Form POD Informed Conse POD Informed Conse Promoting Opportunity Demonstration (POD) Voluntary Part

APPENDIX A

OMB No.: 0960-xxxx
Expiration Date: xx/xx/20xx

Promoting Opportunity Demonstration (POD)
Voluntary Participation Consent Form
What is POD?
• The Social Security Administration (SSA) is conducting a new study called POD for
beneficiaries who receive Social Security Disability Insurance (SSDI). If you work or
want to work, you might find POD attractive because it uses simpler rules for
reporting earnings to SSA. POD also includes new rules to adjust your benefits for
earnings. SSA will randomize volunteers into one of three groups. Two out of three
volunteers randomized into the POD groups will take part in the simpler rules for
reporting earnings.
Do I have to participate in POD?
• No. POD is a voluntary study. There is no penalty if you choose not to participate.
What do I need to do to participate in POD?
• Read, sign, and return this agreement form.
When will POD end?
• POD will end in June 2021. All POD volunteers will return to current SSDI rules
when POD ends.
Who will see my information and how will they use it in POD?
• SSA, POD researchers at Mathematica Policy Research, POD staff at Abt
Associates who operate the study, and possibly vocational rehabilitation (VR) and
Work Incentive Planning and Assistance (WIPA) program staff will see the
information. The researchers will use this information to study whether the POD
rules improve beneficiaries’ outcomes. They will not report your individual
information to anyone else.
How do POD rules differ from current SSDI rules?
• The rules tested under POD will allow you to keep some of your benefits when your
earnings are high enough that you would otherwise lose them all under current rules.
If you discover that current rules are better for you, you can switch back at any time.
Will the new POD rules benefit me?
• You could benefit from the rules tested under POD if you plan to regularly earn more
than $1,200 a month for longer than a year. If you are blind, you could benefit from
POD if you plan to regularly earn more than $2,000 a month for longer than a year.
You can call 1-888-771-9188 from 9 a.m. to 9 p.m. eastern time to learn whether
POD might be right for you. You can also visit www.podssa.org.

A.16

APPENDIX A

What are the potential risks of participating in POD?
• If you are selected for the special POD rules, in some situations, your benefits could
be lower under POD than under current rules (see “How will working affect my
benefits?” in the supplemental information materials).
•

There is a small risk of an accidental release of personal information. Mathematica
has extensive procedures in place to prevent this from happening. We would inform
you immediately of any specific threat to your privacy.

If I agree to be in POD, what will happen?
1. You will receive $25 for signing this form, completing the survey, and returning both
in the provided envelope.
2. SSA will randomly assign you to one of three groups shown in a table in the
supplemental information materials. Mathematica will notify you via mail about your
group.
Mathematica will contact you in the future to ask you to complete one or two
follow-up surveys. All of these surveys are voluntary. SSA will pay you for
participating in them.
Can I withdraw from POD?
• Yes. If SSA assigns you to one of the two groups with special rules, you can choose
to return to current SSDI program rules at any time during the demonstration by
calling 1-888-771-9188. You can also withdraw from the study if you are in any of
the study groups (new rules groups or current rules group) at any time by calling the
same number. We will use any information we collected while you were in the study.
If SSA randomly assigns me to a group with the special POD rules for earnings,
will any current SSDI rules still apply to me?
• Yes. No matter which group SSA randomly assigns you to, the following rules apply:
-

You could be required to undergo periodic medical reviews. You could lose your
benefits if SSA determines your medical condition has improved. However,
working will not result in a medical review, and participation in POD will not
affect selection for these reviews.

-

Your benefits could still be suspended for non-work-related issues.

-

Your auxiliaries (for example, children on your record) will continue to be eligible
for monthly benefits as long as you are eligible for benefits during that month. If
your monthly SSDI is reduced to $0.00 due to the POD offset, then your
auxiliary’s monthly benefit will also be reduced to $0.00 for that month.

-

If you receive more benefits than you are due in any month, you will have to
repay the overpayment. SSA might allow you to repay the overpayment in
installments to avoid financial hardship.

-

You will still be eligible for Ticket to Work.

A.17

APPENDIX A

•

Please read each statement below and if you understand each statement,
check each box to show you understand. If you do not understand any of the
statements below, call 1-888-771-9188 from 9 a.m. to 9 p.m. eastern standard time
for additional information.

•

On the next page, check the box to tell us if you agree to participate in POD
and sign this consent form.

