TTW Provider Survey

Attachment A1g: Survey Instrument for the Ticket Act Provider Survey of ENs/State VR Agencies

Ticket to Work (TTW) Evaluation:

Ticket Act Provider Survey of Employment Networks (ENs) and State Vocational Rehabilitation (VR) Agencies

Dated: 08.06.25

Survey Goal: The purpose of the Ticket Act Provider Survey of Employment Networks (ENs) and State Vocational Rehabilitation (VR) Agencies is to collect data from organizations delivering TTW services to gain insights about their experiences implementing the program, the extent to which they believe it meets Ticketholders’ needs, and features that work well and areas for improvement. The survey will fill information gaps with program information beyond what is available in administrative records.

Sections of the survey instrument:

Section	Descriptor
A	Consent and organization characteristics
B	Beneficiary intake
C	Providing services to Ticketholders
D	Influence of Services on Ticketholders
E	Partnership Plus
F	Closing

Operational assumptions: 

• Mode and language of administration. The survey will be web only, designed in a self-administered format. The survey is designed for administration in English only.  

• Survey population and target respondent. This survey focuses on EN/VR at an organizational level. It will be sent to a single point of contact at each organization – the “program contact” in the SSA record. There will be no sampling - we will invite all current EN and all VR providers in the United States to take part. (As of August 2024, there are 367 EN, 74 VR, total of 441 providers. This number may change prior to implementation in 2026.)

• Duration. It takes 33 minutes, on average, to complete this questionnaire, inclusive of time spent looking up information or consulting with other staff at the organization.  

• Programming. The instrument will be programmed and fielded using Confirmit. In these specifications, each item is accompanied by the documentation such as the source of the item, the “universe” (who the item is asked of), and programming guidance for text fills and other logic. All respondents route to the next item shown unless otherwise specified in the skip logic. Respondents will be able to break off (i.e., end survey without completing it) and re-enter using their personalized link. The survey will resume where they left off.  

• Voluntary participation. The survey is voluntary. After providing consent, none of the items are required; respondents may skip any item they do not wish to answer.

• Incentives. Mathematica will provide survey respondents a $40 post-payment for completing the survey.

• Critical items. Items deemed critical to the planned analysis will include “soft checks” or a prompt provided in a pop-up screen that confirms the response (if out of range) or provides information on how the data will be used – to help motivate response when the item is left blank. Critical items in this instrument are: A2 (business model); A3 (VR Payment structure), A20 (Partnership plus participation); A21 (marketing program participation), C3 (offering online services).

• Privacy policy. Programmer: please place the following link on the bottom of each page of the instrument. [https://www.ssa.gov/agency/privacy.html].

The questions the respondent sees in the survey will depend on the values the following variables take. These values will vary by provider organization. For DIRA testing Mathematica has assigned values for these variables.

Variable Name	Description	Format
SSA Provider ID (PID/DUNS) number	Unique identifier for each organization assigned by SSA	Numeric
MPRID	8-digit unique identifier assigned by Mathematica	Numeric
Org Name	Name of the sampled organization	Alpha
Org_Type	Employment Network (1) Vocational Rehabilitation Provider (2)	Numeric
EN_Type	EN that is a VR agency (1) EN that is not a VR agency (2) VR agency that is not an EN (3)	Numeric

WEB SURVEY LANDING PAGE

OMB No.: XXX

Expiration Date: X/XX/XX

Welcome to the Ticket Act Provider Survey of Employment Networks (ENs)

and State Vocational Rehabilitation (VR) Agencies!

This survey should be completed by someone at your organization who can answer questions about the organization overall and about the employment services delivered to Ticketholders. A list of the topics is provided in the document below, for reference.

Click “begin” to start the survey.

If you have questions, or if this survey should be sent to someone else at your organization, please contact Mathematica at xxx-xxx-xxxx.

Privacy Act Statement

Collection and Use of Personal Information

Section 1110 of the Social Security Act, as amended, allows us to collect this information, which we will use to conduct research and improve SSA programs. Providing us this information is voluntary; not providing all or part of the information will not affect you. As law permits, we may use and share the information you submit, including with other Federal agencies, contractors, and others, as outlined in the routine uses within System of Records Notice 60-0218, available at www.ssa.gov/privacy. The information you submit may also be used in computer matching programs for Federal benefits eligibility and to recoup debts under these programs.

