Intake Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Beneficiary Demographics
Full Name
*
First Name
Middle Name
Last Name
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Social Security Number
*
Date of Birth
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Email
*
example@example.com
Rep Payee's Name
First Name
Last Name
Rep Payee's Email
example@example.com
Rep Payee's Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
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Transportation Plan
Select All That Apply
*
Own modified vehicle
Public transportation
Other (describe below)
Describe Any Additional Information
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Potential Work Barriers
Has Participant ever been convicted of a crime?
*
Yes
No
If you answered yes, please enter penal code
Disabling condition(s) & how it will impact work?
*
Have you / will you request medical documentation, and/or recommendations from doctor/therapist?
*
Yes
No
Are you committed to returning to work?
*
Yes
No
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State VR History
Are you currently receiving services from the State VR agency?
*
Yes
No
If YES, were you successfully placed by VR?
Yes
No
Any notes
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Educational Background
Select all that apply
*
No formal schooling
Elementary education (Grades 1-8)
Secondary education, no H.S. diploma (Grades 9-12)
Special education certificate of completion / attendance
High School diploma equivalent (e.g. GED)
High School diploma
Post-secondary education, no degree
Associate degree or Vocational Technical Certificate
Bachelor's degree
Master's degree or higher
Vocational Assessment
Vocational Goal
*
Employment Goal
Do you currently have the required skills and experience to obtain desired work?
*
Yes (work ready)
No
If not work ready, identify training needs
Are you pursuing education prior to engage in employment?
*
Yes
No
Interested in F/T or P/T work?
*
Full-time
Part-time
How many hours are you willing to commit to your job each week?
*
Desired hourly compensation
*
Number of miles Participant is willing to drive for work one way?
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WORK HISTORY IN LAST 5 YEARS
Job #1
Employer
Job Title
Start Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
End Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Pay Rate
Hours/week
Comments
Job #2
Employer
Job Title
Start Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
End Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Pay Rate
Hours/week
Comments
Job #3
Employer
Job Title
Start Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
End Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Pay Rate
Hours/week
Comments
Has work been reported to Social Security
*
Please Select
Yes
No
When was work reported to Social Security?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How was work reported to Social Security?
By mail
By phone
At the SSA Office
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Benefits Received
Social Security Benefits and Related Health Insurance
SSI
SSDI
CDB
DWB
Child's Benefits
Other
Auxiliaries (list all with payment amounts)
Select all that apply and list payment amount under the yes field
Medicare Part A
*
No
Yes
Medicare Part B
*
No
Yes
Medicare Savings
*
No
Yes
Other Federal / State / Local Benefits
Select all that apply and list payment amount under the yes field
Food Stamps (SNAP)
*
No
Yes
TANF
*
No
Yes
HUD Housing Subsidies
*
No
Yes
Unemployment Insurance
*
No
Yes
Worker's Compensation
*
No
Yes
DoD / VA Benefits
*
No
Yes
Private Disability Insurance
*
No
Yes
Alimony / Maintenance
*
No
Yes
Child Support
*
No
Yes
Energy Assistance
*
No
Yes
State Vocational Rehabilitation
*
No
Yes
Other
*
No
Yes
If you answered yes to State Vocational Rehabilitation, please enter VCR Name
If you answered yes to State Vocational Rehabilitation, please enter phone number
Please enter a valid phone number.
Format: (000) 000-0000.
If you answer yes to Other, please list the name of the Federal, State, or Local benefit
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Medicare Savings Program
Select all Medicare Savings Programs that apply
*
QMB/SLMB
Medicare Part D
Medicare Part D Low-Income Subsidy
None of the above
If you selected Medicare Part D Low-Income Subsidy please indicate % level
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Medicaid Programs
Select all Medicaid Programs that apply
*
Medicaid
Medicaid Wavier Programs
None of the above
If you are on the Medicaid Waiver wait list, please enter the approval date below:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
List any program that are "In Service"
Have you been diagnosed with any of the following disabilities:
Intellectual Disability
Autism
Spina Bifida
Cerebral Palsy
Prader-Willi Syndrome
Down Syndrome
Phelan-McDermid Syndrome
Are any members of your household (spouse and/or children) receiving any type of means-tested benefit (SSI, Medicaid, other) or other benefits not already listed? List all types of benefits with amounts:
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Private Health Insurance
Do you have Private Health Insurance?
*
Yes
No
If you answered yes to Private Health Insurance, how much do you pay for your premium?
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Provisions Applicable to SSI
Select all provisions that apply
*
General Income Exclusion and Earned Income Exclusion
Impairment Related Work Expenses
Blind Work Expenses (BWE)
1619(b) Extended Medicaid
Plan for Achieving. Self-Support (PASS)
None of the above
If you selected Blind Work Expenses (BWE), is the disability on record with Social Security blindness
Yes
No
If yes, describe examples of BWE Expenses: Guide dog expenses, Licensure fees, professional expenses, union dues, Attendant care, Vehicle modification, Prosthesis, transportation to and from work, Federal, state and local taxes, Training to use a work-related item , Physical therapy, work-related equipment and supplies, Non-medical equipment and supplies, drugs and medical services necessary to work, Expendable medical supplies, Meals consumed during work hours , Mandatory pension contributions
If you selected Plan for Achieving Self-Support (PASS), do you have an approved PASS?
Yes
No
Do you have earnings or unearned income (not SSI) or resources that can be set aside in a PASS
Yes
No
If yes to the question above, what are these resources and the amounts?
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Potential Use of Work Incentives (For SSDI Recipients)
Select all potential use of work incentives that apply
Trail Work Period (TWP) / Extended Period of Eligibility (EPE)
Impairment Related Work Incentives (IRWEs)
Subsidy / Special Conditions
Subsidy for Self-Employment (Unpaid help, un-incurred business expenses)
Unsuccessful Work Attempt (UWA)
Extended Period of Medicare coverage
Medicaid Buy-In
Expedited Reinstatement (exR)
Section301
Other
If you selected Impairment Related Work Incentives (IRWEs), please answer the following questions.
If answering yes to any of the following questions about IRWEs, please put the monthly expense amount in the box below the yes option
Are you paying for any medication expenses that aren't covered by Medicaid, Medicare or other insurance?
No
Yes
Are you paying for any treatment, therapies, case management, that isn't covered by Medicaid, Medicare or other insurance?
No
Yes
Are you paying for attendant care, medical devices, residential modifications, or prosthetic devices?
No
Yes
Does your disability prevent you from driving or requires you to use special transportation or do you have a modified vehicle?
No
Yes
If you selected Subsidy / Special Conditions, please answer the following questions.
Do you need extra time to complete work or duties?
Yes
No
Will you need modifications or special equipment to complete tasks due to the disability?
Yes
No
Will you have special job carving or fewer or modified job duties due to the disability?
Yes
No
Is job coaching necessary to help you learn and perform duties?
Yes
No, I learn everything on my own
Would you have missed work or need special arrangements with work hours due to the use of special transportation?
Yes
No
Would you possibly be absent more often than other employees because of your disability?
Yes
No
Is a government agency paying part of the wage?
Yes
No
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Other Agency Involvement
If answering yes to any of the agencies below, please put the contact name and phone number for that agency in the box associated with the question.
State VR Agency / Blind Services Agency
*
No
Yes
EN or Community Rehabilitation Provider
*
No
Yes
American Job Center
*
No
Yes
P&A
*
No
Yes
Center for Independent Living
*
No
Yes
Other Agency Involvement/Services Received
*
No
Yes, please list agency name, contact name, & phone number
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