Attachment A-16. Exiter and Possible Exiter Survey Letter and Consent

Attachment 17. Invitation and Consent to Participate in Survey with Exiters and Possible Exiters

[Date]
Dear [Respondent Name]:
You are invited to participate in the Beyond Benefits Study, a national study paid for by the Social Security
Administration (SSA). The study will collect information about the service, medical and employment needs of
working-age adults who get disability payments now or stopped receiving disability payments due to medical
improvement. By participating in this study, you will help SSA understand the policies and programs that may help
people who stop receiving disability payments.
SSA hired Westat, a national research company, to conduct the study. Westat is inviting you to participate in an
online survey that will take 45 minutes or less. Survey questions are about your health, employment situation, and
experience with using different services in the community. Enclosed is 2 dollars to thank you for your participation.
Once you complete the survey, we will send you a $40 Visa gift card. You can choose not to answer one or more
of the questions and you can stop the survey at any time without penalty.
Participation in this study is voluntary. Participation in this study will not affect your eligibility for benefits now or
in the future. SSA and Westat will protect all information that could identify you. As described in the Study
Consent, we will safeguard the information you provide and will use it for limited purposes, consistent with
applicable Federal law, regulations, and directives. Your name or other identifying information will not be included
in any published reports.
If you would like to participate, visit Westat’s website link below and use the PIN to log in.

Website: https://xxxx.org
PIN: XXXXXX

You can also scan the QR code below using the camera on a smart device to get to the website.

For questions about the study, call the Study Help Desk toll-free number at 1-855-516-3665. For questions about
your rights and welfare as a research participant, call the Westat Human Subjects Protections office at 1-888-9207631. Leave a message only with your first name, the name of the research study (Beyond Benefits Study) and a
phone number beginning with the area code.
I hope you will agree to participate in this very important survey.
Sincerely,
[INSERT SIGNATURE OF SSA SIGNATORY]

Attachment 17. Invitation and Consent to Participate in Survey with Exiters and Possible Exiters

BEYOND BENEFITS STUDY
SOCIAL SECURITY ADMINISTRATION

Consent to Participate in the Beyond Benefits Study (BBS)
What is the purpose of the study?
The Social Security Administration (SSA) is conducting the Beyond Benefits Study to collect information about
the service, medical and employment needs of working-age adults who currently receive disability-related
payments or stopped receiving disability-related payments from SSA due to medical improvement. SSA hired
Westat, a national research company, to carry out the study. The purpose of the research is to help SSA identify
ways to help people who may be leaving or have left disability programs.
What are we asking of you?
You are agreeing to participate in a survey that will take 45 minutes, or less, to complete. You will tell us about
your health and health history, health needs, work history, need for support, and employment goals. You may
skip any question that you prefer not to answer. If you decide not to volunteer, it will not affect any decision
SSA makes about your current, or future, disability benefits or payments. We will ask for your permission to
send text message reminders about the study. Depending on your texting plan, you may incur a charge for these
texts. If you agree, you will be able to opt-out of receiving these reminders at any time by replying “STOP” to
the text or by calling the Help Desk at Westat. 1
0F

What benefits will you get for participating?
You will not benefit directly by completing the survey. But you may help SSA improve policies and programs
that help people who leave disability programs when their condition medically improves. After you complete the
survey, we will mail you a $40 Visa gift card.
Persons eligible for participation in the study.
You were randomly selected to participate in the study from a list of current and former Social Security
Disability Insurance (SSDI) and Supplemental Security Income (SSI) program beneficiaries. Everyone on the list
had the same chance of being selected.
What is the study doing to minimize your risks?
There is a small risk of disclosure of your personal information. To reduce this risk, we will separate any
information that identifies you from the rest of your data and store those identifiers separately. Although it is
not likely, it is possible that some of the survey questions may make you feel anxious or frustrated. If this
happens, you can skip the questions or stop participating. If you get upset, you may request a referral to crisis
management services. It is your decision to use this referral. However, if you tell us that you are planning to hurt
yourself or someone else, the study is required by the law to notify appropriate authorities.
How will we protect your privacy?
We will follow Federal law and regulations to protect your privacy. SSA and Westat will protect your personal
information collected during the study. The information we collect is used for research in limited ways,
consistent with applicable Federal law, regulations, and directives. For example, we use your answers to the
survey questions, combined with answers to the questions from other people, to help SSA understand
applicants’ experiences. Your name or other identifying information will not be included in any published
reports.
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Each text message sent by the study will also include these opt-out instructions.

Attachment 17. Invitation and Consent to Participate in Survey with Exiters and Possible Exiters

Privacy Act Statement Collection and Use of Personal Information. Section 1110(a) of the Social Security
Act, as amended, allows us to collect this information, which we will use to help the Social Security
Administration (SSA) identify ways to help people who may be leaving or have left disability programs.
Providing us this information is voluntary; not providing all or part of the information will not affect your SSA
benefit. As law permits, we may use and share the information you submit, including with other Federal
agencies, contractors, student volunteers, and others, as outlined in the routine uses within System of Records
Notice (SORN) 60-0218, available at www.ssa.gov/privacy. The information you submit may also be used in
computer matching programs to establish or verify eligibility for Federal benefit programs and to recoup debts
under these programs.
Who you can contact if you have questions?
For questions about the study, call the study’s toll-free number at 1-855-516-3665. For questions about your
rights and welfare as a research participant, call the Westat Human Subjects Protections office at 1-888-9207631. Leave a message only with your first name, the name of the research study (Beyond Benefits Study) and a
phone number beginning with the area code, please do not leave any other personal information in the message.