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pdfForm Approved
OMB No. 0960-0282
SOCIAL SECURITY ADMINISTRATION
DEVELOPMENT OF PARTICIPATION IN A
VOCATIONAL REHABILITATION OR SIMILAR PROGRAM
Part I - To be completed by the State DDS or SSA Field Office
Section A - Beneficiary Information
1. Beneficiary's Name (Last, First, MI)
2. Beneficiary’s Date
of Birth
3. Type of claim
DI
4. Beneficiary’s Social Security Number
-
SSI
Concurrent
5. Wage Earner’s Social Security Number
(if different from Beneficiary’s)
-
-
-
6. Beneficiary's address (Number & Street, City, State, Zip Code)
7. Beneficiary reports that he/she is receiving vocational rehabilitation services, employment
services, or other support services from (check one):
An Employment Network under an Individual Work Plan (IWP)
A State Vocational Rehabilitation agency under an Individualized Plan for
Employment (IPE)
Other provider of services under an individualized, written employment plan
similar to an IPE
An educational institution under an Individualized Education Program (IEP)
to beneficiary age 18 through 21 years
8. Name, address and telephone number of a contact person in the organization/agency
identified above:
Section B - DDS/FO Information
9. Signature of Person Who Completed Part I:
10. Title:
11. Date:
12. DDS or FO Code:
13. Telephone number
(include area code):
Form SSA-4290-F5 (12-2010) ef (12-2010)
Page 1
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Part II - To be completed by provider/coordinator of services as shown below
Section A - Employment Network
Section B - State Vocational Rehabilitation Agency
Section C - Other provider of vocational rehabilitation services, employment services, or other support
services (If not an agency of the Federal Government or not an educational institution administering
a student plan in accordance with the Individuals with Disabilities Act, attach a copy of qualifications to
provide vocational rehabilitation services in State services are provided, i.e., license, certification,
accreditation, or registration.)
Section D - Educational Institution under IDEA
Section A -To be completed by Employment Network
1. Is the beneficiary receiving vocational rehabilitation services, employment services, or
other support services under an Individual Work Plan (IWP)?
Yes
No
If no, sign below and return this document to requester.
If yes, give the date the beneficiary and EN signed the IWP and proceed to next question.
Date IWP signed:
No
2. Is the beneficiary taking part in the activities and services outlined in the IWP? Yes
If no, sign below and return this document to requester. If yes, proceed to next question.
3. What is the employment goal?
4. Describe the education, work skills, and/or work experience that the beneficiary will
acquire by completing the IWP or by continuing to participate in the IWP for a specified
period of time.
5. When is the beneficiary expected to complete the activities and services outlined in the
IWP? (Month and Year) :
Signature:
Title:
Date:
Telephone No.
(include area code):
(
)
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Section B - To be completed by the State Vocational Rehabilitation (VR)
1. Is the beneficiary receiving VR services, employment services, or other support under an
Yes
No
Individualized Plan for Employment (IPE)?
If no, sign below and return this document to requester.
If yes, give the date the beneficiary and the VR Counselor signed the IPE and proceed to
next question. Date IPE signed:
Yes
No
2. Is the beneficiary taking part in the activities and services outlined in the IPE?
If no, sign below and return this document to requester. If yes, proceed to next question.
3. What is the employment goal?
Form SSA-4290-F5 (12-2010) ef (12-2010)
Page 2
4. Describe the education, work skills, and/or work experience that the beneficiary will
acquire by completing the IPE or by continuing to participate in the IPE for a specified
period of time.
5. When is the beneficiary expected to complete the activities and services outlined in the
IPE? (Month and Year) :
Signature:
Date:
Title:
Telephone No.
(include area code):
(
)
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Section C - To be completed by Another Provider of Rehabilitation Services
If you are not an agency of the Federal Government or not an educational institution under the Individuals with
Disabilities Act (IDEA), attach a copy of your qualifications to provide vocational rehabilitation services,
employment services or other support services in the State in which you are providing the services (i.e., license,
certification, accreditation, or registration).
1. Is the beneficiary receiving vocational rehabilitation services, employment services or other
support services under an individualized, written employment plan similar to an Individualized
Plan for Employment used by State Vocational Rehabilitation Agencies?
