Child-Care Dropout Questionnaire

MCS 005.027 Disability Information (DISB)
A.
INTRODUCTION
This section explains the procedures for Disability Information (DISB). DISB collects NH disability claim
information.

B.

DISB SCREEN

The DISB screen collects information about the NH's

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disabling condition
earnings after onset
blind status
child care years
permission to release medical information
one-half support of parent
status of filing for other benefits

The DISB screen does not replace forms

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SSA-821-F4
SSA-827
SSA-3368-F8
SSA-3369-F6

Continue to complete these forms to record NH information required by POMS.

C.
FACSIMILE: DISB - DISABILITY INFORMATION
TRANSFER TO: XXXX
DISABILITY INFORMATION
DISB
NH SSSSSSSSS SSSSS SSSSSSSSSS
CL SSSSSSSSS SSSSS SSSSSSSSSS
[1-M]
DISABLING
CONDITION:XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXXXXXXXX
[2-M]
[3-C]
STILL DISABLED (Y/N): X IF NO, DATE DISABILITY ENDED (MMYY): 9999
[4-M]
[5-M]
BLIND (Y/N): X
FREEZE (Y/N): X
[6-M]
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION (Y/N): X
[7-M]
FILED OR INTEND TO FILE FOR: 9 9 9 1. VA 2. WC/Public disability Benefits
3. NOT FILING
[8-M]
[9-C]
DISABILITY WORK RELATED (Y/N):X REASON NOT FILING:
XXXXXXXXXXXXXXXXXXXXXXXXXX
[10-M]
[11-C]

MONEY FROM EMPLOYER AFTER ONSET DATE (Y/N): X
AMOUNT: 99999999
[12-C]
TYPE: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
[13-M]
[14-C]
ADDITIONAL MONEY EXPECTED FROM EMPLOYER (Y/N): X AMOUNT: 99999999
[15-C]
TYPE: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
[16-M]
[17-C]
NUMBER OF CHILD CARE YRS: 9 ACTUAL CHILD CARE YRS: 99 99 99 99 99 99
IF PARENT RECEIVED 1/2 SUPPORT AT TIME OF ONSET OF DISABILITY COMPLETE
[18-C]
NAME: XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX
[19-C]
ADDRESS:
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXX
[20-C]
NAME: XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX
[21-C]
ADDRESS:
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
XXXXXX
FILED OR INTEND TO FILE FOR OTHER DISABILITY (Y/N): S
SPECIFY:SSSSSSSSSSSSSS
D.

HOW YOU GOT HERE

This screen is automatically displayed for disability claims when the CL is the NH.
Note: The questions on this screen never pertain to a non-claimant or a CL who is not a NH.

E.

PROPAGATED FIELDS

Data may be propagated to the Disabling Condition field from the Integrated Client Data Base. If
propagated, data may be over keyed.
MCS may display the following additional fields on the bottom of Disability Information (DISB) when the
NH filed a claim in an earlier phase of MCS. These fields are for informational purposes only.

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F.

FILED OR INTEND TO FILE FOR OTHER DISABILITY (Y/N)
SPECIFY
FIELD DESCRIPTIONS
[1-M]
DISABLING CONDITION: XX[UP TO 57 CHARACTERS]XX
Enter a description of the illness or injury if known.
Enter a "?" if unknown.
[2-M]
STILL DISABLED (Y/N): X
Enter "Y" if the NH is still disabled.

Enter "N" if the NH is not still disabled.
Enter "?" if unknown.
[3-C]
IF NO, DATE DISABILITY ENDED (MMYY): 9999
If the NH is no longer disabled, enter the exact date disability ended. Use MMYY format. If
only the year disability ended is known, enter in 00YY format.
If unknown, enter "?".
Reminder:
Entries of "?" or zeros in the month portion of this field must be resolved before
final adjudication.
[4-M]
BLIND (Y/N): X
Enter "Y" or "N" to indicate whether the NH alleges blindness.
[5-M]
FREEZE (Y/N): X
Enter "Y" or "N" to indicate whether the NH is filing for a disability freeze.
[6-M]
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
(Y/N): X
Enter "Y" or "N" to indicate whether the NH agrees to the release of his/her medical information
to SSA or the State DDS.
[7-M]
FILED OR INTEND TO FILE FOR: 9 9 9
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Enter “1” if the NH filed or intends to file for VA benefits.
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Enter “2” if the NH has filed or intends to file for
 WC (including Black Lung Part C), or PDB that offsets or is offset by
SSA
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Enter “1” and “2” if the NH filed or intends to file for both, VA and WC
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Enter “3” if the NH has not filed or does not intend to file for any of the
above.
[8-M]
DISABILITY WORK RELATED (Y/N): X
Enter "Y" or "N" to indicate whether the NH's disability is work-related.
[9-C]
REASON NOT FILING: XX[UP TO 26 CHARACTERS]XX
Explain why the NH is not filing for WC if
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the NH's disability is work-related, and
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you did not enter "2" (WC) in [7-M] FILED OR INTEND TO FILE FOR
[10-M]
MONEY FROM EMPLOYER AFTER ONSET DATE (Y/N): X
Enter "Y" or "N" to indicate whether the NH received money from his/her employer after the
alleged onset date.
[11-C]
AMOUNT: 99999999
If the NH received money from his/her employer after the alleged onset date, enter the amount of
money received. Use amount format.
[12-C]
TYPE: XX[UP TO 41 CHARACTERS]XX
If the NH received money from his/her employer after the alleged onset date, enter the kind of
payment received, i.e., vacation pay or sick pay.
[13-M]
ADDITIONAL MONEY EXPECTED FROM EMPLOYER (Y/N): X

Enter "Y" or "N" to indicate whether the NH expects to receive more money from his/her
employer.
[14-C]
AMOUNT: 99999999
If the NH expects to receive more money from his/her employer, enter the amount of additional
money he/she expects to receive. Use amount format.
[15-C]
TYPE: XX[UP TO 41 CHARACTERS]XX
If the NH expects to receive more money from his/her employer, enter the kind of payment the
NH expects to receive, i.e., vacation pay or sick pay.
[16-M]
NUMBER OF CHILD CARE YEARS: 9
Enter the number of years the NH, whose child under age 3 lived with him/her, had no covered
or non-covered earnings.
Note: Only valid entries are 0-6
[17-C]
ACTUAL CHILD CARE YRS: 99 99 99 99 99 99
Enter the actual years. Use YY format.
Note: Valid entries are numerics greater than 50 up to and including the current year (e.g.,
[19]99 [20]01).
[18-C]
NAME: XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX
If the NH had a parent(s) who received 1/2 support from him/her when the disability began, enter
the parent's name.
If not, press ENTER and STOP.
[19-C]
ADDRESS: XX[UP TO 60 CHARACTERS]XX
Enter the parent's address.
[20-C]
NAME: XXXXXXXXXX X XXXXXXXXXXXXXXXXXXX
If the NH had another parent(s) who received 1/2 support from him/her when the disability
began, enter the parent's name.
If not, press ENTER and STOP.
[21-C]
ADDRESS: XX[UP TO 60 CHARACTERS]XX
Enter the other parent's address. Press ENTER.