BEGIN

PROGRAMMER: INSERT PDF ON THIS PAGE RESPONDENTS CAN OPEN/DOWNLOAD.

Section A. Consent and organization characteristics

PROGRAMMER: PLEASE DISPLAY ALL SECTION HEADERS ON SCREEN THROUGHOUT SURVEY DURING THEIR RESPECTIVE SECTIONS

ALL ORGANIZATIONS

[ORG NAME FROM SAMPLE FILE]

A1. Do you agree to take part in this survey?

You are invited to complete the survey, responding on behalf of your organization, [ORG NAME].

Mathematica, an independent research firm, is conducting this survey on behalf of the Social Security Administration (SSA), as part of its evaluation of the Ticket to Work program. It will take about 33 minutes to complete, including time spent looking up information or speaking with others at your organization. There are questions about your organization overall and the employment services delivered to Ticketholders. Mathematica will send you a $40 check for completing this survey.

The survey is voluntary. You can choose to complete it or not. If you agree to take part, you may skip any question you do not want to answer. Your answers to these questions will be grouped with everyone else who takes part. Your name, and the name of your organization, will not be used in any reports.

m Yes – I agree to take part. 1 GO TO A2

m No – I do not agree to take part 0 GO TO A1a

NO RESPONSE M GO TO A1a

PROGRAMMER: PLACE AT BOTTOM OF THIS AND EACH PAGE OF INSTRUMENT: www.ssa.gov/agency/privacy.html

HARD CHECK: IF A1=NO RESPONSE; This item records your consent to taking part in this voluntary survey.

If you have questions, or if this survey should be sent to someone else at your organization, please contact Mathematica at XXX-XXX-XXXX.

Source: NEW

ALL NON-CONSENTING (A1=0)

A1a. Thank you for your interest in the Ticket to Work Evaluation and in this survey. We appreciate your time and your consideration of this request.

If you have questions or if this survey should be sent to someone else at your organization, please contact Mathematica at XXX-XXX-XXXX.

PROGRAMMER: TERMINATE AND FINALIZE THIS CASE AS SCREENED IN CONFIRMIT. WE WILL RE-OPEN THE INSTRUMENT FOR THIS ORGANIZATION IF ANOTHER RESPONDENT IS IDENTIFIED HEREAFTER.

Source: NEW

ALL CONSENTING (A1=1)

A_INTRO

The next set of questions are about your organization. This includes topics such as your business model, payment structure, funding sources, outreach and marketing.

Your answers to these questions help the researchers and SSA better understand different Employment Network and Vocational Rehabilitation providers across the country.

m Continue 1

Source: NEW

ALL CONSENTING THAT ARE NOT VR AGENCIES (A1=1) AND EN_TYPE=2)

[PID] FROM SAMPLE FILE

A2. What is your current Social Security approved Ticket to Work Business Model?

Each EN has an active Ticket Program Agreement (TPA) with the Social Security Administration (SSA). If your organization has multiple business models, please refer to the model associated with EN Provider Identification (PID) [PID] for all survey questions.

Is it a:

• Traditional Employment Network (EN) that provides employment services and other support services directly to the Ticketholder

• Employer Employment Network (EN) that serves as the Ticketholder’s employer or an employer's agent

• Administrative Employment Network (EN) that serves as the EN of record for a network of service providers who combine their resources to provide services to Ticketholders

If you are a workforce EN, please indicate whether you are authorized under the traditional or administrative model.

Select one only

m Traditional Employment Network (EN) 1

m Employer Employment Network (EN) 2

m Administrative Employment Network (EN) 3

NO RESPONSE M

SOFT CHECK: IF A2=NO RESPONSE; Your answer will help the researchers and SSA better understand the experiences of different organizations that take part in the survey. It will also help us ensure we ask only the questions that apply to your organization.

Source: New

ALL CONSENTING WHERE ORG TYPE IS VR (A1=1) )

A3. What payment structure does your Vocational Rehabilitation (VR) agency use to serve Ticketholders?

Is it …

• Cost reimbursement only (sometimes called traditional payments)

• EN payments only (sometimes called Ticket to Work or milestone and outcome payments)

• Both cost reimbursement and EN payments

Select one only

m Cost reimbursement only 1

m EN payments only 2 GO TO A9

m Both cost reimbursement and EN payments 3 GO TO A5

NO RESPONSE M GO TO A9

SOFT CHECK: IF A3=NO RESPONSE; Your answer helps us ensure we ask only the questions that apply to your organization.

