g) 20 CFR 411.325 (f)- Annual Performance

2021 Annual Performance Outcome Report Questions

Below are the questions included on the Annual Performance Outcome Report (APOR)
for the January 1, 2021 – December 31, 2021 reporting period. You must complete the
APOR in one sitting. Reviewing the questions prior to beginning the questionnaire will
allow you to research and prepare your answers as needed. If you have questions about
the APOR, email SSAENAPOR@yourtickettowork.ssa.gov. Please note, this document IS
NOT the APOR questionnaire that you must return to the Social Security Administration’s
Ticket Program Manager for the Ticket to Work Program. Your EN’s Program Contact will
receive the link to complete the APOR via email on January 31, 2022.
Note: The 2022 APOR only collects data for ENs active as of January 1, 2021. You must
complete an APOR for each DUNS your EN had an approved business model for as of
January 1, 2021. Your EN is not required to complete a separate APOR for any business
models acquired in 2021.

General Questions
1. Please provide your Employment Network (EN) Data Universal Numbering System
(DUNS) number. (The DUNS number is a 9-digit number assigned by Dun &
Bradstreet Information Services. Every EN obtained a DUNS number prior to
award of the EN Ticket Program Agreement (TPA.)
• DUNS - _ _ _ _ _ _ _ _ _
2. Please provide the following information concerning the individual completing the
APOR for your EN:
• Name:
• Title:
• Email Address:
• Direct Contact Number:
3. What is your Social Security approved Ticket to Work Business Model?
• Traditional EN (EN that provides employment services and other support
services directly to the Ticketholder)
• Consumer Directed Services EN (EN that reimburses the Ticketholder for
employment-related services purchased by the Ticketholder)
• Employer EN (EN that primarily employs Ticketholders for which it has
assigned Tickets)

•

Administrative EN (EN that serves as the EN of record for a network of
service providers who combine their resources to provide services to
Ticketholders)

Note: Provide the business model that is included in your approved Ticket Program
Agreement (TPA). Do not select your EN’s secondary business model if applicable.
4. How many Tickets were assigned to your EN as of December 31, 2021?
• ___________________
5. If your EN operates as an Administrative EN, how many EN Affiliates do you
contract with to provide services under this EN?
• ___________
6. Is your EN an approved State Vocational Rehabilitation Agency vendor?
• Yes
• No
7. How many office locations does your EN currently have?
• ___________
8. Does your EN conduct business out of a home office(s)?
• Yes
• No
9. If you responded ”yes” to the previous question, has Social Security approved the
home office location(s)?
• Yes
• No
10. How do you prefer to list the way your EN provides services to Ticketholders in the
“Find Help” tool on www.choosework.ssa.gov?
• Virtual
• In-person
• Both

11. Do you have a written Partnership Plus agreement with your local State Vocational
Rehabilitation Agency?
• Yes
• No
12. If you answered “yes” to the question above, during the lifetime of the agreement
how many assignments are or have been a direct result of the agreement?
• Number of assignments _____________
13. Is your System for Award Management (SAM) registration current?
• Yes
• No
14. Do you use autodialing/robocalling to contact Ticketholders?
• Yes
• No
15. Is your EN owned by (or, if there are multiple owners, is the person who owns the
largest percentage of your EN)?
Check all of the applicable ownership type(s) for your EN below.
_____ a woman
_____ a racial minority
_____ a Veteran
_____ a person with a disability as defined by the Americans with Disabilities Act
(For the definition, please see https://www.ada.gov/cguide.htm#anchor62335.)
_____ Eligible for the Small Business Administration’s HUBZone program (To
verify the qualifications for the HUBZone program, please visit HUBZone program
(sba.gov).)
_____unknown
16. Is your Signatory Authority:
Check all that apply
_____ a woman
_____ a racial minority
_____ a Veteran
_____ a person with a disability as defined by the Americans with Disabilities Act
(For the definition, please see https://www.ada.gov/cguide.htm#anchor62335.)
_____unknown

17. Is your Program Coordinator:
Check all that apply
_____ a woman
_____ a racial minority
_____ a Veteran
_____ a person with a disability as defined by the Americans with Disabilities Act
(For the definition, please see https://www.ada.gov/cguide.htm#anchor62335.)
_____unknown

