Vermont One-Stop Guidelines for Staff and Management, Paperwork Forms, and Printed Materials: Examples for Other States to Consider

VERMONT DET

Department of Employment & Training

we help vermont work

Ticket To Work

This document contains materials provided by Jim Dorsey, Project Administrator of the Vermont Work Incentive Grant. The Law, Health Policy & Disability Center of the University of Iowa College of Law has reproduced these materials for the Rehabilitation Research and Training Center On Workforce Investment and Employment Policy For People with Disabilities (RRTC). The RRTC is funded by the National Institute on Disability and Rehabilitation Research of the U.S. Department of Education under grant number H133B980042-99. The opinions contained in this publication do not necessarily reflect those of the Department of Education.

These materials have been reproduced to provide examples and to assist other projects to establish, work with, and to administer the Ticket to Work program. While many of these materials are indicative to the state of Vermont, they can provide samples of the kinds of documents that can be reproduced and catered to your state and project.

TABLE OF CONTENTS

Memorandum---Initial Program Implementation 3

Social Security Benefits Overview 6

SSDI 6

SSI 8

Benefit Counseling 10

Ticket to Work Program 11

DET Staff Protocol 12

DVR Ticket to Work (Facts-Answers-Questions) 13

Recommended Flyers to be used in the Career Resource Centers 15

Statement of Rights, Benefits, Conditions (TtW-11) DET (New Form)

To be used with Ticket to Work Clients 17

Points to Note---Mock Application (Information for Case Managers) 20

Participant Record (ET-614) Sample Copy with associated paperwork/notes 21

Social Security Form, Form SSA-1365 (10-2001)

State Agency Ticket Assignment, Ticket to Work and Self-Sufficiency Program 27

Addendum to Vocational Rehabilitation Ticket to Work Assignment Form 29

Sample Ticket to Work 20

Vermont Department of Employment & Training

MEMORANDUM

THRU: Bob Ware, Director, J&T

TO: All Career Resource Center Managers

FROM: Jim Dorsey, Work Incentive (Disability) Grant

SUBJECT: Ticket to Work---Initial Program Implementation

DATE: January 16, 2002

OVERVIEW:

Ticket to Work is an incentive program developed by the Social Security Administration (SSA), whereby service providers will be paid for successfully returning beneficiaries to the workforce and thus closing their Social Security benefits. The payment would be equivalent to 40% of an average benefit amount, and will be paid for every month that the client does not receive SSA benefits for up to 60 months.

MAXIMUS, a private company contracted by Social Security, will oversee the program. Their role includes recruitment and authorization of Employment Networks, referral and resource for clients looking to receive services, and oversight of service plans and provider operations.

Any person or organization can apply to become an authorized Employment Network as long as they can meet the guidelines. At present, the Division of Vocational Rehabilitation is authorized to operate as an Employment Network to provide services independently or in partnership with other providers. Other Networks are Rutland Mental Health, Vermont Division for the Blind and Visually Impaired, Take Charge Vocational Rehabilitation Services, Jim Hartley, and Ability Forum.com. Additional networks may be approved at a later date.

The Department of Employment and Training is currently a partner Provider with the Division of Vocational Rehabilitation (DVR). In this agreement, actual client services can be provided solely by DET or jointly with DVR and/or other providers. In order to participate in the Ticket Program, each Area Resource Center must have a designated liaison that will review and approve plans and assure that paperwork is appropriately forwarded to the DET point of contact. Because Social Security will pay based on outcomes, it is important that DET has well developed and documented plans and enough follow-up to ensure that the client remains employed. If multiple partners provide services, the payment will be prorated. A portion of the payment received by DET will be provided to the servicing CRC. All Ticket related paperwork will be forwarded to---DET Ticket to Work Coordinator.