Source: New

ALL CONSENTING, ORG TYPE VR, RECEIVES COST REIMBURSEMENT ONLY (A1=1 AND A3=1)

A4. There are many different reasons why a VR agency may decide not to receive reimbursement using EN payments.

For each listed below, please record “yes” if it applies for your agency or no if it does not.

PROGRAMMER: CODE ONE PER ROW

Select one per row

	YES This was a reason	NO This was not a reason
a. The EN payment system is too complicated/requires too much paperwork.	1 m	0 m
b. Payments per Ticketholder are higher using cost reimbursement.	1 m	0 m
c. We are better able to fund additional services to Ticketholders when we use cost reimbursement.	1 m	0 m
d. We don’t have sufficient information about the EN payment system.	1 m	0 m
e. I do not have information related to why our VR agency may or may not be using EN payments.	1 m	0 m
f. Other reason why our VR agency may or may not be using EN payments, not listed above.	1m	0 m

Source: New

ALL CONSENTING ORG TYPE VR, WHERE PAYMENT STRUCTURE IS ‘BOTH’ (A1=1 AND A3=3)

A5. How does your VR agency decide whether to use cost reimbursement or the EN payment structure?

Select all that apply

o The VR agency decides it at the agency level for reasons unrelated to the Ticketholders’ characteristics and/or service needs 1

o VR counselors determine case-by-case based on Ticketholder characteristics and/or service needs 2

o Other VR agency staff make a case-by-case determination, based on Ticketholder characteristics and/or service needs 3

o I do not have information available to provide an answer. 0

o Other way(s) not listed above. 99

NO RESPONSE M

PROGRAMMER: DO NOT ALLOW “0” AND OTHER RESPONSES (1 OR 2 OR 3 OR 4)

Source: New

ALL CONSENTING ORG TYPE VRWHERE PAYMENT STRUCTURE IS “BOTH” (A1=1 AND A3=3)

A6. How would the following aspects of a Ticketholders’ employment history or goals affect your organization’s decision to use cost reimbursement or the EN payment structure?

For each characteristic below – select the response that best applies. Does it:

• Increase the likelihood of using cost reimbursement instead of the EN payment structure

• Decrease the likelihood of using cost reimbursement instead of the EN payment structure

• Have no impact on the use of cost reimbursement payment structure

If the Ticketholder…

Select one per row

	Increases the likelihood	Decreases the likelihood	Have no impact on the likelihood
a. Is currently employed or has a job offer	1 m	2 m	3 m
b. Has prior work experience	1 m	2 m	3 m
c. Has a clear career goal	1 m	2 m	3 m
d. Is perceived by staff to have the potential to earn above SGA	1 m	2 m	3 m
e. Has interest in part-time work only	1 m	2 m	3 m
f. Has interest in self-employment only	1 m	2 m	3 m

PROGRAMMER: CODE ONE PER ROW. PROGRAMMER: RANDOMIZE THE SEQUENCE OF THE RESPONSE OPTIONS IN ITEM A6a-A6f.

Source: NEW

ALL CONSENTING ORG TYPE VR WHERE PAYMENT STRUCTURE IS “BOTH” (A1=1 AND A3=3)

A7. How would the following Ticketholder characteristics affect your organization’s decision to use cost reimbursement or the EN payment structure?

For each characteristic below – select the response that best applies. Does it:

• Increase the likelihood of using cost reimbursement instead of the EN payment structure

• Decrease the likelihood of using cost reimbursement instead of the EN payment structure

• Have no impact on the use of cost reimbursement payment structure

If the Ticketholder …

Select one per row

	Increases the likelihood	Decreases the likelihood	Have no impact on the likelihood
a. Receives SSDI benefits	1 m	2 m	3 m
b. Receives SSI benefits	1 m	2 m	3 m
c. Is a college graduate	1 m	2 m	3 m
d. Has no high school diploma or GED	1 m	2 m	3 m
e. Is a veteran	1 m	2 m	3 m
f. Is approaching full retirement age	1 m	2 m	3 m
g. Is a transition-aged youth ages 14 to 25	1 m	2 m	3 m

PROGRAMMER: CODE ONE PER ROW

PROGRAMMER: RANDOMIZE THE SEQUENCE OF THE RESPONSE OPTIONS IN ITEM A7a-A7g.

