Benefits Screening Profile by 5Qlm4cY4

VIEWS: 4 PAGES: 22

									                                                                                                                          Please complete all areas thoroughly
            TACE 7 Benefits Screening Profile                                                                        If not applicable, please indicate with N/A

                                                                      General Information
                             Remember to include all information about the disability and contact information for the beneficiary
                               and others who will be supporting the individual that may be involved in employment supports

                                                   Specifics                                                               Additional comments or updates
                                                                                                                                     (include date of update)
 Beneficiary/Recipient Name:                                                                                        Comment:
 Date of Birth:                 Gender: Male                 Female              Ethnicity:
 Physical Street Address:
 Mailing Address, if different:
 City/State:                                                          Zip
 County of Residence:
 Telephone: Primary:(           )       -               Secondary (         )      -
 Work Phone: (           )      -                                     E-mail:

                                         Disability/Diagnoses:                                                      Comment:
 Primary:
 Secondary:
 Is the person considered Blind by SSA?         Yes              No
           if YES is the person receiving: SAB: Yes              No             or BP: Yes          No
                                                                                              Verified: Yes   No
 Language or Accommodations Needs:
 How condition(s) affect/limit activities or ability to work:


 VRC/Benefit Specialist Name:
 Date of Initial Contact:              Date Benefits Screening Profile Complete:
 Date Benefit Summary and Analysis Completed:                 Date Work Incentive Plan Completed:
 SSI          TITLE II ENTITLEMENTS: SSDI                     DWB                DWB               Concurrent
 SSA information Release: Date Sent:                   Date Received:           Date of Interview:          Interviewer:
 Other person interviewed (i.e. relative or personal assistant):


University of MO,-Disability Policy and Studies, Region 7 TACE              (Adapted from the Work Incentives Network (WIN) of NE)                       March, 2011
Benefits Screening Profile                                                                                                                                      Page 2
                                                               General Information, continued
                                                  Specifics                                                              Additional comments or updates
                                                                                                                                   (include date of update)
           Other Contacts, if desired (i.e. relative, advocate, vocational provider, etc)                         Purpose /Outcome of this Contact:
 Name:
 Mailing Address:
 City/State:                                                                   Zip
 Phone number: :(           )      -              Fax (        )     -
 E-mail:
                       Provide this person a copy of the Benefits Screening Profile: Yes                No


       Releases must be signed by guardian. BPQY requests do not need the representative payee’s signature
                       Guardian or Representative Payee Information                                               Comment:
 Name:
 Mailing Address:
 City/State:                                                                   Zip
 Phone number: :(           )      -              Fax (        )     -
 E-mail:
                       Provide this person a copy of the Benefits Screening Profile: Yes                No
                            Social Security Office Serving Individual                                             Comment:
 Office Name:
 Address:
 City/State:                                                                   Zip
 Phone number: :(           )      -              Fax (        )     -
 CR name:
                                Other Agencies Serving Individual                                                 Comment:
 Local Social Service Office: (    )     -                         Medicaid Eligibility Worker
 HUD Office: :(     )     -
 Other state and federal contact information:




University of MO-Disability Policy and Studies Region 7 TACE              (Adapted from the Work Incentives Network (WIN) of NE)                      January 2011
573 882-3807                   www.dps.missouri.edu
Benefits Screening Profile                                            Living Arrangements Section                                                             Page 3

                                                                      Living Arrangements
  Evaluate if HUD work incentives are applicable. If living in a group home, or assisted living facility, evaluate effect of earnings on incentives and
            income. If individual is receiving SSI, check on in-kind support and VTR (i.e., is individual paying toward living expenses?)

