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Welcome to the Social Security Web Report System, (PABSS)
To begin a new report, please select the Create New Report link. To continue on a report that has been started,
select the Edit Report link. To view or print submitted reports, select the View Completed Report link. To generate
reports, select the Report Generator link.

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Demo Report

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~ Reporting Period

FY 2006 1ST Bi-Annual Report

Grant Award Numberl123456
....- - - - - - - - Report Prepared By
(Matt Hayden

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Part I - Quantitative Statistics" Part II - Narrative Reporting ..
Part I - Quantitative Statistics
Section A: Information and Referral

How many individuals received Information and Referral under the PABSS program
during the Report Period? (Do not count individuals more than once for this response.)

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Individuals Receiving I&R

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Part I - Quantitative Statistics ~ Part II - Narrative Reporting ~
Part I • Quantitative Statistics
Section A: Information and Referral

How many Information and Referral requests were made under the PABSS program
during the report period? (Include alll&R requests, even if more than one for some
individuals. This number should equal or exceed Section A. 1.)

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Information and Referral Requests

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Part I - Quantitative Statistics ~ Part II - Narrative Reporting ~
Part I - Quantitative Statistics
Section B: Individuals and Issue Area Service Requests/Workload Statistics

Individuals
a. How many individuals had open PABSS issue area service requests at the start of the report
period?
b. How many new PABSS individuals were added during the report period?
c. Total number of individuals with all issue area service requests that were closed during the

report period under the PABSS program

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Part! - Quantitative Statistics ~ Part II - Narrative Reporting ~
Part I - Quantitative Statistics
Section B: Individuals and Issue Area Service Requests/Workload Statistics

Services
a. Total PABSS issue area service requests open at the start of the report period.
b. Number of new PABSS issue area service requests added during the report period?

c. Total number of issue area service requests closed during the report period?

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Part I - Quantitative Statistics ~ Part II - Narrative Reporting ~
Part I - Quantitative Statistics
Section C: Individual Demographics

1. Please provide counts of individuals served by Gender:
a. Male
b. Female

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2. Please provide counts of individuals served by race (NOT
ETHNICITY):
a. American Indian or Alaska Native
b. Asian
d. Black or African American
e. Native Hawaiian or Other Pacific Islander
f. White
g. Unknown

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Part I - Quantitative Statistics ~ Part II - Narrative Reporting ~
Part I - Quantitative Statistics

Section C: Individual Demographics

3. Please provide counts of individuals receipted by Age Bracket:
a . 14 to 18
b. 19 to 21

c. 22 to 40
d. 41 to S9

e. 60 to 64

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IPart I - Quantitative Statistics

~ IPart II - Narrative

Reporting

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Part I . Quantitative Statistics
Section C: Individual Demographics

Please provide counts of individuals receipted by Beneficiary
Status.
a. SSI eligible
b. SSDI eligible
c. Dually eligible

________ _f:

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Part I - Quantitative Statistics ~ Part II - Narrative Reporting ~
Part I • Quantitative Statistics

Section C: Individual Demographics

Please provide counts of individuals receipted by Primary Disability:
a. Absence of extremities
b. Autism
c. Auto-immune (lupus, thyroid, ALS, etc.)
d. Blindness (both eyes)

e.Cancer

f. Cerebral palsy
g. Deaf-blind
h. Deafness

i, Diabetes

j. Digestive disorders (chronic pancreatitis, esophageal stricture, fistulae, chronic liver, etc.)
k. Epilepsy

I. Genitourinary conditions (kidney, prostate, etc.)
m. Hard of Hearing (not deaf)
n. Heart and other circulatory problems including cardiovascular
o. HIV/AIDS
p. Mental illness (diagnosis according to DSM-IV)
q. Mental retardation
r. Multiple sclerosis
s. Muscular dystrophy
t. Muscular / Skeletal impairment (arthritis, fibromyalgia, osteogenesis imperfecta, osteomyelitis,

etc.)
u. Neurological disorders (brain tumors, convulsive disorders, Parkinson, etc.)
v. other emotional/behavioral (Provide detail)

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w. Other intellectual such as ADD! ADHD (Provide detail)
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x. Physical/orthopedic including spinal cord injuries, paraplegia, quadriplegia, back problems, etc. 1,-·