Source: NEW

ALL CONSENTING ORG TYPE VR WHERE PAYMENT STRUCTURE IS “BOTH” (A1=1 AND A3=3)

A8. How would the following Ticketholder support needs affect your organization’s decision to use cost reimbursement or the EN payment structure?

For each characteristic below – select the response that best applies. Does it:

• Increase the likelihood of using cost reimbursement instead of the EN payment structure

• Decrease the likelihood of using cost reimbursement instead of the EN payment structure

• Have no impact on the use of cost reimbursement payment structure

If the Ticketholder …

Select one per row

	Increases the likelihood	Decreases the likelihood	Has no impact on the likelihood
a. Has Limited English proficiency	1 m	2 m	3 m
b. Requires communication accommodations, such as American Sign Language (ASL), Video Relay Services (VRS), Teletype (TTY)/relay, Braille, large print, or does not communicate verbally	1 m	2 m	3 m
c. Requires other accommodations	1 m	2 m	3 m
d. Lacks computer literacy skills or resources to access technology, such as reliable internet, access to a computer.	1 m	2 m	3 m
e. Needs long-term services (for example, needs education and training before starting employment)	1 m	2 m	3 m
f. Needs follow-along services. For example, supported employment	1 m	2 m	3 m
g. Lacks access to public or their own transportation	1 m	2 m	3 m

PROGRAMMER: CODE ONE PER ROW. RANDOMIZE THE SEQUENCE OF THE RESPONSE OPTIONS IN ITEM A8a-A8g.

Source: NEW

ALL CONSENTING NON-VR EN OR VR-EN (A1=1 AND EN_TYPE=1 OR 2)

A9. Which payment system does the EN you work for use?

The Milestone-Outcome payment system offers two sets of milestone payments (before benefit cessation) in addition to a set of Outcome payments. The Outcome-Only payment system offers outcome payments after the Ticketholder reaches suspended benefit status due to work and earnings.

Select one only

m Milestone-Outcome payment system 1

m Outcome-Only payment system 2

NO RESPONSE M

Source: New

ALL CONSENTING NON-VR EN OR VR-EN (A1=1AND EN_TYPE=1 OR 2)

FILL FROM A9 [“Milestone-Outcome payment system” IF A9=1 OR “Outcome-Only payment system” IF A9=2]

A10. There are different reasons why organizations select the payment systems they use.

For each below, answer “yes” if it is a reason your organization selected the [Milestone-Outcome payment system/Outcome-Only payment system] or “no” if it was not.

If you do not have information about this decision, please consult with other staff in your organization.

PROGRAMMER: CODE ONE PER ROW

Select one per row

	YES This was a reason	NO This was not a reason	I do not have the information to provide an answer
a. Total payments would be higher under the payment system we selected.	1 m	0 m	D m
b. Many Ticketholders would not maintain the employment levels required to reach the full set of outcome payments.	1 m	0 m	D m
c. Our organization could not maintain contact with Ticketholders for long enough to receive reimbursement for outcome payments.	1 m	0 m	D m
d. Paperwork and processing requirements are easier under the payment system we selected.	1 m	0 m	D m
e. Receive payment sooner under the payment system we selected.	1 m	0 m	D m
f. Other reason(s) not listed above.	1 m	0 m	D m

PROGRAMMER: RANDOMIZE THE SEQUENCE OF THE RESPONSE OPTIONS IN ITEM A10a-A10e. KEEP A10f ANCHORED IN FINAL ROW.

Source: NEW

ALL CONSENTING EN (A1=1 AND ORG_TYPE=1)

A11. Is your organization currently operating as an EN?

ENs have an active Ticket Program Agreement (TPA) with the Social Security Administration’s (SSA).

m Yes 1 GO TO A13

m No 0

NO RESPONSE M GO TO A13

Source: NEW

ALL CONSENTING NOT CURRENTLY OPERATING AS AN EN (A1=1 AND A11=0)

A11A. Thank you for this update about your status as an EN. For the remainder of the questions, please respond about your organization’s experiences during the past year when your EN was active.

m Continue 1

Source: NEW

ALL CONSENTING ORGS NO LONGER OPERATING AS EN (A1=1 AND A11=0)

A12. Organizations have different reasons for choosing to no longer be an EN. For each below, please select “yes” if this is a reason your organization stopped being an EN or “no” if it is not a reason.