                                Details about Living Arrangements                                                      Additional comments or updates
                                                                                                                                 (include date of update)
 Married? No         Yes         (Name of Spouse):                                                              Comment:
 With whom does the individual live?
    Alone         Live with Spouse         Live with children                    Live with roommate
         Live with parent or relative       Share expenses
                                                           Number of Children Under 18 in care:
 HUD/State subsidized housing                Yes                No                                              Comment:
 Total Rent:$       Beneficiary Amount: $
 Are you receiving rental assistance through one of the following HUD programs?
     HOPWA        Supportive Housing Program      Housing Choice Vouchers (Section 8)
     HOME         Other
 Earned Income Disallowance (or "Disregard")
 EID Months Used                             Date EID Began:
 Self-Sufficiency Eligibility Screening       or referral made:
 Name of Non-HUD Housing Assistance Program                                                                     Comment:
 Does the individual have other state funding or support for housing? Yes             No
              Funding amount:$
 Residential Funding                                                                                            Comment:
      Fair Market Rental      Flat Rate Room & Board        Mortgage     Pays no living expense
                         Rent, Food, or Utilities only                Pays no Room & Board
 Type of Residence: Home              Apartment         Group Home        Assisted Living AABD                  Comment:
  Assisting Living with Waiver       Intermediate Care Facility     Other       (describe)
 Expense:           Flat R/B          Rent, Food, or utilities only            Pays no living expenses
 Contact information (Landlord/Housing Authority)




University of MO-Disability Policy and Studies Region 7 TACE            (Adapted from the Work Incentives Network (WIN) of NE)                      January 2011
573 882-3807                   www.dps.missouri.edu
Benefits Screening Profile                                                Employment Goals                                                                  Page 4

                                         Personal Information Regarding Employment Goals
                          Details about Personal Employment Goals                                                    Additional comments or updates
                                                                                                                               (include date of update)
 What questions/concerns do you have about working and your benefits?                                         Comment:
   How much do you hope to earn per month from your job?                             $
   How many hours per week do you hope to work? ......................................
   What are your long range dreams, goals regarding work and your benefits? (job title,
      duties, salary)
   What supports do you need to reach your employment goals? (frame supports)

   What other supports or family connections do you have to help you? (agency/formal
      supports and unpaid supports)
 Ticket to Work                                                                                               Comment:
    Have you assigned the Ticket to Work to anyone?                Yes                   No
    To which Employment Network?




University of MO-Disability Policy and Studies Region 7 TACE          (Adapted from the Work Incentives Network (WIN) of NE)                      January 2011
573 882-3807                   www.dps.missouri.edu
Benefits Screening Profile                                                                     SSA Benefit Information                                                               Page 5

                                                                        Social Security Benefit Information
     Evaluate income in terms of impact of employment on dependants and others living in the household who may be receiving benefits
          (such as dependent benefits for SSDI, deemed income for SSI, etc.)
     Verify benefit information with the Benefits Planning Query (BPQY)

                                               Details about SSA Benefits                                                                     Additional comments or updates
                                                                                                                                                        (include date of update)
 Title II Disability Insurance:                                                                                                        Comment:
   Type of Benefit (check appropriate benefit):
   Title II Entitlements: SSDI: $                             Widows/Widowers: $
       Childhood Disability Beneficiary: $                TBD       Other
   Date of Entitlement:               Disability on Record with SSA (blind or non/blind):
 Supplemental Security Income:                               SSI Amount $                                                              Comment:
   Date of Entitlement:                    Disability on Record with SSA (blind or non blind):
 Are there others in the household receiving Title II benefits?               Yes       No                                             Comment:
 If yes, are they receiving survivor’s benefits under the beneficiary?                                   Yes           No
 Indicate who is receiving benefits and amounts:
  Name:           ....................................................................................................... Amount: $
  Name:           ....................................................................................................... Amount: $
  Name:           ....................................................................................................... Amount: $
  Name:           ....................................................................................................... Amount: $
 Are there others in the household receiving SSI benefits?                                                         Yes            No   Comment:
  If yes, indicate who is receiving benefits and amounts:
  Name:           ........................................................................................... Amount: $
  Name:           ........................................................................................... Amount: $
  Name :          ........................................................................................... Amount: $
  Name:           ........................................................................................... Amount: $
  Name:          ............................................................................................ Amount: $




University of MO-Disability Policy and Studies Region 7 TACE                                   (Adapted from the Work Incentives Network (WIN) of NE)                      January 2011
573 882-3807                   www.dps.missouri.edu
Benefits Screening Profile                                                                             Other Benefit Information                                                                    Page 6

                                                 Other Benefits, Income-Based or Needs-Based Assistance
                                              Evaluate other state and federal benefits for impact of employment on these benefits