•

Return the last two pages of this form to Mathematica along with the survey
included in this packet. You can make a copy for your own records. You must
sign the form and check all boxes for the agreement form to be complete.

I have read and understand the following statements:
Agreement statement

I understand

□
□

•

I understand that the purpose of this study is to test special
rules for SSDI beneficiaries who work.

•

I understand that my participation is voluntary. I understand that
there is no penalty if I choose not to participate in POD.

•

I understand that if I agree to take part, SSA, POD researchers
at Mathematica, POD staff at Abt who operate the study, and
possibly program staff will see my information.

□

•

I understand that under the special POD rules my benefits
might be higher or lower depending on my earnings.

□

•

I understand that I will receive $25 for sending back this signed
consent form and completing the survey included in this packet.

•

I understand that if I volunteer for POD and send back the
consent form and survey in this packet, SSA will randomly
assign me to one of three groups.
I understand that I will be asked to participate in either one or
two additional surveys, and that I will be paid to participate in
each survey.
I understand that I can withdraw from the study at any time
without penalty by calling Mathematica at the number below.

□
□
□
□

•
•

A.18

APPENDIX A

SIGNATURE PAGE
SSDI BENEFICIARY
Please check () one of the following boxes and sign the form:
IF YOU WANT TO BE IN THE
STUDY, CHECK () THIS BOX

□

IF YOU DON’T WANT TO BE IN THE
STUDY, CHECK () THIS BOX

□

YES, I agree to be in the Promoting
Opportunity Demonstration study.

NO, I do not want to be in the Promoting
Opportunity Demonstration study.

Sign your name here:
Print your name here:
Write the last four digits of your Social Security number: |

|

|

|

|

Date of birth: _________/________/__________
MONTH

Telephone number: (|

DAY

|

|

|)-|

YEAR

|

|

|-|

|

|

|

| Today’s date: ______________

Please place the following items in the prepaid envelope and mail it to Mathematica to receive
your $25 payment:
1) The pages with your signature and the checkboxes (pages 3 and 4 of this form)
2) Your completed survey
Questions? Call 1-888-771-9188 from 9 a.m. to 9 p.m. eastern standard time.

A.19

APPENDIX A

OMB No.: 0960-xxxx
Expiration Date: xx/xx/20xx

Promoting Opportunity Demonstration (POD)
Voluntary Participation Consent Form for
Beneficiaries with Representative Payees
What is POD?
• The Social Security Administration (SSA) is conducting a new study called POD for
beneficiaries who receive Social Security Disability Insurance (SSDI). If you work or
want to work, you might find POD attractive because it uses simpler rules for
reporting earnings to SSA. POD also includes new rules to adjust your benefits for
earnings. SSA will randomize volunteers into one of three groups. Two out of three
volunteers randomized into the POD groups will take part in the simpler rules for
reporting earnings.
Do I have to participate in POD?
• No. POD is a voluntary study. There is no penalty if you choose not to participate.
What do I need to do to participate in POD?
• Read, sign, and return this agreement form.
When will POD end?
• POD will end in June 2021. All POD volunteers will return to current SSDI rules
when POD ends.
Who will see my information and how will they use it in POD?
• SSA, POD researchers at Mathematica Policy Research, POD staff at Abt
Associates who operate the study, and possibly vocational rehabilitation (VR) and
Work Incentive Planning and Assistance (WIPA) program staff will see the
information. The researchers will use this information to study whether the POD
rules improve beneficiaries’ outcomes. They will not report your individual
information to anyone else.
How do POD rules differ from current SSDI rules?
• The rules tested under POD will allow you to keep some of your benefits when your
earnings are high enough that you would otherwise lose them all under current rules.
If you discover that current rules are better for you, you can switch back at any time.
Will the new POD rules benefit me?
• You could benefit from the rules tested under POD if you plan to regularly earn more
than $1,200 a month for longer than a year. If you are blind, you could benefit from
POD if you plan to regularly earn more than $2,000 a month for longer than a year.

A.20

APPENDIX A

You can call 1-888-771-9188 from 9 a.m. to 9 p.m. eastern time to learn whether
POD might be right for you. You can also visit www.podssa.org.
What are the potential risks of participating in POD?
• If you are selected for the special POD rules, in some situations, your benefits could
be lower under POD than under current rules (see “How will working affect my
benefits?” in the supplemental information materials).
•

There is a small risk of an accidental release of personal information. Mathematica
has extensive procedures in place to prevent this from happening. We would inform
you immediately of any specific threat to your privacy.

