Attachment A-21. Exiter MI Pilot Letter and Consent

Attachment A-22. Invitation and Consent to Participate in Motivational Interviews with Exiters

[Date]
Dear [Respondent Name]:
You are invited to participate in the Beyond Benefits Study, a national study paid for by the Social Security
Administration (SSA). The study will collect information about the service, medical and employment needs of
working-age adults who get disability payments now or stopped receiving disability payments due to medical
improvement. By participating in this study, you will help SSA understand the policies and programs that may help
people who stop receiving disability payments.
SSA hired Westat, a national research company, to conduct the study. Westat is inviting you to participate in a series
of six (6) 1 hour meetings with a motivational interviewing counselor. In each meeting, you and the interviewer will
talk about your goals and dreams, and brainstorm with you about ways of thinking about work and careers. The
goal of the meetings is to help you think through your feelings about looking for work or advancing your career and
support you in pursuing the goals you set. The meetings will be virtual (video conference using Microsoft Teams) or
by phone over a period of three to six months. Once you have completed the first meeting, we will mail you a $40
Visa gift card. We will mail you a $25 Visa gift card after you complete each subsequent meeting; up to a total of
$165 in Visa gift cards if you complete all six meetings. You can stop each meeting at any time without penalty.
You can choose not to answer one or more of the questions.
Participation in this study is voluntary. Participation in this study will not affect your eligibility for benefits now or
in the future. SSA and Westat will protect all information that could identify you. As described in the Study
Consent, that you will review before you participate, we will safeguard the information you provide and will use it
for limited purposes, consistent with applicable Federal law, regulations, and directives. Your name or other
identifying information will not be included in any published reports.
If you would like to participate, visit Westat’s website link below and use the PIN to log in.

Website: https://xxxxx.org
PIN: XXXXXX

You can also scan the QR code below using the camera on a smart device to get to the website.
For questions about the study, call the Study Help Desk toll-free number at 1-855-516-3665. For questions about
your rights and welfare as a research participant, call the Westat Human Subjects Protections office at 1-888-9207631. Leave a message only with your first name, the name of the research study (Beyond Benefits Study) and a
phone number beginning with the area code.
I hope you will agree to participate in this very important study.
Sincerely,
[INSERT SIGNATURE OF SSA SIGNATORY]

Attachment A-22. Invitation and Consent to Participate in Motivational Interviews with Exiters

BEYOND BENEFITS STUDY
SOCIAL SECURITY ADMINISTRATION

Consent to Participate in Motivational Interviews
What is the purpose of the study?
The Social Security Administration (SSA) is conducting the Beyond Benefits Study to collect information about
the service, medical and employment needs of working-age adults who currently receive disability-related
payments or stopped receiving disability-related payments from SSA due to medical improvement. SSA hired
Westat, a national research company, to carry out the study. The purpose of the research is to help SSA identify
ways to help people who may be leaving or have left disability benefit programs.
What we are asking of you?
We seek your consent for your voluntary participation in six (6) 1-hour meetings with a motivational
interviewing counselor via Microsoft Teams videoconference 1 or telephone over a period of three to six
months. We will ask for your permission to send text message reminders about the study. Depending on your
texting plan, you may incur a charge for these texts. If you agree, you will be able to opt-out of receiving these
reminders at any time by replying “STOP” to the text or by calling the Help Desk at Westat. 2 During the
meetings, the interviewer will talk to you about your goals and dreams, and brainstorm with you about ways of
thinking about work and careers. The purpose of each session is to help you think about how you feel about
looking for work or advancing your career and support you in pursuing the goals you set. The interviewer will
ask questions about your willingness to get a job or your interest in advancing your career; your employment
goals; and what employment activities you would like to do or have done.
0F

1F

We ask for your permission to record each interview so we accurately capture what you tell us. If at any point
you do not wish to be audio-recorded, the interviewer will stop the audio-recording and end your interview
session. The recording will be used to develop the report and will be destroyed at the conclusion of the study
The reports will not contain information that could identify you. If you decide not to volunteer, it will not affect
any decision SSA makes about your current, or future, disability benefits or payments.
What benefits will you get for participating?
You may receive support to pursue your goals related to employment. You will contribute to SSA’s
understanding and improvement of policies and programs that may be helpful to people who leave disability
programs when their condition medically improves. After completing the first interview meeting, we will mail
you a $40 Visa gift card. You will receive a $25 Visa gift card for each subsequent completed meeting; up to
$165 in Visa gift cards if you complete all six meetings.
Persons eligible for participation in the study.
You were randomly selected to participate in the study from a list of current and former Social Security
Disability Insurance (SSDI) and Supplemental Security Income (SSI) program beneficiaries. Everyone on the list
had the same chance of being selected.
What is the study doing to minimize your risks?

1

Privacy Notice : Microsoft Teams is a nongovernment application that may have different privacy policies from those of the Social Security Administration

(SSA). This application is not under SSA’s control and may not follow SSA’s privacy, security, or accessibility policies located on their official website at
https://www.ssa.gov/privacy. Once you access this application, you are subject to Microsoft’s policies. As such, by using this application, you may be providing
non-government third parties access to your personally identifiable information (PII). Westat is taking precautions to protect your privacy and PII, such as by using
secure equipment in a private location. To minimize any risk of access by unauthorized third parties, we recommend that you use a reliable, secured, and private
internet connection and ensure no one enters the room with you during the meeting. General information about SSA programs may be found at
http://www.ssa.gov/.

2

Each text message sent by the study will also include these opt-out instructions.

Attachment A-22. Invitation and Consent to Participate in Motivational Interviews with Exiters

There is a small risk of disclosure of your personal information. To reduce this risk, we will separate any
information that identifies you from the rest of your data and store those identifiers separately. Although it is
not likely, it is possible that some of the questions may make you feel anxious or frustrated. If this happens, you
can skip the questions or stop participating. If you get upset, you may request a referral to crisis management
services. It is your decision to use this referral.
How will we protect your privacy?
We will follow Federal law and regulations to protect your privacy. SSA and Westat will protect your personal
information collected during the study. The information we collect is used for research in limited ways,
consistent with applicable Federal law, regulations, and directives. For example, we use your thoughts and
comments about employment, combined with thoughts and comments about employment from other people
interviewed, to understand experiences associated with finding employment. Your name or other identifying
information will not be included in any published reports.
Privacy Act Statement Collection and Use of Personal Information. Section 1110(a) of the Social Security
Act, as amended, allows us to collect this information, which we will use to help the Social Security
Administration (SSA) identify ways to help people who may be leaving or have left disability programs.
Providing us this information is voluntary; not providing all or part of the information will not affect your SSA
benefit. As law permits, we may use and share the information you submit, including with other Federal
agencies, contractors, student volunteers, and others, as outlined in the routine uses within System of Records
Notice (SORN) 60-0218, available at www.ssa.gov/privacy. The information you submit may also be used in
computer matching programs to establish or verify eligibility for Federal benefit programs and to recoup debts
under these programs.
Who you can contact if you have questions?
For questions about the study, call the study’s toll-free number at 1-855-516-3665. For questions about your
rights and welfare as a research participant, call the Westat Human Subjects Protections office at 1-888-9207631. Leave a message only with your first name, the name of the research study (Beyond Benefits Study) and a
phone number beginning with the area code, please do not leave any other personal information in the message.