                                     Details about Other Benefits of Individual                                                                              Additional comments or updates
                                                                                                                                                                       (include date of update)
 Other Benefits                                                                                                                                        Comment:
    Unemployment .............................$
    Veterans Benefit Compensation .....$                                                 SSI .....................................................$
    Alimony/Palimony .........................$                                          Veterans Benefit Pension : ...............$
    Railroad Retirement Pension ......$                                                  Child Support .....................................$
    Workers Compensation ...............$
    Private Disability Insurance ..........$
                                                                                                   Total of Benefits Listed: $
 Other Financial Needs-Based Assistance                                                                                                                Comment:
    Federal Work Study Program: ............... $                                                     Pell Grant: ......................... $
    SNAP .............................................................. $                             TANF ................................. $
 Other Assistance
 Amount $       .............. Source:                               ............................................... Reason:


                                                                             Other Household Assistance Income
                                             Evaluate impact of beneficiary’s employment on benefits of others living in household

                                    Details about Other Household Assistance                                                                           Document information Verification.
 Are there others in the household receiving other public assistance (such as TANF)?                                                Yes           No   Verification:
   Name:            .................................................................................................. Relationship
              Source of Assistance                    ................................................................... Amount: $
   Name:            .................................................................................................. Relationship
              Source            ......................................................................................... Amount: $
   Name:            .................................................................................................. Relationship
              Source            ......................................................................................... Amount: $
   Name:            .................................................................................................. Relationship
              Source            ......................................................................................... Amount: $




University of MO-Disability Policy and Studies Region 7 TACE                                           (Adapted from the Work Incentives Network (WIN) of NE)                             January 2011
573 882-3807                   www.dps.missouri.edu
Benefits Screening Profile                                        Medicaid & Medicare                                                      Page 7

                                                      Resources Pertaining to Medicaid/SSI
If the individual receives SSI or Medicaid, evaluate potential impact of recourses on SSI and Medicaid eligibility, or what may be used to
            be set aside for work related supports (i.e., PASS or Savings for Independence and Self Sufficiency for MED Works)
                          Vehicle modifications for transportation may be evaluated in terms of IRWE if applicable

                           Details about Resources & Medicaid/SSI                                        Document how information was verified.
 Home/Property Ownership: Does the person own his or her home? Yes                         No           Verification:
        If jointly owned, who are the other owner(s):
 Does the person own or have interest in any other property or land?          Yes         No
        Approximate Value of other property $
 Bank Accounts:                                                                                         Verification:
 Is the individual nearing $2,000 (999.99 in MO) in resources in any bank accounts that may
 affect Medicaid?           Yes          No
 Checking $                                   Savings $
 Retirement Accounts (IRA, tax deferred annuity, etc.)
 describe and list amounts:
 Stocks/Bonds/Certificates of Deposit, etc.
 Vehicles owned by individual:                  Car              Van              Truck                 Verification:
           Other (trailer, boat, etc.)     (describe Other)
           Is the vehicle modified for use by person with disability?       Yes           No
           Is vehicle used as transportation to work?                       Yes           No
           Is vehicle used as transportation for medical appointments?      Yes           No
                    Approximate Value $




University of MO-Disability Policy and Studies Region 7 TACE    (Adapted from the Work Incentives Network (WIN) of NE)           January 2011
573 882-3807                   www.dps.missouri.edu
Benefits Screening Profile                                                 Medicaid & Medicare                                                                  Page 8

                                            Health Insurance Information Pertaining to Medicaid
                            Evaluation of Section 1619 Medicaid protection, Medicaid Buy-In and Medicaid Work Incentives

                               Details about Health Insurance & Medicaid                                                    Document how information was verified
                                                                                                                             (agency records, confirmation from caseworker, etc.)
 Medicaid type (check all that apply):                                                                                    Verification:
    SSI eligible        1619a or 1619b         Medically Needed
          TTW       Premium (if applicable): $
       Other Medicaid Category
 Spend-down amount: (if applicable): $         Share of Cost amount $
 Is the individual receiving both Medicaid and Medicare?        Yes          No
      If yes: Qualified Beneficiary (QMB) ?      Specified Low Income Beneficiary (SLMB)                 ?
     Medicaid Waiver:         Type of Waiver:
 Other Medicaid information: describe):
 Did the person lose SSI eligibility due to receipt of some form of Social Security Benefits? Yes     No