PROGRAMMER: CODE ONE PER ROW

Select one per row

	YES This was a reason	NO This was not a reason
a. Change to organization (leadership, mission, other)	1 m	0 m
b. Lack of Ticketholder demand for services	1 m	0 m
c. Challenges with meeting Ticketholders’ needs for services	1 m	0 m
d. Limited staff capacity to serve Ticketholders	1 m	0 m
e. Limited staff capacity to manage administrative work associated with being an EN	1 m	0 m
f. Inadequate financial benefit relative to cost of operating as an EN	1 m	0 m
g. Terminated by SSA for not meeting requirements to remain in good standing	1 m	0 m
h. Other reason(s) not listed above	1 m	0 m

PROGRAMMER: RANDOMIZE THE SEQUENCE OF THE RESPONSE OPTIONS IN ITEM A13a-A13g.

Source: NEW

ALL CONSENTING ORGS WITH OTHER REASONS NOT OPERATING AS EN (A1=1 AND A12h=1)

A12i. What other reason(s) contributed to your organization choosing to no longer operate as an EN?

Do not include any personal information (such as name, SSN, date of birth) in your response.

OTHER REASON FOR NOT OPERATING AS AN EN

(STRING 1000)

NO RESPONSE M

Source: NEW

ALL CONSENTING EN (A1=1 AND ORG_TYPE=1)

A13. In your opinion, what are the most important changes SSA could make to the TTW program to help more providers to become ENs?

Do not include any personal information (such as name, SSN, or date of birth) in your response.

NO RESPONSE M

PROGRAMMER: CREATE OPEN-ENDED TEXT BOX ON SCREEN. ALLOW FOR UP TO 1,000 CHARACTERS

Source: NEW

ALL CONSENTING ADMINSTRATIVE ENS (A1=1 AND A2=3)

A14. How many contracted community partners or affiliates operate under your organization?

Contracted community partners or affiliates refer to organizations or service providers that provide services to Ticketholders under the umbrella of an Administrative EN.

# CONTRACTED PARTNERS

NO RESPONSE M

Source: NEW

ALL CONSENTING ADMINSTRATIVE ENS (A1=1 AND A2=3)

A15. Thinking back to this time last year, how has the number of contracted community partners or affiliates affiliated with your EN changed?

Has it increased, decreased, or remained the same?

Select one only

m Increased 1

m Decreased 2

m Remained the same 3

NO RESPONSE M

Source: NEW

ALL CONSENTING, NON-VR (A1=1 AND EN_TYPE=2)

A16. Does your organization currently receive funding from any sources other than SSA?

m Yes 1

m No 0 GO TO A19

NO RESPONSE M GO TO A19

Source: NEW

ALL CONSENTING, NON-VR WITH FUNDING BEYOND SSA (A1=1 AND A16=1)

A17. From what other sources does your organization receive funding, in addition to Ticket to Work payments from SSA?

Select all that apply

o Federal/State Vocational Rehabilitation program 1

o Other federal government grants or contracts 2

o State or local government grants or contracts 3

o Foundation grants 4

o Donations from individuals, corporations, charities or religious organizations 5

o Other organization(s) not listed above 99

NO RESPONSE M

Source: PHE, A11, REV

ALL CONSENTING, NON-VR WITH FUNDING BEYOND SSA (A1=1 AND A16=1)

A18. What percentage of your organization’s total funding is provided by SSA through Ticket to Work payments?

Your best estimate is fine.

Is it …

Select one only

m < 10 % 1

m 10 to < 25 % 2

m 25 to < 50% 3

m 50 to < 75% 4

m 75% or more 5

NO RESPONSE M

Source: NEW

ALL CONSENTING (A1=1)

A19. Does your organization also operate as a Work Incentives Planning and Assistance (WIPA)?

Select all that apply

o Yes – we operate as a WIPA 1

o No – we do not operate as a WIPA 0

NO RESPONSE M

Source: NEW

ALL CONSENTING (A1=1)

A20. Does your organization have a formal written Partnership Plus agreement?