If I agree to be in POD, what will happen?
3. You will receive $25 for signing this form, completing the survey, and returning both
in the provided envelope.
4. SSA will randomly assign you to one of three groups shown in a table in the
supplemental information materials. Mathematica will notify you via mail about your
group.
Mathematica will contact you in the future to ask you to complete one or two followup surveys. All of these surveys are voluntary. SSA will pay you for participating in
them.
Can I withdraw from POD?
• Yes. If SSA assigns you to one of the two groups with special rules, you can choose
to return to current SSDI program rules at any time during the demonstration by
calling 1-888-771-9188. You can also withdraw from the study if you are in any of
the study groups (new rules groups or current rules group) at any time by calling the
same number. We will use any information we collected while you were in the study.
If SSA randomly assigns me to a group with the special POD rules for earnings,
will any current SSDI rules still apply to me?
• Yes. No matter which group SSA randomly assigns you to, the following rules apply:
-

You could be required to undergo periodic medical reviews. You could lose your
benefits if SSA determines your medical condition has improved. However,
working will not result in a medical review, and participation in POD will not
affect selection for these reviews.

-

Your benefits could still be suspended for non-work-related issues.

-

Your auxiliaries (for example, children on your record) will continue to be eligible
for monthly benefits as long as you are eligible for benefits during that month. If
your monthly SSDI is reduced to $0.00 due to the POD offset, then your
auxiliary’s monthly benefit will also be reduced to $0.00 for that month.

-

If you receive more benefits than you are due in any month, you will have to
repay the overpayment. SSA might allow you to repay the overpayment in
installments to avoid financial hardship.

A.21

APPENDIX A

-

You will still be eligible for Ticket to Work.

•

Please read each statement below and if you understand each statement,
check each box to show you understand. If you do not understand any of the
statements below, call 1-888-771-9188 from 9 a.m. to 9 p.m. eastern standard time
for additional information.

•

On the next page, check the box to tell us if you agree to participate in POD
and sign this consent form.

•

Return the last two pages of this form to Mathematica along with the survey
included in this packet. You can make a copy for your own records. You must
sign the form and check all boxes for the agreement form to be complete.

I have read and understand the following statements:
Agreement statement

I understand

•

I understand that the purpose of this study is to test special
rules for SSDI beneficiaries who work.

□

•

I understand that my participation is voluntary. I understand that
there is no penalty if I choose not to participate in POD.

□

•

I understand that if I agree to take part, SSA, POD researchers
at Mathematica, POD staff at Abt who operate the study, and
possibly program staff will see my information.

□

•

I understand that under the special POD rules my benefits
might be higher or lower depending on my earnings.

□

•

I understand that I will receive $25 for sending back this signed
consent form and completing the survey included in this packet.

□

•

I understand that if I volunteer for POD and send back the
consent form and survey in this packet, SSA will randomly
assign me to one of three groups.

□

•

I understand that I will be asked to participate in either one or
two additional surveys, and that I will be paid to participate in
each survey.

□

•

I understand that I can withdraw from the study at any time
without penalty by calling Mathematica at the number below.

□

A.22

APPENDIX A

SIGNATURE PAGE
SSDI BENEFICIARY
Please check () one of the following boxes and sign the form:
IF YOU WANT TO BE IN THE
STUDY, CHECK () THIS BOX

□

IF YOU DON’T WANT TO BE IN THE
STUDY, CHECK () THIS BOX

□

YES, I agree to be in the Promoting
Opportunity Demonstration study.

NO, I do not want to be in the Promoting
Opportunity Demonstration study.

Sign your name here:
Print your name here:
Write the last four digits of your Social Security number: |

|

|

|

|

Date of birth: _________/________/__________
MONTH

Telephone number: (|

DAY

|

|

|)-|

YEAR

|

|

|-|

|

|

|

| Today’s date: ______________

REPRESENTATIVE PAYEE
If you have listed someone with SSA as your representative payee (a person or
company that manages your money issues for you), please have the person sign
and print their name and telephone number below.
Representative payee: By signing this form, you are agreeing that the beneficiary
named above may participate in POD.
Sign your name here:
Print your name here:
Telephone number: (|

|

|

|)-|

|

|

|-|

|

|

|

| Today’s date: ______________

Please place the following items in the prepaid envelope and mail it to Mathematica to receive
your $25 payment:
1)

The pages with your signature and the checkboxes (pages 3 and 4 of this form)

2)

Your completed survey

Questions? Call 1-888-771-9188 from 9 a.m. to 9 p.m. eastern standard time.

A.23