                                            Health Insurance Information Pertaining to                                  Medicare
                                Evaluation of How Extended Medicare coverage or work incentives impact and Medicare Part D

                              Details about Health Insurance & Medicare                                                     Document how information was verified
                                                                                                                             (agency records, confirmation from caseworker, etc.)
 Part A (hospitalization)                   Part B (outpatient)               Part D (medication)                         Verification:
 Paying Part B premium? Yes            No       Medicare Savings Program (QMB, SLMB) ?
 Are they receiving the extra help subsidy for Medicare Part D? Yes          No
         If yes, are they Dual Eligible? Yes         No
 Screened for MO RX Program: Yes          No
           See Mo RX website forannual gross household income amounts (http://www.morx.mo.gov/)
 Private Insurance                    Yes             No                                                                  Verification:
 Describe type:
 Premium paid by beneficiary: $                   (monthly          quarterly       annually         )
 Does the state pay premium? Yes                      No          Other, (please describe)
 Other Health Insurance                                                                                                   Verification
 Describe:
University of MO-Disability Policy and Studies Region 7 TACE             (Adapted from the Work Incentives Network (WIN) of NE)                       January 2011
573 882-3807                   www.dps.missouri.edu
Benefits Screening Profile                                            Medical Expenses                                                                  Page 9

                                                                Medical Expenses
                                 Details about Medical Expenses                                                  Additional comments or updates
                                                                                                                           (include date of update)
 Are they seeing a doctor or therapist?        Yes          No                                            Comment:
 Describe Service/Reason
 How are expenses covered?
 Out of Pocket Expenses: $             (monthly         annually )
 Are they seeing a Mental Health Counselor or therapist?             Yes              No                  Comment:
 Describe Service
 How are expenses covered?
 Out of Pocket Expenses: $             (monthly         annually )
 Are they taking Medications or have any medical needs? Yes                     No                        Comment:
 Describe
 How are expenses covered?
 Out of Pocket Expenses: $             (monthly         annually )
 Other therapies        (occupational, physical, speech, home health care, personal assistance etc.)      Comment:
 Describe Service
 How are expenses covered?
 Out of Pocket Expenses: $                (monthly          annually )
 Other Health-Related Expenses                                                                            Comment:
 Describe Expenses
 How are expenses covered?
 Out of Pocket Expenses: $                (monthly          annually )

 Potential Application to Work Incentives (such as IRWE)                                                  Comment:
 How does the person's disability impact their ability to work?




University of MO-Disability Policy and Studies Region 7 TACE      (Adapted from the Work Incentives Network (WIN) of NE)                      January 2011
573 882-3807                   www.dps.missouri.edu
Benefits Screening Profile                                                 Support Agencies                                                                Page 10

                                           Involvement with Agencies and Support Systems
              If there is a need for sharing/coordinating of information, get appropriate Release of Information forms completed.
                                             Releases must be updated annually if services continue.


                         Details about Agencies & Support Systems                                                     Additional comments or updates
                                                                                                                                (include date of update)
 Enrollment in Secondary School or Post Secondary Education                                                    Comment:
 Are they in school now? Yes    No                     Intend to return to school?    Yes       No
 Name of school:
 Type of School:
 Number of hours:
 Teacher/Counselor/Support Person:
 Phone:
 Vocational Rehabilitation Client                        Yes          No                                       Comment:
 Name of Counselor:
 Office:                                                              Phone:
 Supports Provided:
 One-Stop Services                                       Yes          No                                       Comment:
 Name of Counselor:
 Office:                                                              Phone:
 Type of Services:
 Community Mental Health Services                        Yes          No                                       Comment:
 Agency
 Primary Support Person Contact:
 Name of Counselor:
 Office:                                                              Phone:
 Type of Services:
 Case Management Provider                                Yes          No                                       Comment:
 Agency:
 Case Manager/Services Coordinator:
 Office:                                                              Phone:
 Type of Services:




University of MO-Disability Policy and Studies Region 7 TACE           (Adapted from the Work Incentives Network (WIN) of NE)                      January 2011
573 882-3807                   www.dps.missouri.edu
Benefits Screening Profile                                          Support Agencies                                                               Page 11