PROCEDURAL GUIDELINES

a. Answer all telephone inquiries to the extent possible using the prepared protocol sheet furnished by the Work Incentive (Disability) Program Project Specialist.

b. If after an initial interview, the client appears to warrant further services, refer her/him to an appropriate case manager.

c. The ticket should only be accepted after extensive assessment and agreement between the client and the case manager(s) as to the steps needed to reach the employment goal. When service steps are completed they must be documented on the ET-614 as they are accomplished.

d. Prior to accepting the Ticket call MAXIMUS (800-986-7642) to verify status. If the ticket is not assigned and you and the client agrees that DET should be the Ticket holder, complete the forms listed below, have the Ticket liaison review the plan, and proceed with services as needed.

If DET elects to accept the Ticket the following must be completed:

The ET-614 (Participant Record) including a description of the specific employment goal, an all-inclusive description of services to be provided leading to that employment, and signatures of the client, case manager, and CRC liaison that agree to the plan.

The new General Provisions Form, which includes how the program works, how the plan can be amended or agreement terminated, description of confidentiality, the fact that there is no cost to the client to participate, and information to the client's right to protection and advocacy services. The client, case manager, and the CRC liaison all must sign.

Complete the State Agency Ticket Assignment Form (Form SSA-1365) dated October 2001. Have the Ticket Holder or Representative sign and date the form at the bottom in the designated space. DVR will sign as the State VR Agency Representative.

e. When plans are completed, they will be reviewed and approved by the CRC Manager or her/his designated staff person that is the liaison for the Ticket to Work Program. Approval will be indicated in the "Additional Signature" portion of the ET-614. The original Ticket with the authenticated forms (also originals) will be forwarded to the DET Ticket to Work Coordinator who will review and subsequently forward to DVR. Copies of all documents will be retained in the local CRC files.

f. Beneficiaries will be monitored by SSA for five years after the client stops receiving SSA benefits. CRC case managers will provide sufficient follow up to assist the client in maintaining their employment status during the Social Security maintenance period (at least once a month for the first year).

g. A DET Project Specialist is available to render technical advice in developing or reviewing Individual Work Plans.

SOCIAL SECURITY BENEFITS OVERVIEW

(Information current as of January 16, 2002)

SSDI - Social Security Disability Insurance

Eligibility:

The person must have worked and paid into the Social Security tax (FICA) or they can collect off a parent who has a disability or is retired (adult child with a disability) or deceased spouse.

Has a medically documented impairment that is expected to result in death or to last for at least 12 months.

Is not able to perform Substantial Gainful Activity (SGA). This is the ability to earn $780.00 a month ($1300.00 for people with blindness).

Benefits may also be paid to the dependents (spouse or child) of an insured person.

There is a five-month waiting period, from the onset of disability, before benefits will start (unless imminently terminally ill).

Benefit Amount:

Benefit amount will vary depending on how much the recipient has paid into the insurance fund.

Continuing Disability Review:

Continuing Disability Review may be accomplished at six-month to seven-year intervals, depending on the recipients' diagnosis and likelihood of recovery, to determine if the disability still exists.

Impact of Employment on SSDI:

Trial Work Period (TWP): A trial work period is any month that an SSDI recipient earns $560.00 or more. A recipient is allowed nine trial work months (not necessarily consecutive) in a rolling period of 60 consecutive months. During TWP the recipient will receive their full SSDI benefits.

Once the recipient has completed their nine-month trial work period, Social Security will conduct a Continuing Disability Review to determine if the person is working at a level of SGA ($780.00 or $1300.00 for people with blindness per month). If they are exceeding SGA, they will receive benefits for three months, but the benefits will cease on the fourth month if they continue to work at SGA, or the first month thereafter that they reach SGA.

Extended Period of Eligibility (EPE): The Extended Period of Eligibility applies to individuals who still possess their original disability. They will begin an extended period of eligibility the month after their trial work period ends. This will last for 36 consecutive months. During that time they will receive a benefit check whenever their earnings fall below SGA ($780.00 or $1300.00 for people with blindness per month) for that month.

Special Conditions and Impairment Related Expenses: Special conditions and impairment related expenses might be deducted from earnings in determining if someone meets SGA. This may include items such as using a job coach to complete the job or adaptive equipment needed to enable the person to work.