Partnership Plus is an agreement between ENs and VR agencies. Under this agreement, ENs focus their service provision on ongoing supports for Ticketholders exiting the VR system after being served under the VR Cost Reimbursement program.

m Yes 1

m No 0

NO RESPONSE M

SOFT CHECK: IF A20=NO RESPONSE; Your answer to this question helps us ensure we ask only the questions that are relevant to your organization. If you are not sure if your organization participates in Partnership Plus, please consult with others who may have this information.

Source: NEW

ALL CONSENTING AND ORG TYPE IS EN (A1=1 AND ORG TYPE=1)

A21. Does your EN currently participate in the marketing program for Ticket to Work operated by SSA?

Under the marketing program for Ticket to Work, SSA provides a file of contact information based on SSI/SSDI Ticketholders who are not participating in the Ticket to Work program. ENs that request this information from SSA based on a set of Ticketholder characteristics. ENs who participate agree to assign the Tickets of at least 0.5% of the Ticketholders in file.

m Yes 1

m No 0 GO TO A23

m I have never heard of the marketing program 2 GO TO A25

NO RESPONSE M GO TO A25

SOFT CHECK: IF A21=NO RESPONSE; ENs make different choices about taking part in the marketing program. There are no right or wrong answers. Your answer to this question helps ensure you receive only the questions that are relevant to your EN.

Source: NEW

ALL CONSENTING WHO PARTICIPATE IN THE MARKETING PROGRAM (A1=1 AND A21=1)

A22. Which of the following reasons, if any, influenced your organization’s decision to participate in the marketing program for Ticket to Work?

If you do not have information about this decision, please consult with other staff at your organization.

Select all that apply

o Meet demand for employment services that we provide 1

o Ability to focus outreach to Ticketholders with certain characteristics 2

o Capacity to serve more Ticketholders 3

o Potential financial benefit from a higher volume of Ticket payments 4

o Other reason not listed above. 99

NO RESPONSE M

Source: NEW

ALL CONSENTING WITH OTHER REASON FOR PARTICIPATING IN MARKETING PROGRAM (A1=1 AND A22_99=1)

A22A. What other reason(s) influenced your organization’s decision to participate in the marketing program for Ticket to Work?

Do not include any personal information (such as name, SSN, date of birth) in your response.

OTHER REASON(S) (STRING 50)

NO RESPONSE M

Source: NEW

ALL CONSENTING, NOT PARTICIPATING IN MARKETING PROGRAM (A1=1 AND A21=0)

A23. Has your EN previously participated in the marketing program for Ticket to Work?

m Yes 1

m No 0

NO RESPONSE M

Source: NEW

ALL CONSENTING, NOT PARTICIPATING IN MARKETING PROGRAM (A1=1 AND A21=0)

A24. Which, if any, of these are reasons why your organization decided not to participate in the marketing program for Ticket to Work right now?

For each, select “yes” if it applies for your organization and “no” if it does not.

If you do not have information about this decision, please consult with other staff at your organization.

PROGRAMMER: CODE ONE PER ROW

Select one per row

	Yes This is a reason	No This is not a reason
a. Lack of staff capacity or technology to proactively contact Ticketholders	1 m	0 m
b. Lack of staff capacity to serve more Ticketholders	1 m	0 m
c. Required minimum number of new assignments is too large for our EN to commit to	1 m	0 m
d. Did not think that we could assign 0.5% of Ticketholders on the outreach list to the Ticket to Work (TTW) program	1 m	0 m
e. SSA did not allow our participation in the marketing program	1 m	0 m
f. Other reason(s) not listed above.	1 m	0 m

Source: NEW

ALL CONSENTING NON-VR EN (A1=1 AND EN_TYPE=2)

A25. Does your organization conduct proactive outreach to Ticketholders who do not have a Ticket assigned to raise awareness about the Ticket to Work program or services your organization offers?

This outreach might include written advertisements, email, mail, text messaging, or phone calls. It may or may not be part of the marketing program.

m Yes 1

m No 0 GO TO A27

NO RESPONSE M GO TO A27

Source: NEW

ALL CONSENTING NON-VR EN CONDUCTING OUTREACH (A1=1 AND EN_TYPE=2 AND A25=1)

A26. What type(s) of outreach does your organization conduct to Ticketholders who do not have a Ticket assigned to raise awareness about the services your organization offers?