                         Details about Agencies & Support Systems                                             Additional comments or updates
                                                                                                                        (include date of update)
 Residential Provider                                 Yes      No                                      Comment:
                                              Group Home       Assisted Living
 Agency/Facility:
 Contact Person:
 Address:
 Phone:
 Veteran Services                                        Yes   No                                      Comment:
 Support Person :
 Office:                                                       Phone:
 Type of Services:             _

 Other State or Private Agency                           Yes   No                                      Comment:
 Agency:
 Primary Support Person Contact:
 Contact Information:
 Type of Services:




University of MO-Disability Policy and Studies Region 7 TACE   (Adapted from the Work Incentives Network (WIN) of NE)                      January 2011
573 882-3807                   www.dps.missouri.edu
Benefits Screening Profile                                              Employment Info                                                              Page 12

                                                               Employment Information
                   Evaluate in terms of impact of previous work on benefits/ especially if SSDI/SSDAC and use of TWP or EPE
                                     Explore applicable work incentives for employment or self-employment

                                                                                                        Did the job          Additional comments or updates
                                  Details of Past Employment                                           begin before              (include date of update)
                                                                                                      cash benefits?
 Place Employed 1:                                                                                                          Comment:
                                                                                                        Before:
          Job Title:
                                                                                                          After
    From:            To:                    Gross Monthly Wages             Monthly hours
 Place Employed 2:                                                                                                          Comment:
                                                                                                        Before:
          Job Title:
                                                                                                          After
    From:            To:                    Gross Monthly Wages             Monthly hours
 Place Employed 3:                                                                                                          Comment:
                                                                                                        Before:
          Job Title:
                                                                                                          After
    From:            To:                    Gross Monthly Wages             Monthly hours
 Self Employment 1                                                                                                          Comment:
     Business Type:                                                                                     Before:
           Location:                                                                                      After
     From:           To:                    Gross Monthly Income
 Self Employment 2                                                                                                          Comment:
     Business Type:                                                                                     Before:
           Location:                                                                                      After
     From:           To:                    Gross Monthly Income




University of MO-Disability Policy and Studies Region 7 TACE       (Adapted from the Work Incentives Network (WIN) of NE)                    January 2011
573 882-3807                   www.dps.missouri.edu
Benefits Screening Profile                                                                       Employment Info                                                              Page 13

                                                         Current or Potential Employment Information
                           Details about Current or Potential Employment                                                                 Additional comments or updates
                                                                                                                                                   (include date of update)
 Name of Employer or Business:                                                                                                    Comment:
 Address:
 Job Title:
 Job Duties:
 Date of Hire:
    If self-employed (or potentially self-employed)
       Type of business:
       Startup Date:            Hours
 Weekly Gross wages: $            Bi-Monthly wages: $           Monthly wages: $
 Benefits:
    If this job was selected because of disability issues, please describe:
 Earned Income Tax Credit 2011 table                                                                                              Comment:
   Individuals with current earned income who are between age 25 and 65 may be
       eligible for EITC
   If they have no children, did they earn less than $13,460 per year
              ($18,470 if married, filing jointly)? .......................................................... Yes      No
   If they have children, did they earn :
        One child – less than $35,535 ($40,545 if married filing jointly)? ............ Yes                            No
        Two children - less than $40,363, ($45,373 if married filing jointly)? ..... Yes                               No
        Three or more – less than $43,352, ($48,362 if married filing jointly)? . Yes                                  No

      If the answer is yes to any of the above, have they applied for the Earned
                  Income Tax Credit? ............................................................................ Yes   No




University of MO-Disability Policy and Studies Region 7 TACE                              (Adapted from the Work Incentives Network (WIN) of NE)                      January 2011
573 882-3807                   www.dps.missouri.edu
Benefits Screening Profile                                             Trial Work Period & EPE                                                         Page 14

                                                 Trial Work Period Analysis (SSDI, DWB, CDB)
                                    Verify TWP and EPE with BPQY, paycheck stubs or other supporting documents

                                                                                                                   Document how information was verified
                                  Details about Trial Work Period
                                                                                                                     and any questions to be answered
 Date of Entitlement to a Title II disability program:                                                         Comment:
 Did person use up nine months TWP before January, 1992?               Yes        No
         If yes, no TWP available unless eligibility for Title II was re-established
 Date of last TWP:
 What months were TWP used in the past 60 months?                                                              Comment:
 How many TWP months are remaining?
                                Confirmed correct on BPQY form?                      Yes           No