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y. Respiratory disorders (emphysema, asthma, pulmonary hypertension, cystic fibrosis, etc.)

z, Specific learning disabilities (SLD)

aa. Speech impairment

bb, Spina bifida

cc. Substance abuse (alcohol or drugs)

dd. Tourette syndrome

ee. Traumatic brain injury (TBI)

ft. Visual Impairment (not blind)

99· Disability not known/Other than Above (Specify)

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Part I - Quantitative Statist ics ·~ Part II - Narrative Reporting ~
Part I . Quantitative Statistics

Section 0: Major Source of Concern

Please Provide counts of all PABSS issue are service request receipts by major source
of individual's concern for the current report period:
1. State Vocational Rehab Agency (public VR program)

2. Employment Networks (SSA contractor)

3. Agencies other than 1. or 2. above
4. Employment discrimination - hire, fire, promotion

5. Employment wages and benefits
6. Housing
7. Healthcare (not 5 above)

8. Insufficient/improper benefits planning
9. Transition services (Student beneficiary between 14-18 (or under age 22) engaging/needing a

transition plan)

10. Post Secondary accommodation
11. Transportation

12. Social Security benefits cessation based on SGA (including CDR's) - not Overpayment
13. Benefits Questions/Work Incentives - Not 12 or 14

14. Work Related Overpayment
15. other (IF SELECTED MUST SPECIFY)
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En te r Rep ort Dat a

Part I - Quantitative Statistics ~ Part II - Narrative Reporting ~
Part I • Quantitative Statistics
Section E: Closed Issue Area Service Requests

What was the problem/sub-problem area?
a. [AT] Assistive Technology
b. [Education] Transition school to work
c. [Employment] Discrimination in employment benefits
d. [Employment] Discrimination in hiring
e. [Employment] Unlawful termination / firing

f. [Employment] other employment discrimination
g. [Employment] Reasonable accommodation - not d, e, or f from above
h. [Employment] Service provider issues - not c-g above
i. [Employment] Wage and hour issues

j. [Financial Entitlements] SSI: Overpayments based on work issues

k, [Financial Entitlements] SSDI: Overpayments based on work issues

I. [Financial Entitlements] (other) - Specify

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m, [Healthcare] Medicaid only issues
n. [Healthcare] Medicare/Medicaid issues

o, [Healthcare] Medicare only issues
p. [Healthcare] Private Insurance Issues
q. [Housing] Accommodations in housing
r. [Housing] Subsidized housing/Section 8

s, [Housing] Rental termination ­ not q .
t. [Housing] Other - Specify
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u, [Childcare]

v. [Rehab services] Related to State VR
w. [Rehab Services] Related to Employment Network (EN)
x. [Rehab Services] Related to Agencies other than State VR or Employment Network (EN)

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y. [Post-Secondary Ed] Accessibility

z, [Post-Secondary Ed] Funding issues
aa. [Post-Secondary Ed] Grievance Against College - Not y or z above
bb. [Post-Secondary Ed] Other - Specify
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cc. [Services] Personal assistance - not Employment

dd. [Transportation]

ee. [Benefits Planning] referral! access to BPAO services

ft. [Other] (IF SELECTED MUST SPECIFY)

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Part I - Quantitative Statistics ~ Part II - Narrative Reporting ~
Part I - Quantitative Statistics
Section E: Closed Issue Area Service Requests

What was the reason for closing the individual's issue area service request?
a. Issue Resolved in Individual's Favor

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b. Issue Partially Resolved in Individual's Favor
c. Issue Lacked Legal Merit
d. Individual decided not to pursue resolution or Individual Withdrew Complaint (Not e-g below)
e. Other Representation Obtained (Individual found other representation)
f. Individual Not Responsive to Agency / Individual refused to cooperate with P&A
g. Services Not Needed Due to lost contact, Death, Relocation, etc.
h. Advocacy efforts/appeals were unsuccessful (Issue not resolved in Individual's Favor)
i. Other (IF SELECTED MUST SPECIFY)
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IPart I - Quantitative Statistics .. IPart II - Narrative Reporting ..

