Addendum to the Supporting Statement - 0629

Addendum to the Supporting Statement for

Work Incentives Planning and Assistance (WIPA) Projects

OMB No. 0960-0629

Revisions to the Collection Instrument SSA-4565, and SSA-4567

SSA is making the following revisions:

• Change #1: We are consolidating Form SSA-4565 (WIPA Intake Information) and Form SSA-4567 (Help Line WIPA Referral) and naming the new version of the form: Help Line Work Incentives Planning and Assistance (WIPA) Referral and WIPA Intake.

Justification #1: We are consolidating the two forms to allow SSA to streamline data collected by the WIPA grantees and Ticket to Work Help Line by reducing the number of data items collected and minimizing the burden for all respondents (WIPA grantees, Ticket to Work Help Line agents and beneficiaries). Consolidating the forms will also increase the functionality of the form by removing the character limits on some fields.

Revisions to the Collection Instrument SSA-4566

SSA is making the following revisions:

• Change #2: We are revising Form SSA-4566 to streamline data to make a one page and a 7-question form.

Justification #2: We are streamlining the form to allow for the collection of seven case notes to one case note because the WIPA grantees are expected to enter the case note in the WIPA STAR system.

• Change #3: We are revising the language in question #2

• Old language: Date of contact

• New Language: Unique Identification Number for BSADOCS and other electronic media.

Justification #3: We are revising the language to improve the functionality of the form

• Change #4: We are revising the language on questions number 3

• Old language: Purpose of contact

• New language: Person or agency contacted

Justification #4: We are revising to improve the functionality of the form, and for clarity.

• Change #5: We are revising the language in number 5

• Old Language: What work incentive, health care options, or other benefits did you discuss to

• New Language: Purpose of contact

Justification #5: We are revising to improve the functionality of the form, and for clarity.

• Change #6: We are revising the language in number 6

• Old Language: List any referrals you made to other agencies

• New Language: What did you discuss

Justification #6: We are revising to improve the functionality of the form, and for clarity.

• Change #7: We are revising the language in #7

• Old Language; Notes and steps

• New Language: Additional Notes (Synapsis of discussion, work incentives, health care options, or other benefits discussed, documents you gave or received)

Justification #7: We are revising to improve the functionality of the form, and for clarity.

New Information Collection Instrument

SSA is also clearing a new information collection instrument, the WIPA STAR system. The WIPA STAR system is new management and reporting tool Social Security is developing for the WIPA program. The initial release of the data system, scheduled for the summer of 2022, will contain: (1) select fields from the form SSA-4565 to provide Social Security with information on beneficiaries served under the WIPA program; (2) all of the fields on the form SSA-4566 to allow WIPA grantees to record case notes on beneficiaries; and (3) fields necessary for Social Security to monitor WIPA grantees’ performance and progress toward meeting the nine WIPA benchmarks. Future releases of the system will collect all the fields on the form SSA-4565.

We will implement these revisions upon OMB’s approval, and that these changes do not affect the public reporting burden