Medicare:

Medicare may continue for up to 91 months after the trial work period if the person is still eligible for SSDI. If the person becomes ineligible for premium free Medicare, they may be able to continue coverage by paying the premium themselves. Some people who receive SSDI can receive Medicaid for employed individuals with disabilities

SSI - Supplemental Security Income

Eligibility:

Has a medically documented impairment that is expected to result in death or to last for at least 12 months.

Is not able to perform Substantial Gainful Activity (SGA). This is the ability to earn $780.00 a month. (For people who have blindness there is a level of blindness test instead of an SGA test. There is a separate criteria for people under the age of 18.)

Meets an economic needs test.

Benefit Amount:

The standard rate of Vermont is currently $604.04 a month effective January 2002. However, the actual benefit may be reduced due to earned income, unearned income, deemed income, in-kind support, or resources that the recipient has. Deemed Income and In-Kind Support are contributions made by someone living in or out of the recipient's household to cover all or part of the recipients living expenses. Resources are cash or anything that can be converted to cash (with few exceptions). The current Resource Limit is $2000.00 for an individual or $3000.00 for a couple. If the recipient exceeds the resource limit they will not be eligible for benefits during that month.

Continuing Disability Review:

A Continuing Disability Review may be accomplished at six month to seven-year intervals, depending on the recipients' diagnosis and likelihood of recovery, to determine if the disability still exists.

Impact of Employment on SSI:

Income Exclusions: Social Security gives a $20.00 general income exclusion (earned or unearned) and a $65.00 earned income exclusion before making adjustments in benefits. Impairment Related Work Expenses and payments made into a PASS plan may also be excluded. The remainder is considered to be countable income. The SSI benefit will be reduced $1.00 for every $2.00 of countable income.

Impairment Related Work Expenses: Impairment Related Work Expenses can be anything that a person pays for specifically related to their disability that allows them to work. This can include things such as adaptive equipment or hiring a job coach.

PASS (Plan for Achieving Self-Support): A Plan for Achieving Self-Support is an formal agreement that the recipient enters into with Social Security, where by the person sets aside a portion of their income to cover specific work goals such as education costs or support services that will allow the person to work.

Medicaid:

The recipient may continue to be eligible for Medicaid even after they are no longer eligible for SSI benefits if the medical coverage is necessary for them to work under legislation called 1619b. The Medicaid for Working People with Disabilities program allows people to pay the Medicaid premium and buy into coverage if they don't qualify for other coverage.

BENEFIT COUNSELING -- DISABILITY GRANT

There are disability counselors at Vocational Rehabilitation offices throughout the state who can help social security recipients understand what will happen to their benefits if they go to work or change their employment status. They are also knowledgeable about how changes will impact other benefits such as food stamps, Medicaid and section 8, housing. It is advisable to put clients in touch with the benefit counselors prior to implementing any vocational services plan.

If someone is formally enrolled in the Benefit Counseling Disability Grant they can be excused from Continuing Disability Reviews for the duration of the grant. The Benefit Counselors will decide if enrollment is advisable.

NOTE: The specifics of each case can have many variables. Under certain circumstances people can be eligible for both SSDI and SSI, or if eligibility for one runs out they may be eligible for the other benefit. Therefore, it is advisable to inform clients of the Benefits Counselor roles and how they can be reached.

TICKET TO WORK PROGRAM

The Ticket to Work Program is another incentive offered by the Social Security Administration (SSA) that is expected to start in February 2002.

SSA recipients will be given "tickets" that will allow them to negotiate with various employment networks to obtain job training or rehabilitation services. Once the person is employed and off Social Security benefits, SSA will pay the network a portion of the benefit savings.

The "ticket" has no cash value to the recipient. The clients will be excused from Continuing Disability Reviews during the duration of their employment services plan as long as they are making steady progress on the plan.

PROTOCOL FOR ANSWERING TICKET TO WORK

QUESTIONS FOR FRONT LINE STAFF

1) WHAT IS THE TICKET TO WORK?

