Protection and Advocacy for Beneficiaries of Social Security (PABSS)--Grant Awardees

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We use the information to manage the Protection and Advocacy for Beneficiaries of Social
Security programs, with particular emphasis on contract administration, budgeting, and training.

See Revised Privacy Act Statement Attached

There are certain situations authorized by Federal law in which SSA may release the information
you give us through this Project. For example, we release the information to a congressional
office in response to an inquiry that office may make at your request.
Explanations about these and other reasons why information you provide us may be used or
given out are available in Social Security Offices. If you want to learn more about this, contact
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Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to
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Part I - Quantitative Statistics
Section A: Information and Referral

1. 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.)

Individuals Receiving I&R
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Section A: Information and Referral

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

Information and Referral Requests
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Section B: Individuals and Issue Area Service Requests/Workload Statistics

1. 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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Section B: Individuals and Issue Area Service Requests/Workload Statistics

2. 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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Section C: Individual Demographics

1. Please provide counts of individuals served by Gender:  

a. Male

b. Female
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Section C: Individual Demographics

2. Please provide counts of individuals served by Ethnicity:  

a. Alaskan Native

b. American Indian
c. Arab American (Middle Eastern)
d. Asian
e. Black (Not Hispanic/Latino Origin)

f. Hispanic/Latino
g. Multi Racial / Multi Cultural
h. Pacific Islander
i. White (Not Hispanic/Latino Origin)
j. Unknown
Other (IF SELECTED MUST SPECIFY)

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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 59
e. 60 to 64
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Section C: Individual Demographics

4. Please provide counts of individuals receipted by Beneficiary Status.  
a. SSI eligible

b. SSDI eligible

c. Dually eligible
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Section C: Individual Demographics

5. 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
l. 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.
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)
ff. Visual Impairment (not blind)
gg. Disability not known/Other than Above (Specify)

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Section D: 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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Section E: Closed Issue Area Service Requests

1. 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
l. [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)
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
ff. [Other] (IF SELECTED MUST SPECIFY)

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Section E: Closed Issue Area Service Requests

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

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 eg 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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Section E: Closed Issue Area Service Requests

3. 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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Section E: Closed Issue Area Service Requests

4. As a result of P&A intervention, the following major outcome was
achieved:
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
l. Other outcome (IF SELECTED MUST SPECIFY)

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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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Section B: Detail of Actions Taken on the Project

1. 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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Section B: Detail of Actions Taken on the Project

2. Outreach Statistics:  

Total Number of Outreach/Presentations
Total Number of Persons Reached by Outreach/ Presentation Events
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Section B: Detail of Actions Taken on the Project

3. Other Information Dissemination Activities: (Number of Instances)  
1. Radio/TV appearances by PABSS staff

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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Section B: Detail of Actions Taken on the Project

4. 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 PABSS project.]

Outreach Narrative

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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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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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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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Name
Reporting Period

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FY 2012 Annual Report

Grant Award
Number

123456789

Report Prepared By

Matt Hayden
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OMB Number: 0960-0768
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PROTECTION and ADVOCACY for BENEFICIARIES of SOCIAL SECURITY (PABSS)
SEMI-ANNUAL PROGRAM PERFORMANCE REPORT

REPORTING PERIOD:

From 10/1/2011 To 9/30/2012

GRANT AWARD NUMBER: 123456789
STATE: DC
AGENCY NAME: NDRN
AGENCY ADDRESS: 900 2ND ST NE
STE 211
Washington, DC 20002
REPORT PREPARED BY: Matt Hayden
TELEPHONE NUMBER: 2024089514
FAX NUMBER: 2024089520
E-MAIL ADDRESS: matt.hayden@ndrn.org
DATE SUBMITTED: 6/24/2013

1

OMB Number: 0960-0768
Expiration Date: 2/28/2014

Part I - Quantitative Statistics
Section A: Information and Referral
1. 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.)
Individuals Receiving I&R

10

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

12

Section B: Individuals and Issue Area Service Requests/Workload Statistics
1. 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?
Total Individuals Served
c. Total number of individuals with all issue area service requests that were
closed during the report period under the PABSS program
Total Individuals Still Being Served

5
5
10
5
5

2. 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?
Total Services
c. Total number of issue area service requests closed during the report
period?
Total Services Still Open

5
5
10
5
5

Section C: Individual Demographics
1. Please provide counts of individuals served by Gender:
a. Male
b. Female
Total individuals receipted

