WIPA STAR System

Status: Original and derived artifacts are available for this document.

Download: docx | pdf | html

Attachment H: WIPA STAR System Fields
Module 1:  Beneficiary Information 

Data Element
Field Type
Values

First name
Text
Text

Middle name
Text
Text

Last name
Text
Text

Address 1
Text
Text

Address 2
Text
Text

City
Text
Text

State
Text
Text

ZIP code
Text
Text

County
Text
Text

Note – we will investigate having this field auto-populate based on ZIP code

Cell phone
Text
Text

Home phone
Text
Text

Work phone
Text
Text

TTY/Videophone Number/IP address
Text
Text

Email address
Text
Text

Representative Payee?
Radio button (choose one)
Yes/No

Representative Payee first name
Text
Text

Representative Payee middle name
Text
Text

Representative Payee last name
Text
Text

Representative Payee address 1
Text
Text

Representative Payee address 2
Text
Text

Representative Payee city
Text
Text

Representative Payee state
Text
Text

Representative Payee ZIP code
Text
Text

Representative Payee phone
Text
Text

Representative Payee email address
Text
Text
Is Representative Payee also legal guardian?
Drop down (choose one)
Yes/No/Not applicable

Note – If “Yes” selected, we will investigate having the system auto-populate the information entered for the Representative Payeee in the legal guardian fields
Legal guardian first name
Text
Text
Legal guardian middle name
Text
Text
Legal guardian last name
Text
Text
Legal guardian address 1
Text
Text
Legal guardian address 2
Text
Text
Legal guardian city
Text
Text
Legal guardian state
Text
Text
Legal guardian ZIP code
Text
Text
Legal guardian phone
Text
Text
Legal guardian email address
Text
Text

SSN
Text
Text

Claim number (if different from beneficiary SSN)
Text
Text

Date of birth
Date
MM/DD/YYYY

Beneficiary unique ID
Text
Text

Beneficiary status
Drop down (choose one)
Receives SSI 

Receives Title II (SSDI, CDB, DWB) 

Receives SSI and SSDI (Concurrent)

Benefits terminated

Reached Full Retirement Age

Residence outside service area

Deceased

Race 
Check box (choose all that apply)
American Indian or Alaska Native

Asian 

Black or African/American 

Native Hawaiian or Other Pacific Islander 

White

Prefers not to provide

Ethnicity 
Drop down (choose one)
Hispanic or Latino

Not Hispanic or Latino

Prefers not to Provide

Sex
Drop down (choose one)
Male

Female

Other

Date CWIC assigned 
Date
MM/DD/YYYY

Name of assigned CWIC
Drop down (choose one)
Select from a list of CWICs assigned to the organization
 
Module 2:  Referral Information
Data Element
Field Type
Values
Date of referral
Date
MM/DD/YYYY
Source of referral
Drop down
(choose one)
Ticket to Work Help Line

Beneficiary or Representative Payee self-referral

Vocational Rehabilitation agency

Employment Network

Other community agency
Is beneficiary between the ages of 14 and 25 at the time of referral?
Radio button (choose one)
Yes/No
Is beneficiary a U. S. Veteran?
Radio button (choose one)
Yes/No
Employment status at time of referral
Drop down
(choose one)
Full-time employment or self-employment

Part-time employment or self-employment
 
Job offer pending

Not employed
Health insurance 

Check box
(choose all that apply)
Medicare (list parts in “Notes”)

Medicaid (list type in “Notes”)

Private

Employer-sponsored

Veteran’s Affairs

Other (describe in “Notes”)

None
Health insurance notes
Text box
Text
Employment services received at intake
Check box
(Choose all that apply)
Vocational Rehabilitation

Ticket to Work

Other vocational services or supports
Is beneficiary eligible for WIPA services?
Radio button (choose one)
Yes/No
Status of referral for WIPA services
Drop down
(choose one)


Note:  If answer to question above is “No”, this question will auto populate with “Not engaged.  Ineligible for WIPA services.” Status.

Conducting initial outreach.

Not engaged. Ineligible for WIPA services.

Not engaged. Eligible beneficiary declined individualized WIPA services.

Not engaged. Eligible beneficiary receiving information and referral services, but not requesting individualized WIPA services.

Not engaged. Eligible beneficiary did not respond following 3rd outreach attempt.

Not engaged. Eligible beneficiary is already receiving suitable services elsewhere. 

Not engaged. Eligible beneficiary did not return 3288s.

Pending engagement. Eligible beneficiary requesting individualized WIPA services; verifications pending. 

Engaged. Eligible beneficiary engaged in individualized WIPA services; verifications received.

Module 3:  Actions and Services
Data Element
Field Type
Values
Action created date
Computed Date
MM/DD/YYYY

Note this is an auto-populated field
Action created by
Computed Text
User first name User last name.  

Note this is an auto-populated field
Intake Services


Date releases sent
Date
MM/DD/YYYY
Date releases returned
Date
MM/DD/YYYY
Date intake process completed
Date
MM/DD/YYYY
Verification


Date BPQY requested
Date
MM/DD/YYYY
Date BPQY received
Date
MM/DD/YYYY
Individualized Services


Does beneficiary want to work more to (check one of following options):
Drop-down
(choose one)
Increase income without losing SSDI or SSI benefits

Reduce SSDI or SSI benefits

Eliminate SSDI or SSI benefits
Comments on work goals
Text
Text
Date initial or follow-up BS&A completed
Date
MM/DD/YYYY
Did CWIC use BSADOCs to develop BS&A?
Radio button (choose one)
Yes/No
Date discussed initial or follow-up BS&A with beneficiary
Date
MM/DD/YYYY
If BS&A prepared, what is status of follow-up services?
Drop-down
(choose one)
Beneficiary accepted offer for follow-up services

Beneficiary declined offer for follow-up services

Beneficiary was not offered follow-up services
Date provided beneficiary follow up services plan 
Date
MM/DD/YYYY
Additional Services


Date referred beneficiary to Vocational Rehabilitation
Date
MM/DD/YYYY
Date referred beneficiary to Employment Network
Date
MM/DD/YYYY
Date referred beneficiary to other vocational services
Date
MM/DD/YYYY
Date assisted beneficiary with earnings reporting
Date
MM/DD/YYYY
Date discussed Plan to Achieve Self-Support (PASS) with beneficiary
Date
MM/DD/YYYY
Date assisted beneficiary to complete and submit PASS 
Date
MM/DD/YYYY
Date assisted beneficiary to report IRWE, subsidy or use of work incentives to SSA
Date
MM/DD/YYYY
Date provided follow-up contact with beneficiary at key touchpoints
Date
MM/DD/YYYY
Comments
Text
Text
Module 4: Case Notes
Data Element
Field Type
Values
Case note created date
Date
MM/DD/YYYY
Case note created by
Text
User first name User last name.  

Note this is an auto-populated field 
Date of contact 
Date
MM/DD/YYYY
Person or agency contacted
Text
Text
Purpose of the contact
Text
Text
What did you discuss?
Text
Text
Additional notes
Text
Text
Contact mode
Drop-down (choose one)
Phone

Email

In-person 

Mail
Contact disposition
Drop-down (choose one)
Contact made

No answer/No show

Voicemail

Busy

Bad contact info