This is a program that Social Security has developed to let you know that there are services to help you with employment if you are interested in going to work.

2) WHAT HAPPENS IF I DO NOT USE IT OR AM NOT INTERESTED IN GOING TO WORK?

Nothing. This is a voluntary program. If you choose not to participate in the program, it will not affect your SSI or SSDI benefits.

If you are not interested in working right now but may want to in the future, you can save the Ticket and use it at a later date.

3) WHAT HAPPENS IF I DO USE IT?

You would have to meet with one of our Career Development Facilitators to determine what type of employment would be good for you, and what steps would be needed for you to reach that goal.

If you are already working with staff, we would suggest that you start by discussing your options with them.

If you are not currently working with anyone, I can schedule an appointment for you with one of our staff.

Once you agree on a plan of action, you would be formally enrolled in Ticket to Work. While participating in the program, you can be exempt from your Continuing Disability Reviews with Social Security.

4) WHAT IS MAXIMUS?

That is a company that has been hired by Social Security to help get this information out to people, and to monitor the success of the program. You can call their toll free number (866-968-7842) to get more information.

® Ticket to Work ¬

FACTS, ANSWERS, QUESTIONS

Below is a list of common questions you may get around the Ticket to Work.

Tickets will be mailed to individuals beginning in February 2002.

1) What is a Ticket to Work?

A ticket is a document some individuals on Social Security SSI or SSDI benefits will receive. They can give their Ticket to Vocational Rehabilitation or other registered vocational providers (called "employment networks") and the provider can use the Ticket to get payments from SSA when an individual works his or her way off of cash benefits.

2) Who will get a Ticket?

Anyone on SSI or SSDI who is not expected to "medically recover" and who receives a cash benefit will get a Ticket to Work. Furthermore, only people 18 and over will get Tickets.

3) Do people have to use the Ticket?

No, the program is voluntary. There is no consequence for not using the ticket.

4) Who can people give the Ticket to?

A person may give their Ticket to any Employment Network or Vocational Rehabilitation (VR) agency that is willing to provide services. A person cannot place a Ticket with two ENs simultaneously, though they can move their Ticket when they are dissatisfied with services.

5) What Organizations can become Employment Networks?

Any organization that is willing and able to provide employment services to the ticket holder. A community mental health agency or developmental services provider can be an employment network, either individually or in partnership with other agencies. Non-traditional providers such as employers, for profit agencies could also become ENs.

6) Is there a benefit for a person who chooses to use their Ticket?

Yes! A person who deposits their Ticket with VR or another EN will be exempt from continuing disability reviews (CDR) while their Ticket is active. For the first two years after they deposit their Ticket, participants will have all CDRs suspended, and for each year after that they will have to work at a certain level to maintain their CDR exemption.

7) How will an EN or VR agency be paid for services?

If a person works at a level where they no longer receive cash benefits from SSA, an EN will be able to submit claims to SSA for outcome payments. In general, outcome payments equal 40% of what the person would have received in cash benefits for up to 60 months.

8) If people go off cash benefits will they lose their necessary healthcare coverage?

People who receive SSI who work themselves off can continue to receive Medicaid coverage through the 1619B program, and earn up to $22,000 per year. People who receive SSDI and who are working are eligible for Medicaid for employed individuals with disabilities, which will entitle them to maintain those Medicaid benefits even if they go off cash benefits.

9) When a person goes off cash benefits because of work, how do they get back on benefits if they lose their job at a later date?

Under the "Expedited Reinstatement" provision, people who go off cash benefits as a result of employment can, if they lose their job, get back on benefits the following month. The "Expedited Reinstatement" provision is in effect for five years from the point the person goes off benefits.

TICKET TO WORK

DO YOU RECEIVE SOCIAL

SECURITY DISABILITY

PAYMENTS? SSI OR SSDI?

DO YOU WANT TO WORK?