                                                               Person's Use of TWP Months
                        TWP           Calendar                  Gross Earned               TWP          Calendar                Gross Earned
                                                       Year                                                             Year
                        Month          Month                       Wages                   Month         Month                     Wages

                           1                                       $                        6                                      $

                           2                                       $                        7                                      $

                           3                                       $                        8                                      $

                           4                                       $                        9                                      $

                           5                                       $




University of MO-Disability Policy and Studies Region 7 TACE           (Adapted from the Work Incentives Network (WIN) of NE)                  January 2011
573 882-3807                   www.dps.missouri.edu
Benefits Screening Profile                                     Subsidy & Special Conditions                                                           Page 15

                                Extended Period of Eligibility Analysis (SSDI, DWB, CDB only)
                                    Verify TWP and EPE with BPQY, paycheck stubs or other supporting documents

                          Details about Extended Period of Eligibility                                     Document how information was verified
 Ninth TWP month:       Month:           Year:                                                            Comment:
 Beginning of EPE:               Last month of 36 month EPE:
             If 36 months have lapsed, is the person still in cash status? Yes                  No
 Cessation Month:                        Grace Period Months:               Year:


              Subsidy and Special Condition Analysis (pertaining to Title II SSDI, DWB, or CDB)
                                            Explore Subsidy and Special Conditions
Subsidy and Special Conditions help SSA make SGA determinations. This could result in earning below SGA, continuing cash benefits
                                         until the client is more independent on the job.


                        Details about Subsidy and Special Conditions                                             Additional comments or updates
                                                                                                                           (include date of update)
 Subsidy                                                                                                  Comment:
   Does the Individual receive on the job assistance from workplace personnel?        Yes      No
   Does the individual perform fewer duties than others?                              Yes      No
   Does the employer accept less productivity from the individual than others?        Yes      No
   Does the individual receive extra rest periods/ breaks?                            Yes      No
   Are they absent frequently or working irregular hours because of the disability?   Yes      No
   Describe employer subsidy:
 Special Conditions                                                                                       Comment:
   Does anyone other than employer pay all or part of wage? .........................Yes        No
   Describe any Supported Employment, Job Coaching, extra supervision, extra assistance,
      or other supports the person receives:
   Contact person for this support:
   Other workplace supports by coworkers or employer:
   Other accommodations and supports:




University of MO-Disability Policy and Studies Region 7 TACE      (Adapted from the Work Incentives Network (WIN) of NE)                      January 2011
573 882-3807                   www.dps.missouri.edu
Benefits Screening Profile                                                                   Subsidy & Special Conditions                                                                Page 16


                             Details about Subsidy and Special Conditions                                                                              Additional comments or updates
                                                                                                                                                              (include date of update)
   Calculating the Effect of a Job Coaching Subsidy                                                                                                Comment:
    Step One:
              Hours of job coach intervention on site per month or number of
                  additional hours of supervision given per month ................................
              Multiply by hourly wage of worker ................................................................... X $
              Equals monthly subsidy ...................................................................................... = $
      Step Two:
                      Monthly gross earnings .............................................................................................$
                      Minus monthly Subsidy ......................................................................................... − $
                      Equals monthly earnings counted toward SGA ..........................................= $
 Un-incurred Business Expenses                                                                                                                     Comment:
   Is the individual self-employed? ..................................................................................... Yes                 No
   Does an agency or other entity provide equipment or materials for business? .. Yes                                                         No
   Has someone (unpaid help) supported the individual in conducting the business? .. Yes                                                      No
   Describe circumstances for un-incurred business expense:




University of MO-Disability Policy and Studies Region 7 TACE                                      (Adapted from the Work Incentives Network (WIN) of NE)                         January 2011
573 882-3807                   www.dps.missouri.edu
Benefits Screening Profile                                                                                 IRWE                                                                  Page 17

                           Impairment-Related Work Expenses (IRWE) Analysis for SSDI and SSI
                                            Evaluate IRWE based on information available from individual and supports