Select all that apply

o General advertisements (online, radio, other formats) 1

o Direct email outreach 2

o Direct mail outreach 3

o Text messaging 4

o Phone calls 5

o Webinars or workshops 6

o Other type of outreach, not listed above 99

NO RESPONSE M

Source: NEW

ALL CONSENTING (A1=1)

FOR ADMIN EN ONLY (A2=3) FILL [Please consider only staff at your organization.]

A27. Thinking about staff who provide direct services to Ticketholders at your organization, how many full time equivalents (FTEs) does your organization have on staff?

These staff might be job specialists, job counselors, or others.

A full time equivalent (FTE) is one full-time staff person, or a combination of part-time staff whose time adds up to a full time equivalent (for example, two staff who work half-time).

[Please consider only staff at your organization.]

NUMBER OF FTEs

NO RESPONSE M

PROGRAMMER: ALLOW FOR USE OF DECIMALS IN THE RESPONSE.

Source: NGPL, B3

ALL CONSENTING (A1=1)

A28. How many clients does each direct service provider at your organization serve each month, on average? Please include all clients served by your organization, not just Ticketholders.

This might be referred to as your staff caseload. Your best estimate is fine.

Select one only

m Fewer than 10 1

m 10-19 2

m 20-29 3

m 30-39 4

m 40-49 5

m 50-74 6

m 75-100 7

m 100-149 8

m 150 or more 9

NO RESPONSE M

Source: NEW

ALL CONSENTING (A1=1)

IF RESPONSE FROM A28 NE M, FILL: [RESPONSE FROM A28]

A29. What share of this average caseload of [RESPONSE FROM A28] is typically comprised of Ticketholders?

Your best estimate is fine.

Select one only

m Less than 25% are Ticketholders 1

m 25-49% are Ticketholders 2

m 50-74% are Ticketholders 3

m 75-99% are Ticketholders 4

m 100% are Ticketholders 5

Source: NEW

ALL CONSENTING (A1=1)

A30. Which of the following statements below best describes how your organization provides benefits counseling services to Ticketholders?

Select one only

m All benefits counseling provided to Ticketholders is through a contract with a WIPA project 1

m Some benefits counseling provided to Ticketholders is through a contract with a WIPA project 2

m Our organization does not contract with a WIPA project to provide benefits counseling but refers Ticketholders to them 3

m Our organization does not contract with a WIPA project to provide benefits counseling or refer Ticketholders to them 4

NO RESPONSE M

Source: NEW

ALL CONSENTING (A1=1)

A31. How many certified benefits counselors (CWICs, CPWICs, BWIPs or BINs) are employed or contracted by your organization provide services to Ticketholders?

Please provide a count below. If there are currently no certified benefits counselors, enter “0.” If you are an administrative EN, consider the certified benefits counselors contracted by your affiliates.

If needed:

• Community Work Incentives Coordinators (CWICs) and Community Partner Work Incentives Coordinators (CPWICs) are certified by Virginia Commonwealth University (VCU).

• Benefits Work Incentives Practitioners (BWIPs) are certified through Cornell University.

• Benefits Information Network (BIN) training is conducted by Indiana University.

	# of certified benefits counselors
TOTAL CERTIFIED BENEFITS COUNSELORS AT ORGANIZATION

PROGRAMMER: THE RANGE IS 0-999.

Source: NEW

ALL CONSENTING (A1=1)

A32. Does your organization offer services to Ticketholders in any of the following alternative formats or languages (including through interpreters or other third-party services)?

Select all that apply

o American Sign Language (ASL), Video Relay Services (VRS), or using Teletype

(TTY)/relay 1

o Staff who speak languages other than English or interpreters for languages

other than English 2

o None of the above 0

PROGRAMMER: DO NOT ALLOW “0” AND OTHER RESPONSES (1 OR 2)

Source: APOR, 16, REV

Section B. Ticketholder intake

ALL CONSENTING (A1=1)

B_INTRO

The next set of questions ask about the intake process for Ticketholders.

The information you provide will help the researchers and SSA better understand this process from the perspective of Employment Networks and Vocational Rehabilitation providers across the country.

m Continue 1

Source: NEW

ALL CONSENTING, NON-VR EN (A1=1 AND EN_TYPE=2)

B1. How would the following Ticketholder’s employment history and goals affect your organization’s decision to assign a Ticket, if at all?

For each, select the response that best reflects your organization’s Ticket assignment practices.

