history table	P (line 63)
List out of pocket expenses that could be Impairment Related Work Expenses (IRWE) or Blind Work Expenses (BWE):	P (line 64)
Describe special employment supports the beneficiary received in the past, currently uses, or expects to need in the near future. Also describe any other indication that the beneficiary has a possible subsidy, such as working with a job coach	P (line 65)
Notes, additional information and next steps	P (line 66)
Person or agency contacted		P (line 4)	E (module 4)
Purpose of the contact		P (line 5)	E (module 4)
What did you discuss		P (line 6)	E (module 4)
Additional notes		P (line 7)	E (module 4)
Date CWIC assigned			E (module 1)
Employment services received at intake			E (module 2)
Status of referral			E (module 2)
Date releases sent			E (module 3)
Date releases returned			E (module 3)
Date intake process completed			E (module 3)
Date BPQY requested			E (module 3)
Date BPQY received			E (module 3)
Date completed initial or follow-up BS&A			E (module 3)
Did CWIC use BSADOCS to develop BS&A?			E (module 3)
Date discussed initial or follow-up BS&A with beneficiary			E (module 3)
If BS&A prepared, what is status of follow-up services?			E (module 3)
Date provided beneficiary follow up services plan			E (module 3)
Date referred beneficiary to Vocational Rehabilitation			E (module 3)
Date referred beneficiary to Employment Network			E (module 3)
Date referred beneficiary to other vocational services			E (module 3)
Date assisted beneficiary with earnings reporting			E (module 3)
Date discussed Plan to Achieve Self-Support (PASS) with beneficiary			E (module 3)
Date assisted beneficiary to complete and submit PASS			E (module 3)
Date assisted beneficiary to report IRWE, subsidy or use of work incentives to SSA			E (module 3)
Date provided follow-up contact with beneficiary at key touchpoints			E (module 3)
Comments			E (module 3)
Contact mode			E (module 4)
Contact disposition			E (module 4)

1 The Form SSA-4566 uses the term “Beneficiary” in place of “Name”.