                                              Details about IRWE                                                                               Additional comments or updates
                                                                                                                                                      (include date of update)
 Transportation                                                                                                                            Comment:
 Nature of any transportation need:
 How is it related to the person's disability and work?
 Monthly cost paid by the person             $

 Medication                                                                                                                                Comment:
 Names of Medications the person takes:
 How are the medications related to the person's disability and work?
 Monthly out of pocket cost paid by the person:
 Potential IRWE Identification                                                                                                             Comment:
 Attendant care at home .........               Attendant care at work ..........................................................
 Prosthetic devices .....................       Medical devices ........................................................................
 Work related equipment..........               Residential modification to work at home ......................
                                                Residential modification to work away from home ....
  Other Potential IRWEs
   1) Nature of item/service:
     How is it related to the disability and work:
     Monthly cost paid by the individual:
   2) Nature of item/service:
     How is it related to the disability and work:
     Monthly cost paid by the individual:




University of MO-Disability Policy and Studies Region 7 TACE                            (Adapted from the Work Incentives Network (WIN) of NE)                           January 2011
573 882-3807                   www.dps.missouri.edu
Benefits Screening Profile                                                                         BWE & SEIE                                                                       Page 18

                                                                  Blind Work Expenses Pertaining to SSI
                                              If individual is statutorily blind with SSA disability determination, explore BWE

                                       Details about Blind Work Expense                                                                          Additional comments or updates
                                                                                                                                                        (include date of update)
 Is the person considered Blind by SSA? ................................................. Yes                     No                         Comment:
         If blind and working, is the person an SSI recipient? .......... Yes                                     No
 Consider Potential expenses for BWE:
 Licensure fees/professional dues, union dues ......                            Guide dog expenses ..........................
 Transportation to and from work .................................              Vehicle modification ..........................
 Federal state and local taxes .......................................          Child care costs ...................................
 Work-related Equipment, uniforms and supplies .                                Prosthesis ...............................................
 Drugs and medical services necessary to work ...                               Expendable medical supplies ........
 Non-medical equipment and supplies ......................                      Physical Therapy .................................
 Meals consumed during work hours .........................                     Mandatory pension contributions ......
 Attendant care services ..................................................



                                                   Student Earned Income Exclusion Pertaining to SSI
                  If individual is under the age of 22 and regularly attending school consider SEIE in the countable income formula

                           Details about Student Earned Income Exclusion                                                                         Additional comments or updates
                                                                                                                                                        (include date of update)
 Is the individual:                                             Under age 22? Yes             No                                             Comment:
 In a college or university for at least 8 hours a week .           For less than 8 hours a week .........
 In grades 7 – 12 for at least 12 hours a week ............         For less than 12 hours a week .......
 In a training course to prepare for employment for
      at least 12 hours a week (15 hours a week if
      the course involves shop practice) ......................     For less than 12/15 hours a week ..
                   If enrolled for less than 8 or 12 hours, is it due to factors
                              beyond the student’s control, such as illness? ................... Yes                               No
      2011 SEIE Monthly Amount .. $1,640.00                              2010 SEIE Annual Amount .... $6,660.00
 Amount excluded this year thus far if already receiving SEIE:$


University of MO-Disability Policy and Studies Region 7 TACE                           (Adapted from the Work Incentives Network (WIN) of NE)                               January 2011
573 882-3807                   www.dps.missouri.edu
Benefits Screening Profile                                                                                   PASS                                                                Page 19

                                                                    Plan to Achieve Self-Support (PASS)
                               Consider PASS if resources or income are available to set aside for achieving employment goals

