Part I Part I

Attachment A

Revisions to the

SAMHSA SOAR Web-Based Data Form

Part I: SSI/SSDI Application Outcomes

(4 Revisions)

Screenshots of the Current Form

Registration Page for New Users to the System

New users, who are case workers, agency directors, local leads, or state leads, need to complete and submit this registration form. Users create a username and password, select their role, location, funding source and SOAR training completed.

Demographic Information (Four Revisions)

The demographic information on each applicant is collected on this screen. Basic information including gender, age, military service, benefits received, employment status and housing status are included. The additional questions will be asked in this section. The revisions include:

• 1. [Race] With what race does the applicant identify?

  • Black or African American

  • White

  • American Indian

  • Alaska Native

  • South Asian

  • Chinese

  • Filipino

  • Japanese

  • Korean

  • Vietnamese

  • Other Asian

  • Native Hawaiian

  • Guamanian or Chamorro

  • Samoan

  • Other Pacific Islander

  • Other (Specify)___________________

  • Unknown

• 2. [Ethnicity] Is the applicant Hispanic, Latino/a, or Spanish origin?

  • Yes

  • No

  • Unknown

    • [IF YES] What ethnic group are they? You may indicate more than one.

      • Central American

      • Cuban

      • Dominican

      • Mexican

      • Puerto Rican

      • South American

      • Other (Specify)_____________

      • Unknown

• 3: What sex was the applicant assigned at birth, on their original birth certificate?

• Female

• Male

• (Don’t know)

• (Prefer not to answer)

• 4: What is the applicant’s current gender? [Select one]

• Female

• Male

• Transgender

• [If respondent is American Indian/Alaskan Native:] Two-Spirit

• I use a different term: [free text]

• (Don’t know)

• (Prefer not to answer)

• 5. Was the applicant involved in the criminal justice or legal system at the time of application?

  • Yes

  • No

    • If Yes, please select one (Drop-down options)

      • Treatment Court (Mental Health, Drug, Homeless, or Veterans)

      • Jail (Local or State)

      • Prison (State or Federal)

      • Community Supervision (Probation or Parole)

      • Reentry Program or Services

Application Type

The second section asks about the application type. There are four types: initial, reconsideration, ALJ hearing and non-SOAR claim.

Application Detail

The third section asks a few questions about what SOAR critical components were used while assisting with the application. Questions include the protective filing date, forms and records that are submitted, whether quality review was done, if the application is complete, if consultative exams were ordered, (and if so, the total number), and the application date.

Decision

These questions ask if there has been notification of a decision, the date of the decision, and if denied, whether an appeal was filed.

Post Decision

Most of the questions that are asked post-decision are optional for the user. They are asked the amount the applicant was approved for, and then can optionally track other reimbursement amounts and qualitative outcomes including housing status, employment status and hours to complete the claim.

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0930-0329, and it expires 03/31/2023. Public reporting burden for this collection of information is estimated to average 15 minutes per respondent, per year, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 5600 Fishers Lane, Room 15E57A, Rockville, MD 20857.