2
3
5

2

OMB Number: 0960-0768
Expiration Date: 2/28/2014

2. Please provide counts of individuals served by Ethnicity:
a. Alaskan Native
b. American Indian
c. Arab American (Middle Eastern)
d. Asian
e. Black (Not Hispanic/Latino Origin)
f. Hispanic/Latino
g. Multi Racial / Multi Cultural
h. Pacific Islander
i. White (Not Hispanic/Latino Origin)
j. Unknown
Other (IF SELECTED MUST SPECIFY)
Other Example
Total individuals receipted

0
0
0
1
1
1
0
0
1
0
1
1
5

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 59
e. 60 to 64
Total individuals receipted

1
1
1
1
1
5

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

1
2
2
5

5. 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

0
0
0
1
0
0
0

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OMB Number: 0960-0768
Expiration Date: 2/28/2014

h. Deafness
i. Diabetes
j. Digestive disorders (chronic pancreatitis, esophageal stricture, fistulae,
chronic liver, etc.)
k. Epilepsy
l. 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)
Sample Other Disability
w. Other intellectual such as ADD/ADHD (Provide detail)
x. Physical / orthopedic including spinal cord injuries, paraplegia,
quadriplegia, back problems, etc.
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)
ff. Visual Impairment (not blind)
gg. Disability not known/Other than Above (Specify)
Total individuals receipted

1
0
0
1
0
0
0
0
1
0
0
0
0
0
1
1
0
0
0
0
0
0
0
0
0
0
0
5

Section D: 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)

4

0

OMB Number: 0960-0768
Expiration Date: 2/28/2014

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)
Sample Other Problem Area
Total issues/service requests of individuals receipted.

0
0
0
0
0
1
1
1
0
1
0
0
0
1
1
5

Section E: Closed Issue Area Service Requests
1. 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
l. [Financial Entitlements] (other) – Specify
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
5

0
0
1
0
0
0
0
0
0
0
0
0
1
0
0
0
1

OMB Number: 0960-0768
Expiration Date: 2/28/2014

r. [Housing] Subsidized housing/Section 8
s. [Housing] Rental termination – not q .
t. [Housing] Other – Specify
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)
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
cc. [Services] Personal assistance – not Employment
dd. [Transportation]
ee. [Benefits Planning] referral / access to BPAO services
ff. [Other] (IF SELECTED MUST SPECIFY)
Sample Other Problem
Total closed issue area service requests.

0
0
0
0
0
0
0
0
1
0
0
0
0
0
1
1
5

2. What was the reason for closing the individual's issue area service request?
a. Issue Resolved in Individual’s Favor
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)
Total closed issue area service requests.

5
0
0
0
0
0
0
0
0
5

3. What was the highest intervention strategy used?
a. Short Term/Technical assistance
b. Informal Resolution
c. Investigation/Monitoring
d. Negotiation

1
0
1
1
6

OMB Number: 0960-0768
Expiration Date: 2/28/2014

e. Mediation / Alternative Dispute Resolution
f. Administrative Remedies
g. Legal remedy / Litigation
h. Class Action Suits
i. Systemic / Policy activities
Total closed issue area service requests.

1
0
1
0
0
5

4. As a result of P&A intervention, the following major outcome was achieved:
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
l. Other outcome (IF SELECTED MUST SPECIFY)
Total outcomes of closed issue area service requests.

1
1
1
1
1
0
0
0
0
0
0
0
5

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.
Sample Narrative Response
Section B: Detail of Actions Taken on the Project
1. 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]
Sample Narrative Response

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OMB Number: 0960-0768
Expiration Date: 2/28/2014

2. Outreach Statistics:
Total Number of Outreach/Presentations
Total Number of Persons Reached by Outreach/ Presentation Events

2
30

3. Other Information Dissemination Activities: (Number of Instances)
1. Radio/TV appearances by PABSS staff
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)

5
2
1
5
2
25000
0

4. 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 PABSS project.]
Sample Narrative Response
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.]
Sample Narrative Response
Section D: Planned Future Activities
Planned activities: [Please provide activities you plan to undertake to further the
objectives of the PABSS project.]
Sample Narrative Response
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.]
Sample Narrative Response

8

SSA will insert the following revised Privacy Act Statement into the screens upon OMB’s
approval:
Collection and Use of Personal Information
Section 1150 of the Social Security Act, as amended, allows us to collect the requested
information. We will use the information you provide to ensure beneficiaries receive appropriate
services. Providing us this information is voluntary. However, not providing this information
may result in some loss of the beneficiary’s service. Additional information about this and other
Social Security programs is available on our Internet website, www.socialsecurity.gov, or at your
local Social Security office.