Yes
No
If no, sign below and return this document to requester.
If yes, give the date the provider and the beneficiary signed the plan and proceed to next
question. Date employment plan signed:
2. Is the beneficiary taking part in the activities and services outlined in the employment plan?
Yes
No
If no, sign below and return this document to requester. If yes, please proceed to next
question.
3. What is the employment goal?
4. Describe the education, work skills, and/or work experience that the beneficiary will
acquire by completing the employment plan or by continuing to participate in the
employment plan for a specified period of time.
5. When is the beneficiary expected to complete the activities and services outlined in the
employment plan? (Month and Year) :
Signature:
Title:
Form SSA-4290-F5 (12-2010) ef (12-2010)
Date:
Telephone No.
(include area code):
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Section D - To be completed by an educational institution under the IDEA
1. Is the beneficiary’s educational program provided under an Individualized Education Plan
(IEP)?
Yes
No
If no, complete Section C above.
If yes, give the date the educational institution implemented the IEP and proceed to next
question.
Date initial IEP implementation:
Date current IEP implementation(if applicable):
2. Is the beneficiary taking part in the activities and services outlined in the IEP?
Yes
No
If no, sign below and return this document to requester. If yes, please proceed to
next question.
3. When is the beneficiary expected to complete the IEP? (Month and Year):
Signature:
Title:
Form SSA-4290-F5 (12-2010) ef (12-2010)
Date:
Telephone No.
(include area code):
Page 4
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Privacy Act Statement
Collection and Use of Personal Information
Development of Participation in a Vocational Rehabilitation or Similar Program, Form SSA-4290-F4.
Public Law 106-170 and section 234 of the Social Security Act, as amended (42 U.S.C. 434) authorize us
to collect this information. The information you provide will allow you or a beneficiary participating in
the Ticket-to-Work and Self-Sufficiency Program to have more choices in receiving employment
services. The information you provide on this form is voluntary. However, without this information,
employment services, vocational rehabilitation services or other support services necessary for a
participant to achieve a vocational goal may not be available to him or her.
We rarely use the information you provide on this form for any purpose other than for the reasons
explained above. However, we may use it for the administration and integrity of Social Security
programs. We may also disclose information to another person or to another agency in accordance with
approved routine uses, which include but are not limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing rights to Social
Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social Security records
(e.g., to the Government Accountability Office, General Services Administration, National
Archives Records Administration, and the Department of Veterans Affairs);
3. To make determinations for eligibility in similar health and income maintenance programs at the
Federal, State, and local level; and
4. To facilitate statistical research, audit, or investigative activities necessary to assure the integrity
of Social Security programs.
We may also use the information you provide in computer matching programs. Matching programs
compare our records with records kept by other Federal, State, or local government agencies.
Information from these matching programs can be used to establish or verify a person's eligibility for
Federally-funded or administered benefit programs and for repayment of payments or delinquent debts
under these programs.
A complete list of routine uses for this information is available in our Systems of Records Notice
entitled, Completed Determination Record--Continuing Disability Determinations, 60-0050; Claims
Folder System, 60-0089; Vocational Rehabilitation Reimbursement Case Processing System, 60-0221;
Electronic Disability (eDib) Claim File, 60-0320. These notices, additional information regarding this
form, and information regarding our programs and systems, are available on-line at
www.socialsecurity.gov or at any Social Security office.
Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C.
§ 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer
these questions unless we display a valid Office of Management and Budget control number. The OMB
control number for this form is 0960-0282. We estimate that it will take about 15 minutes to read the
instructions, gather the facts, and answer the questions. You may send comments on our time estimate
above to: SSA, 6401 Security Boulevard, Baltimore, MD 21235. Send only comments on our time
estimate to this address, not the completed form.
Form SSA-4290-F5 (12-2010) ef (12-2010)
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File Type | application/pdf |
File Title | Development of Participation in a Vocational Rehabilitation or Similar Program |
Subject | Development of Participation in a Vocational Rehabilitation or Similar Program |
Author | SSA |
File Modified | 2015-01-07 |
File Created | 2015-01-07 |