Staffing Questions
18. Do you have an SSA approved Certified Benefits Counselor on staff?
Note: Social Security considers Certified Benefits Counselors as any EN employee
or subcontractor who has gone through, passed, and has an active Community
Partner Work Incentives Coordinator certification (CPWIC) from Virginia
Commonwealth University (VCU), Benefits Work Incentives Practitioner
certification (BWIP) from Cornell University or Benefits Information Network (BIN)
Training through Indiana University.
a. Yes
b. No
19. If you answered “Yes” to the question above, what are the names of the staff at
your organization that are an SSA approved Certified Benefits Counselor?
For “Position,” please list the individual’s title as listed in your TPA, for example:
Signatory Authority, Program Contact, Ticketholder Contact, Payments Contact,
etc.
For Training “Type,” please specify where the training was received (e.g., VCU,
Cornell University or Indiana University).
a. Individual 1 Name
b. Individual 1 Position
c. Individual 1 Training Type
d. Individual 2 Name

e. Individual 2 Position
f. Individual 2 Training Type
g. Individual 3 Name
h. Individual 3 Position
i. Individual 3 Training Type
j. Individual 4 Name
k. Individual 4 Position
l. Individual 4 Training Type
m. Individual 5 Name
n. Individual 5 Position
o. Individual 5 Training Type
20. If your organization has more than five SSA approved Certified Benefits
Counselors, please upload an Excel document with their Names in Column A,
Positions in Column B, and Training Type in Column C.
a. Option to upload file
21. Please upload all SSA approved Certified Benefits Counselor certifications as
either a single PDF or a single zip file.
Note: We will use Certificates to verify Certified Benefits Counselor status and
populate the “Benefits Counselor Badge” shown in the Find Help Tool.
a. Option to upload file
22. Have you obtained suitability clearances for all employees working under the TPA
who access or handle Personally Identifiable Information (PII), including volunteers
and interns?
a. Yes
b. No
23. Have you notified SSA of any employees who previously received a suitability
clearance who are no longer working under the TPA?
a. Yes

b. No

EN Service-Related Questions
24. How many years of experience does your EN have serving Youth in Transition
clients?
• 0
• Less than 1
• 1-2
• 2-3
• 3+
25. How many years of experience does your EN have serving Veterans?
• 0
• Less than 1
• 1-2
• 2-3
• 3+
26. How many years of experience does your EN have serving clients with physical
impairments?
• 0
• Less than 1
• 1-2
• 2-3
• 3+
27. How many years of experience does your EN have serving clients with hearing
impairments?
• 0
• Less than 1
• 1-2
• 2-3
• 3+

28. How many years of experience does your EN have serving clients with visual
impairments?
• 0
• Less than 1
• 1-2
• 2-3
• 3+
a.
29. How many years of experience does your EN have serving clients with cognitive
impairments? Some examples include traumatic brain injury (TBI), autism,
intellectual disabilities, and learning disabilities such as dyslexia and attention
deficit disorder (ADD).
• 0
• Less than 1
• 1-2
• 2-3
• 3+
30. How many years of experience does your EN have serving with psychiatric
disorders or mental behavioral impairments? Some examples include anxiety,
bipolar disorder, depression, and schizophrenia.
• 0
• Less than 1
• 1-2
• 2-3
• 3+
31. How many years of experience does your EN have serving clients pursuing selfemployment?
• 0
• Less than 1
• 1-2
• 2-3
• 3+

32. Does your EN explain Timely Progress Review (TPR) expectations to your Ticket
clients?
a. Yes
b. No
33. Does your EN offer a special language service (including Braille, American Sign
Language, materials and services in languages other than English)?
a. Yes
b. No

34. If you answered “Yes” to the question above, what specifically, does your EN
offer?
a. Braille
b. American Sign Language
c. Materials and services in languages other than English (please specify)
____________
35. What services does your EN or provider affiliates offer to your Ticketholders?
Check all that apply:
___ Career planning/counseling
___ Job accommodations
___ Job coaching/training/development
___ Job search/job placement
___ Ongoing employment support/job retention
___ Resume writing
___ Transportation
___ Training
___ Wage reporting
___ Other (please specify) ____________