ASK OUR STAFF ABOUT

CHANGES IN THE

SOCIAL SECURITY LAWS

THAT MAKE IT EASIER

FOR YOU TO WORK

ASK ABOUT OUR SKILLS ASSESSMENT AND

JOB TRAINING PROGRAMS

THAT CAN HELP YOU FIND A JOB

THAT IS RIGHT FOR YOU

TICKET TO WORK

DO YOU RECEIVE SOCIAL

SECURITY DISABILITY

PAYMENTS? SSI OR SSDI?

DO YOU WANT TO WORK?

CHANGES IN THE

SOCIAL SECURITY LAWS

NOW MAKE IT EASIER

FOR YOU TO WORK

YOU CAN RECEIVE

REEMPLOYMENT SERVICES

THROUGH ANY OF THE

FOLLOWING AGENCIES:

· State Vocational Rehabilitation Offices

· Employment and Training Career Resource Centers

· Local Mental Health Centers

Statement of Rights, Benefits, and Conditions of Participation

For the Ticket to Work and Self-Sufficiency Program

Department of Employment & Training

Rights of a Disability Beneficiary / Ticket Holder

1. There is no cost to the Ticket Holder for participating in the Ticket-to Work Program

2. The Ticket Holder has the right to seek employment services and other support services from Employment Networks (ENs) and partners of ENs such as the department of Employment & Training One-Stop Career Resource Centers.

3. The Ticket Holder has the right to benefits planning and assistance in order to determine feasibility of employment.

4. The Ticket Holder has the right to retrieve the Ticket at any time if dissatisfied with the services being provided.

5. The Ticket Holder has the right to advocacy services and assistance to resolve disputes between the Ticket Holder and the Employment Network and its partner.

6. The Ticket Holder has the right to dispute resolution procedures.

The Responsibilities of the Department of Employment & Training, DET (Employment Network's partner)

1. DET shall protect the privacy and confidentiality of the information it receives from the Ticket Holder.

2. DET agrees to use and access the beneficiary information only for the purposes of SSA's Ticket-to-Work Program and to provide vocational and employment services to the Ticket Holder.

3. DET agrees to dispose of Ticket Holder information in a safe and secure manner.

4. DET agrees not to duplicate or disseminate beneficiary information outside of DET or DVR (Employment Network) without a release from the client.

5. DET agrees to provide physical safeguards for the protection of the security of the information, including the restriction of access to data only by authorized employees of DET who need the data to perform their official duties in connection with the Ticket-to-Work program.

Requirements of an Individual Work Plan

1. The individual work plan shall describe the vocational goal of the Ticket Holder and shall be developed with the Ticket Holder.

2. The individual work plan shall describe the services and supports to be provided by or through DET to the Ticket Holder, as well as steps the Ticket Holder will take to accomplish the vocational goal.

3. The Ticket Holder understands that there is no cost to them for the services and supports provided by DET.

4. The Ticket Holder understands that the individual work plan may be amended or revised if the Ticket Holder and DET both agree to the changes.

5. The Ticket Holder may have a copy of the individual work plan in an accessible format at any time.

Grievance and Resolution of Dispute Procedures between the Ticket Holder and DET

1. All information and complaints involving fraud, abuse or other criminal activity shall be reported directly and without time limits to the Jobs & Training Division Hearing Officer, Department of Employment & Training.

2. If you are seeking to bring a complaint alleging discrimination on grounds of race, color, religion, sex, national origin, age, disability, political affiliation or belief, you may file a complaint within 180 days from the date of the alleged discrimination with either the Equal Opportunity Officer at the Department of Employment & Training (DET), or the Director, Civil Rights Center (CRC), U.S. Department of Labor, 200 Constitution Avenue, NW, Room N-4123, Washington, DC 20210. If you elect to file your complaint with DET, you must wait either until DET issues a written Notice of Final Action, or until 90 days have passed (whichever is sooner), before filing with the Civil Rights Center. If DET does not give you a written Notice of Final Action within 90 days of the day on which you filed your complaint, you do not have to wait for the recipient to issue that Notice before filing a complaint with CRC. However, you must file your CRC complaint within 30 days of the 90 days deadline (in other words, within 120 days after the day on which you filed your complaint with DET). If DET does give you a written Notice of Final Action on your complaint, but you are dissatisfied with the decision or resolution, you may file a complaint within 30 days of the date on which you received the Notice of Action.

