Form SSA-1370 Ticket to Work Individual Work Plan

SOCIAL SECURITY ADMINISTRATION

Ticket to Work Program
INDIVIDUAL WORK PLAN (IWP)
Part One: Employment Network and Ticketholder Contact Information

1. Employment Network Name:
DUNS:
Address:
Telephone:
Email:
Business Model (Select one Ticketholder service model):
Traditional Services

Consumer Directed Services

Employer or Employer Agent

2. Ticketholder's Name:
SSN:
Address:
Telephone:
Email:
3. Ticketholder's Alternate Contact Name:
Relationship to Ticketholder:
Address:
Telephone:
Email:

Part Two: Documentation of EN-Ticketholder Discussion

Section 1: Discussion Arrangement

1. Date of Discussion:
2. Discussion Modality:
Face to Face
Form SSA-1370 (03-2017)

Telephone

Other (Explain)
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Administrative

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3. Location:
4. Duration:
5. Name and Position of EN Interviewer:
Section 2: Ticketholder's Recent Work History

1. Check all that apply
Currently working

No earnings in the past 18 months

Earnings in the month prior to the month Ticket assigned

Earnings in 3 of the past 6 months

Earnings in 6 of the past 12 months

Earnings in 12 of the past 18 months

2. List all work and earnings during the last 18 months (most recent employer first) in the chart below:
Employer

Form SSA-1370 (03-2017)

Job Title

Start Date

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End Date

Hourly Wage

Weekly Hours

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Section 3: Ticketholder's Employment Goals

1. Describe short-term goal (next 3-18 months)

2. Describe long-term goal

3. Has the Ticketholder's previous employment provided any experience relative to the achievement of the:
Short-term goal above?

Yes

No

Yes

No

If "Yes" please explain:

Long-term goal above?
If "Yes" please explain:

4. Does the Ticketholder require additional supports and services to achieve the:
Short-term goal above?

Yes

No

Yes

No

If "Yes" please explain:

Long-term goal above?
If "Yes" please explain:

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Section 4: EN Supports and Services

1. Short-term (Initial Job Acquisition)
Check all blocks that apply and explain how the services contribute to achievement of the Ticketholder's
short-term goal.
Career Planning

Benefits counseling

Goal setting

Job coaching

Job development

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Career Planning (continued)

Training (specify)

Other (specify)

Job Placement Assistance

Job search

Job accommodation

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Job Placement Assistance (continued)

Job placement

Other (specify)

2. Long-term (Ongoing Employment Support)
Check all blocks that apply and explain how the services contribute to achievement of the Ticketholder's
long-term goal.
Regular follow-up with Ticketholder (mandatory)

Job stabilization and retention

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2. Long-term (continued)
Career advancement counseling

Other (specify)

3. Will the EN directly provide the supports and services above?

Yes

No

If "No," please complete question 4 below.
4. If known, list the names of the provider(s) to whom you will refer the Ticketholder, along with the
services provided.

5. Will the EN coordinate or arrange for medical and/or related health services to the Ticketholder?
Yes

No

If "Yes," please explain:

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Part Three: IWP Terms and Conditions

The following terms and conditions apply to the EN and the Ticketholder identified in
Part One above:
1.) The EN and the Ticketholder shall inform one another immediately of any changes
in the contact information shown in Part One above.
2.) The Ticketholder shall report all earnings to the EN and to Social Security.
3.) The Ticketholder shall authorize the EN to contact employers on the
Ticketholder’s behalf, as necessary, to verify or obtain evidence of the Ticketholder’s
work and earnings.
4.) The EN may not request or accept compensation from the Ticketholder for the
costs of services and supports provided the Ticketholder under the IWP.
5.) The EN shall use only qualified employees and/or providers to provide supports
and services to the Ticketholder.
6.) The EN shall establish and explain to the Ticketholder a process to resolve any
disputes that arise under this IWP, including the process for escalating an unresolved
dispute to Social Security.
7.) The EN shall inform the Ticketholder of the availability of, and contact information
for, free protection and advocacy services under the Protection and Advocacy for
Beneficiaries of Social Security program.
8.) The EN shall inform the Ticketholder of annual Timely Progress Reviews (TPR)
performed by Social Security to assess the Ticketholder’s work progress, and explain
to the Ticketholder the TPR guidelines.
9.) The EN shall keep private and confidential the Ticketholder’s personal information,
including his or her Social Security Number and disability, and shall maintain all
private and confidential information in a secure area.
10.) The EN shall provide the Ticketholder with a copy of the completed IWP, as well
as any subsequent changes to the IWP, in the Ticketholder’s preferred format.
11.) Both the Ticketholder and the EN must agree to any change to the IWP. All
changes to the IWP must be in writing and supported by evidence of mutual consent.

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12.) The EN shall provide the Ticketholder with a copy of his or her EN file upon
request.
13.) Either the Ticketholder or the EN may choose unilaterally to un-assign the
Ticket at any time by notifying the other in writing, thereby terminating the
Ticketholder-EN relationship established by the IWP.
14.) Upon approval of the IWP by both the Ticketholder and the EN, the Ticketholder
acknowledges assignment of his or her Ticket to the EN and the EN acknowledges
acceptance of that Ticket.
15.) Are there any other terms and conditions relating to the implementation and
administration of this IWP?
Yes

No

If "Yes," list additional terms and conditions:

I choose to participate in the Ticket to Work Program with the Employment Network (EN) named below.
I understand that my EN will provide me employment support to help me find a job, increase my
earnings, and reduce my reliance on cash benefits. I have read and understand the requirements,
obligations, terms, and conditions expressed in this IWP. I declare under penalty of perjury that I have
examined all the information on this form, and on any accompanying statements or forms, and it is
true and correct to the best of my knowledge.
Ticketholder's Signature:______________________________________ Date:_______________________
EN Representative's Signature:__________________________________ Date:_______________________
EN Name:
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