                                                    Details about PASS                                                                    Additional comments or updates
                                                                                                                                                     (include date of update)
 Does the Individual have an approved PASS?                                    Yes            No                                    Comment:
 Describe the work             goal of the PASS:
             Is a copy on file?    Yes         No
                     If no, when will one be provided?
 Does the individual’s job goal involve eliminating their need for SSDI or
        reducing the need for SSI? Yes                    No
        If yes, describe:
 Other Income                                                                                                                       Comment:
 Does the individual have income other than SSI? Yes                                          No
        If yes, describe type of income and source:
 Can the individual live on what they will have left after the PASS contribution?                                 Yes        No
         Explain:
 Other Resources                                                                                                                    Comment:
 Does the individual have resources that could be converted to
    cash (bank accounts or other items)?            Yes        No
             If yes, describe the resources:
 Goods/Services to Reach Goal                                                                                                       Comment:
 Are there goods or services which would help the individual reach a vocational goal and
     which he or she would purchase if extra money were available?           Yes      No
 Does the person meet the criteria for PASS Application? ....................................... Yes                         No     Comment:
 Does the person have a feasible work goal? ................................................................. Yes            No
 Does the person have a specific savings/spending plan for
       work related items or services for employment? ............................................ Yes                       No
 Does the person have a clearly identifiable accounting of the
      funds set aside in the PASS? ................................................................................... Yes   No
 Does the person have a Savings/Spending Plan? ...................................................... Yes                    No
 Source for accounting funds:
University of MO-Disability Policy and Studies Region 7 TACE                                (Adapted from the Work Incentives Network (WIN) of NE)                       January 2011
573 882-3807                   www.dps.missouri.edu
Benefits Screening Profile                                                  PASS                                                                    Page 20


                                          Details about PASS                                                 Additional comments or updates
                                                                                                                        (include date of update)
 Is the individual able to (or have the necessary support to):                                         Comment:
           Manage a second bank account
           Track PASS expenses
           Collect and keep receipts
           Follow milestones of the PASS
           Communicate with the PASS Cadre when a change to their PASS is necessary
           Yes           No
           Explanation:




University of MO-Disability Policy and Studies Region 7 TACE   (Adapted from the Work Incentives Network (WIN) of NE)                       January 2011
573 882-3807                   www.dps.missouri.edu
Benefits Screening Profile                                                        EXR                                                                    Page 21

                                                 Expedited Reinstatement of Benefits (EXR)
                                                   Discuss EXR if benefits have ceased due to work activity

                                           Details about EXR                                                      Additional comments or updates
                                                                                                                             (include date of update)
 EXR for Title II Beneficiaries                                                                             Comment:
   If the Individual has lost Title II due to performance of SGA:
           Has the Individual completed the TWP and EPE?                          Yes             No
           Has the individual stopped working or ceased performing
                SGA due to their disability?                                      Yes             No
 EXR for SSI                                                                                                Comment:
      If the individual has lost SSI due to work and meeting all other SSI criteria:
           Did the individual lose SSI due to wages and other income?             Yes             No
           Is the individual currently receiving Medicaid through 1619b?          Yes             No
           Has the individual received either SSI cash benefits or 1619b in
                 the past 12 months?                                              Yes             No
           Would the individual be eligible for SSI based on current income
                 because he/she stopped working or is earning less money
                 due to disability?                                               Yes             No




University of MO-Disability Policy and Studies Region 7 TACE        (Adapted from the Work Incentives Network (WIN) of NE)                       January 2011
573 882-3807                   www.dps.missouri.edu
Benefits Screening Profile                                                              Signatures                                              Page 22


                       Note to Beneficiary/Recipient regarding Recordkeeping:
Please keep this Benefits Screening Profile in your records. Remember to also keep letters you get about your benefits. Keep notes and receipts
whenever you report changes and be sure to keep everything together in one place so you can find it. The notes should include:
             The agency where you made the report
             The date you made the report
             Who you talked to
             What you told them
             What papers you submitted

Things to tell SSA:
You need to notify SSA about the following things as they happen. Remember that you should always provide notification of changes in writing!
             Start or stop working
             Increase or decrease your hours
             Get married
             Leave school or go back to school
             Move


I understand the information in this packet is meant to be a resource. It is designed to help me understand my current
benefits and how employment will impact them. I understand my VRC/benefits specialist depended on the information I
provided to prepare this packet, and if I gave incomplete or inaccurate information, or if my situation changes, this
information will not be accurate. I understand only SSA and other agencies make decisions about my benefits. This
packet is only a planning resource in reaching my employment goal; it is not an official judgment about my eligibility


Signature:
                                      Beneficiary/Recipient                                                            Date




Signature:
                                      VRC/Benefit Specialist (if applicable)                                           Date




Signature:
                                      Other (if applicable)                                                            Date


University of MO-Disability Policy and Studies Region 7 TACE                   (Adapted from the Work Incentives Network (WIN) of NE)   January 2011
573 882-3807                   www.dps.missouri.edu

								
To top