3. If you believe you are being treated unfairly, subjected to unequal employment practices, or discriminated against on the basis of a disability, or if you have questions related to any of the complaints listed here, contact your local staff person. If your complaint is about a staff person and you have been unable to resolve it, contact the local Career Resource Center Manager. If your complaint is still not resolved, contact the DET Jobs & Training Division.

4. DET maintains written complaint procedures. When necessary, the DET staff or CRC Manager will assist you in following the procedures to present your complaint for a hearing. If you are unable to obtain assistance, contact the DET Jobs & Training Division.

Protection and Advocacy

1. In every State and U.S. Territory, there is an agency that protects the rights of individuals with disabilities. Each Protection and Advocacy System administers the Social Security Administration funded Protection and Advocacy for Beneficiaries of Social Security (PABSS) program. Each PABSS project can:

a. Check out any complaint you have against an employer network or other service provider that is helping you return to work.

b. Give you information and advice about vocational rehabilitation and employment services.

c. Tell you about SSA's work incentives that will help you return to work.

d. Provide consultation and legal representation to protect your rights in the effort to secure or regain employment.

e. Help you with problems concerning your individual work plan under the Ticket-to-Work Program.

2. These services are free to persons receiving Social Security or Supplemental Security Income benefits based on disability or blindness. If you want to locate the PABSS project nearest you, please call 866-833-2967 (TTY/TDD) for the hearing impaired. You can also find a list with contact information at:

http://www.ssa.gov/work/ServiceProviders/PADirectory.html

________________________________________________________________________

(please fold and detach here for file copy)

Acknowledgement of Receipt of Statement of Rights, Benefits

And Conditions of Participation

I have received a copy of the Vermont Department of Employment & Training's Statement of Rights, Benefits and Conditions of Participation on the Ticket-to-Work and Self-Sufficiency Program. I have read or have had it explained to me and agree to abide by the stated conditions.

________________________________ __________/______/__________

Participant's Signature Date

POINTS TO NOTE ON 614 FOR TICKET TO WORK

1. History page should include:

· All relevant work history, not just the last five years.

· An indication of what type of disability payment the client receives, as well as any other income coming into the household, or other benefits such as food stamps or section 8.

· Information about other family members that would indicate what kind of support or personal needs the client may have.

2. The "Ticket" should not be accepted until the following items have been addressed:

· The client has chosen a clear vocational goal. This may require several appointments, the use of formal assessment tools, and/or obtaining (a release) information from the client's doctor, counselor or other professionals.

· It has been determined what financial impact employment and/or training will have on the client's benefits. The best way to address this is to have a joint meeting with the client and a Benefits Counselor.

· You have reviewed the "Ticket" options with the client including the option of not using the Ticket at this time, and the fact that they could choose to assign their Ticket to another network.

· You have checked with Maximus (866-968-7842) to make sure that the Ticket has not been assigned to another Network.

· You and the client have agreed on a plan of action to reach their employment goal.

3. The plan should include:

· A specific vocational goal.

· Steps that will take the client all the way to employment and closure of the Social Security benefits.

· The plan will be reviewed by the Local Office Manager or the Ticket Liaison and signed on the "additional signature" line.

· The "general provisions" form must be reviewed with the client and signed. The Ticket assignment form and addendum must also be completed. Copies of the plan and these forms will be mailed to:

· NOTE: If you are providing joint services with Vocational Rehabilitation or another partner in a Network, you may decide that they should be the primary provider, and they would assume responsibility of completing and filing the Ticket assignment paperwork.

· Completion dates must be entered on the plan when steps are completed.

