WIPA STAR System

Attachment H: WIPA STAR System Fields

Module 1: Beneficiary Information

	Data Element	Field Type	Values
	First name	Text	Text
	Middle name	Text	Text
	Last name	Text	Text
	Address 1	Text	Text
	Address 2	Text	Text
	City	Text	Text
	State	Text	Text
	ZIP code	Text	Text
	County	Text	Text Note – we will investigate having this field auto-populate based on ZIP code
	Cell phone	Text	Text
	Home phone	Text	Text
	Work phone	Text	Text
	TTY/Videophone Number/IP address	Text	Text
	Email address	Text	Text
	Representative Payee?	Radio button (choose one)	Yes/No
	Representative Payee first name	Text	Text
	Representative Payee middle name	Text	Text
	Representative Payee last name	Text	Text
	Representative Payee address 1	Text	Text
	Representative Payee address 2	Text	Text
	Representative Payee city	Text	Text
	Representative Payee state	Text	Text
	Representative Payee ZIP code	Text	Text
	Representative Payee phone	Text	Text
	Representative Payee email address	Text	Text
Is Representative Payee also legal guardian?		Drop down (choose one)	Yes/No/Not applicable Note – If “Yes” selected, we will investigate having the system auto-populate the information entered for the Representative Payeee in the legal guardian fields
Legal guardian first name		Text	Text
Legal guardian middle name		Text	Text
Legal guardian last name		Text	Text
Legal guardian address 1		Text	Text
Legal guardian address 2		Text	Text
Legal guardian city		Text	Text
Legal guardian state		Text	Text
Legal guardian ZIP code		Text	Text
Legal guardian phone		Text	Text
Legal guardian email address		Text	Text
	SSN	Text	Text
	Claim number (if different from beneficiary SSN)	Text	Text
	Date of birth	Date	MM/DD/YYYY
	Beneficiary unique ID	Text	Text
	Beneficiary status	Drop down (choose one)	Receives SSI Receives Title II (SSDI, CDB, DWB) Receives SSI and SSDI (Concurrent) Benefits terminated Reached Full Retirement Age Residence outside service area Deceased
	Race	Check box (choose all that apply)	American Indian or Alaska Native Asian Black or African/American Native Hawaiian or Other Pacific Islander White Prefers not to provide
	Ethnicity	Drop down (choose one)	Hispanic or Latino Not Hispanic or Latino Prefers not to Provide
	Sex	Drop down (choose one)	Male Female Other
	Date CWIC assigned	Date	MM/DD/YYYY
	Name of assigned CWIC	Drop down (choose one)	Select from a list of CWICs assigned to the organization

Module 2: Referral Information

Data Element	Field Type	Values
Date of referral	Date	MM/DD/YYYY
Source of referral	Drop down (choose one)	Ticket to Work Help Line Beneficiary or Representative Payee self-referral Vocational Rehabilitation agency Employment Network Other community agency
Is beneficiary between the ages of 14 and 25 at the time of referral?	Radio button (choose one)	Yes/No
Is beneficiary a U. S. Veteran?	Radio button (choose one)	Yes/No
Employment status at time of referral	Drop down (choose one)	Full-time employment or self-employment Part-time employment or self-employment Job offer pending Not employed
Health insurance	Check box (choose all that apply)	Medicare (list parts in “Notes”) Medicaid (list type in “Notes”) Private Employer-sponsored Veteran’s Affairs Other (describe in “Notes”) None
Health insurance notes	Text box	Text
Employment services received at intake	Check box (Choose all that apply)	Vocational Rehabilitation Ticket to Work Other vocational services or supports
Is beneficiary eligible for WIPA services?	Radio button (choose one)	Yes/No
Status of referral for WIPA services	Drop down (choose one)	Note: If answer to question above is “No”, this question will auto populate with “Not engaged. Ineligible for WIPA services.” Status. Conducting initial outreach. Not engaged. Ineligible for WIPA services. Not engaged. Eligible beneficiary declined individualized WIPA services. Not engaged. Eligible beneficiary receiving information and referral services, but not requesting individualized WIPA services. Not engaged. Eligible beneficiary did not respond following 3rd outreach attempt. Not engaged. Eligible beneficiary is already receiving suitable services elsewhere. Not engaged. Eligible beneficiary did not return 3288s. Pending engagement. Eligible beneficiary requesting individualized WIPA services; verifications pending. Engaged. Eligible beneficiary engaged in individualized WIPA services; verifications received.

Module 3: Actions and Services

Data Element	Field Type	Values
Action created date	Computed Date	MM/DD/YYYY Note this is an auto-populated field
Action created by	Computed Text	User first name User last name. Note this is an auto-populated field
Intake Services
Date releases sent	Date	MM/DD/YYYY
Date releases returned	Date	MM/DD/YYYY
Date intake process completed	Date	MM/DD/YYYY
Verification
Date BPQY requested	Date	MM/DD/YYYY
Date BPQY received	Date	MM/DD/YYYY
Individualized Services
Does beneficiary want to work more to (check one of following options):	Drop-down (choose one)	Increase income without losing SSDI or SSI benefits Reduce SSDI or SSI benefits Eliminate SSDI or SSI benefits
Comments on work goals	Text	Text
Date initial or follow-up BS&A completed	Date	MM/DD/YYYY
Did CWIC use BSADOCs to develop BS&A?	Radio button (choose one)	Yes/No
Date discussed initial or follow-up BS&A with beneficiary	Date	MM/DD/YYYY
If BS&A prepared, what is status of follow-up services?	Drop-down (choose one)	Beneficiary accepted offer for follow-up services Beneficiary declined offer for follow-up services Beneficiary was not offered follow-up services
Date provided beneficiary follow up services plan	Date	MM/DD/YYYY
Additional Services
Date referred beneficiary to Vocational Rehabilitation	Date	MM/DD/YYYY
Date referred beneficiary to Employment Network	Date	MM/DD/YYYY
Date referred beneficiary to other vocational services	Date	MM/DD/YYYY
Date assisted beneficiary with earnings reporting	Date	MM/DD/YYYY
Date discussed Plan to Achieve Self-Support (PASS) with beneficiary	Date	MM/DD/YYYY
Date assisted beneficiary to complete and submit PASS	Date	MM/DD/YYYY
Date assisted beneficiary to report IRWE, subsidy or use of work incentives to SSA	Date	MM/DD/YYYY
Date provided follow-up contact with beneficiary at key touchpoints	Date	MM/DD/YYYY
Comments	Text	Text

Module 4: Case Notes

Data Element	Field Type	Values
Case note created date	Date	MM/DD/YYYY
Case note created by	Text	User first name User last name. Note this is an auto-populated field
Date of contact	Date	MM/DD/YYYY
Person or agency contacted	Text	Text
Purpose of the contact	Text	Text
What did you discuss?	Text	Text
Additional notes	Text	Text
Contact mode	Drop-down (choose one)	Phone Email In-person Mail
Contact disposition	Drop-down (choose one)	Contact made No answer/No show Voicemail Busy Bad contact info