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Part I • Quantitative Statistics
Section E: Closed Issue Area Service Requests

What was the highest intervention strategy used?
a. Short Term/Technical assistance
b. Informal Resolution
c. Investigation/ Monitoring
d. Negotiation
e. Mediation / Alternative Dispute Resolution
f. Administrative Remedies
g. Legal remedy / Litigation
h. Class Action Suits
i. Systemic / Policy activities

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Part I - Quantitative Statistics. Part II - Narrative Reporting.
Part I • Quantitative Statistics

Section E: Closed Issue Area Service Requests

As a result of P&A intervention, the following major outcome was achieved:
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a. Individual gained / maintained access to services including those of VR, EN or other agency
b. Individual obtained employment
c. Individual regained employment
d. Individual maintained employment
e. Individual advanced in employment
f. Individual's employment opportunities increased
g. Individual obtained an increase in salary and/or benefits
h. Validity of discrimination complaint was upheld
i, Overpayment situation addressed (it doesn't matter if it was waived or the efforts weren't

successful)

j. Individual acquired knowledge concerning his/her rights

k, Outcome information is not available
I. Other outcome (IF SELECTED MUST SPECIFY)
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!part I - Quantitative Statistics

~ Ipart II - Narrative Reporting ~ I

Part II - Narrative Reporting
Section A: Description of Progress and Status Update

Please provide a brief overview of overall project status, staff changes, staff training or
other major developments with regard to the PABSS program. This could include
information about boards and committees where decisions are made concerning
disability service delivery and local policy.
Progress and Status Update

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Ipart I - Quantitative Statistics

~ Ipart II - Narrative Reporting ~ I

Part II - Narrative Reporting
Section B: Detail of Actions Taken on the Project

Issue Area Service Requests Summaries: [Please provide summaries of three Issues!
Service Requests undertaken as part of the PABSS project. Indicate clearly the issue or
problem, the PABSS intervention, and the results if known]
Issue Area Service Requests Summaries

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Ipart I - Quant itative Statistics

~ IPart II - Narrative Reporting ~ I

Part II - Narrative Reporting

.
Section B : Detail of Actions Taken on the Project

Outreach Statistics:

B

Total Number of Outreach/Presentations
Total Number of Persons Reached by Outreach I Presentation Events

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Part I - Quantitative Statistics ~ Part II - Narrative Reporting ~
Part II - Narrative Reporting
Section B: Detail of Actions Taken on the Project

Other Information Dissemination Activities: (Number of Instances)
1. Radio/TV appearances by PABSSstaff
2. Newspaper/Magazine/Journal articles prepared by staff
3. PSAs/videos/films aired by the Agency

4. Reports disseminated
5. Publications/ Booklets/ Brochures disseminated
6. Number of Website hits

7. Other media activities (IF SELECTED MUST SPECIFY)

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[Part I - Quantitative Statistics

~ Ipart II - Narrative Reporting ~ I

Part II - Narrati ve Reporting
Section B: Detail of Actions Taken on the Project

Outreach Narrative: [Describe the agency's outreach efforts. Describe the trainings
presented by the staff including information about the topics covered, the purpose of
the training, and a description of the attendees. Describe media events, informational
materials developed or other activities undertaken as part of the PAB55 project.]
Outreach Narrative

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Ipart I - Quantitative Statistics

~ Ipart II - Narrative Reporting ~ I

Part II - Na rrative Reporting
Section C: Problems Encountered and Steps Taken to Resolve Problems

Problems encountered and steps taken to resolve problems: [Please provide detail
information about problems encountered in implementing or administering the PABSS
program and actions you have taken to resolve the problems you encountered.]
Problems encountered and steps taken to resolve problems

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Ipart I

~>Quantitative Statistics ~ !part II - Narrative

Reporting

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Part II - Narrative Reporting
Section D: Planned Future Activities

Planned activities: [Please provide activities you plan to undertake to further the
objectives of the PABSS project.]
Planned activities

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Ipart I - Quantitative Statistics

~ Ipart II - Narrative Reporting ~ I

Part II - Narrative Reporting
Section E: Diversification Activities

Diversification activities: [Please provide a description of activities undertaken to
address the needs of individuals with disabilities from diverse ethnic and racial
communities.]
Diversification activities

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