VERMONT DEPARTMENT OF EMPLOYMENT & TRAINING PARTICIPANT RECORD

_____________________________________________________________________________________

Name___________________________________________________ Date ____________________

Address_________________________________________________ Staff_____________________

________________________________________________________ Referred by_______________

SSN____________________________________________________ Date of Birth______________

Car �Yes �No Make____________ Model Year____ Operating Condition_______ License �Yes �No

____________________________________________________________________________________________

EDUCATION/TRAINING/TESTING (Highest Grade Completed):____ (Last School Attended:_____________

Major Subject Areas:___________________________________________________________________________

Best Subjects:____________________________ (General Feelings towards schooling):______________________

Additional Training Experiences: (military, correspondence school, trade schools, etc.):______________________

____________________________________________________________________________________________

ASSESSMENT Reading Level_____Grade Math Level _____Grade Date of Test:_______________

Assessment Method/Instrument Used: _____________________________________________________________

____________________________________________________________________________________________

WORK HISTORY (List employment [complete additional sheets if needed])

Employer:__________________________________________________ Dates of Employment______________

Job Title and Duties:__________________________________________________________________________

___________________________________________________________________________________________

General Feelings Towards Job:_____________________ Reason for Leaving:____________________________

Employer:__________________________________________________ Dates of Employment______________

Job Title and Duties:__________________________________________________________________________

___________________________________________________________________________________________

General Feelings Towards Job:_____________________ Reason for Leaving:____________________________

___________________________________________________________________________________________

BARRIERS (Please identify any personal, family, medical, dental, educational, substance abuse, transportation, childcare, clothing, or work-related issues that may cause you difficulty in finding and/or keeping employment:

____________________________________________________________________________________________

STRENGTHS _______________________________________________________________________________

____________________________________________________________________________________________

INTERESTS/HOBBIES _______________________________________________________________________

____________________________________________________________________________________________

OTHER INFORMATION COMMENTS _________________________________________________________

____________________________________________________________________________________________

ACTION PLAN / INDIVIDUAL SERVICE STRATEGY

VOCATIONAL GOAL: ________________________________________ ____________________

Projected Employment Date

STEPS TO ACHIEVE GOAL (Include support service needs)	Person Responsible	Anticipated Completion Date	Date Completed

We are in agreement with the above plan that has been developed. Support service needs have been identified and are being addressed.

RELEASE STATEMENT: I understand that in an effort to help me get a job, my situation may be discussed with employers or other agencies. I give this service provider permission to do so as long as it is relevant to my employability.

__________________________ __________ ____________________ ___________

Individual's Signature Date Staff Signature Date

__________________________ _________

Additional Signature if necessary Date

USE ADDITIONAL PAGES AS NEEDED

ACTION PLAN / INDIVIDUAL SERVICE STRATEGY

VOCATIONAL GOAL: ________________________________________ ____________________

Projected Employment Date

STEPS TO ACHIEVE GOAL (Include support service needs)	Person Responsible	Anticipated Completion Date	Date Completed

We are in agreement with the above plan that has been developed. Support service needs have been identified and are being addressed.

__________________________ __________ ____________________ ___________

Individual's Signature Date Staff Signature Date

__________________________ _________

Additional Signature if necessary Date

USE ADDITIONAL PAGES AS NEEDED

Date Initial	ASSESSMENT SUMMARY AND CONTACT / PROGRESS NOTES

Note: After Assessment Summary has been completed, continue with Contact/Progress Notes.

Additional Contact/Progress Notes Sheets may be stapled to this page or on the back.

Date Initial	ASSESSMENT SUMMARY AND CONTACT / PROGRESS NOTES

EMPLOYMENT & TRAINING

PROGRAM APPLICANT INFORMATION RELEASE AUTHORIZATION

� Vermont Department of Employment & Training

is hereby authorized to

� _________________________________________

(Agency Name)

_____Release ______Obtain _____Obtain and Release (Check One)

Information regarding ___________________________________________ (Client's Name)

To or from the following sources: (Name of agency, physician, clinic, school, etc.)

_____________________________________________________

The following information to be _____Released _____Obtained _____Shared mutually

Is as follows:

______________________________________________________________________________

The purposes of this requested disclosure and/or release are checked below:

_____ 1. To help the client obtain suitable employment and/or training.

_____ 2. To verify the client's eligibility for employment and training programs.

_____ 3. To assist the client in overcoming barriers, or obstacles, to employment and training.

_____ 4. To authorize exchange of information and case coordination between or among agencies

serving the clients.

_____ 5. Other: ______________________________________________________________

______________________________________________________________

I have read and have had explained to me the reason for this authorization, and hereby consent to the release and/or disclosure described above.

I further understand that I may revoke my permission for this disclosure or release at any time, and that this permission will automatically expire two years from the date of signature unless renewed in writing.

SIGNATURE: ___________________________________________________ DATE: ___________

PARENT'S SIGNATURE: _________________________________________ DATE: ___________

(If client is a minor)

Form Approved

OMB No. 0960-0641

STATE AGENCY TICKET ASSIGNMENT FORM

TICKET TO WORK AND SELF-SUFFICIENCY PROGRAM

Instructions - This form must be completed to record that a beneficiary who is a ticket holder has decided to assign the ticket to a State Vocational Rehabilitation (VR) Agency. The form must be completed by both the State VR agency representative and the ticket holder or, as appropriate, the ticket holder's representative. The State VR agency will submit this form in lieu of submitting the Individualized Plan for Employment. The ticket holder or his/her representative, as appropriate must sign this form to confirm the decision to assign the ticket to the State VR agency. The State VR agency will either send or fax the completed and signed form to:

Mail - MAXIMUS Ticket to Work Fax - 703-683-3289

ATTN: Ticket Assignment

P.O. Box 25105

Alexandria, VA 22313

A. To be Completed by State VR Agency (after verifying the beneficiary has a ticket which may be assigned to the State VR agency)

1. Enter the State VR Agency's name

Enter the State VR Agency's Employer Identification Number (EN)

2. Ticket Holder's Name (Last, First, Middle Initial)

3. Ticket Holder Number (This is the Social Security Number on the ticket with the TW suffix)

______ ______ ______ TW _______

4. (a) What vocational objective or employment outcome is outlined in the ticket holder's Individualized Plan for

Employment?

(b) What is the expected type of job? (Check one EEOC classification below):

� Executive/Managerial

� Professional

� Sales

� Technical/Paraprofessional

� Skilled Craft

� Secretarial/Office/Clerical

� Service Worker

� Operative

� Laborer

5. (a) Date the Individualized Plan for Employment was

signed by ticket holder or his/her representative (month/day/year)

5. (b) Date the Individualized Plan for Employment was

signed by the State VR agency counselor (month/day/year)

6. In the Individualized Plan for Employment, date established for meeting the vocational objective chosen (month/year)

7. What SSA Payment system is the State VR agency selecting with respect to this ticket holder?

(Place an X in the appropriate box)

� Cost Reimbursement Payment System

� State VR agency

(If this option is selected, submit Form SSA-1366, "State Vocational Rehabilitation Ticket to Work Information Sheet" or equivalent information with this SSA-1365)

B. To be Completed by the ticket holder or ticket holder's representative

Check the appropriate box and sign your name in the space provided below.

� I am the ticket holder to whom the information on this form applies.

� I am the representative of the ticket holder to whom the information on this form applies and am acting on his/her behalf.

I understand that once my ticket is assigned to the State VR agency, I have the right to retrieve my ticket for any reason. I acknowledge that the information contained on this form relating to the ticket holder is correct, and that I do willingly agree to assign my ticket to the State VR agency shown above.

I understand that if I make, or cause to be made, a representation which I know is false concerning the requirements of the Ticket to Work and Self-Sufficiency program, I could be punished by a fine, or imprisonment, or both.

Ticket Holder or Representative Signature

State VR Agency Representative Signature

Date

Form SSA-1365 (10-2001)