PROGRAMMER: CODE ONE PER ROW

Select one per row

	Increases the likelihood of Ticket assignment	Decreases likelihood of Ticket assignment	Does not affect Ticket assignment
a. Is employed or has a job offer	1 m	2 m	3 m
b. Has prior work experience	1 m	2 m	3 m
c. Has a clear career goal	1 m	2 m	3 m
d. Is perceived by staff to have the potential to earn above SGA	1 m	2 m	3 m
e. Is interested in part-time work only	1 m	2 m	3 m
f. Is interested in self-employment only	1 m	2 m	3 m

PROGRAMMER: RANDOMIZE THE SEQUENCE OF THE RESPONSE OPTIONS IN ITEM B1a-B1f.

Source: NEW

ALL CONSENTING, NON-VR EN (A1=1 AND EN_TYPE=2))

B2. How would the following Ticketholder characteristics affect your organization’s decision to assign a Ticket, if at all?

For each characteristic below, select the response that best reflects your organization’s Ticket assignment practices.

PROGRAMMER: CODE ONE PER ROW

Select one per row

	Increases the likelihood of Ticket assignment	Decreases likelihood of Ticket assignment	Does not affect Ticket assignment
a. SSDI beneficiary	1 m	2 m	3 m
b. SSI recipient	1 m	2 m	3 m
c. College graduate	1 m	2 m	3 m
d. No high school diploma or GED	1 m	2 m	3 m
e. Veteran	1 m	2 m	3 m
f. Age approaching full retirement	1 m	2 m	3 m
g. Transition-aged youth (ages 14 to 25)	1 m	2 m	3 m

PROGRAMMER: RANDOMIZE THE SEQUENCE OF THE RESPONSE OPTIONS IN ITEM B2a-B2g.

Source: NEW

ALL CONSENTING, NON-VR EN (A1=1 AND EN_TYPE=2)

B3. How would the following characteristics related to Ticketholder support needs affect your organization’s decision to assign a Ticketholder’s Ticket, if at all?

For each, select the response that best reflects your organization’s Ticket assignment practices.

PROGRAMMER: CODE ONE PER ROW

Select one per row

	Increases the likelihood of Ticket assignment	Decreases likelihood of Ticket assignment	Does not affect Ticket assignment
a. Limited English proficiency	1 m	2 m	3 m
b. Requires communication accommodations (American Sign Language (ASL), Video Relay Services (VRS), Teletype (TTY)/relay, Braille, large print, or does not communicate verbally)	1 m	2 m	3 m
c. Requires an accessible EN office location	1 m	2 m	3 m
d. Lacks computer literacy skills or resources to access technology, such as reliable internet, access to a computer.	1 m	2 m	3 m
e. Need for long-term services (for example, needs education and training before starting employment)	1 m	2 m	3 m
f. Need for follow-along services (for example, need for supported employment)	1 m	2 m	3 m
g. Lacks access to public or their own transportation	1 m	2 m	3 m

PROGRAMMER: RANDOMIZE THE SEQUENCE OF THE RESPONSE OPTIONS IN ITEM B3a-B3g.

Source: NEW

ALL CONSENTING (A1=1)

B4. From the list below, please select the top 3 most common employment goals Ticketholders request help with:

Select the top 3.

Select all that apply

 Returning to part-time work 1

 Returning to full-time work 2

 Obtaining training 3

 Starting work for the first time 4

 Becoming self-employed 5

 Avoiding continuing disability reviews 6

 Obtaining benefits counseling 7

NO RESPONSE M

PROGRAMMER: RANDOMIZE THE SEQUENCE OF THE RESPONSE OPTIONS IN ITEM B4_1-B4_7.

Source: NEW

ALL CONSENTING (A1=1)

B5. Where do staff typically refer Ticketholders who need services your organization does not offer?

Note that not all the options might apply to your organization.

o Employment Network (EN) 1

o Work Incentives Planning and Assistance (WIPA) 2

o Protection and Advocacy for Beneficiaries of Social Security (PABSS) agency 3

o SSA’s Ticket to Work Beneficiary Helpline 4

o SSA's National 1-800 number (also known as the Teleservice Center) 5

o Vocational Rehabilitation agency 6

o Other organization(s) – not listed above 7

NO RESPONSE M

PROGRAMMER: RANDOMIZE THE SEQUENCE OF THE RESPONSE OPTIONS IN ITEM B5_1-B5_6. KEEP B5_7 ANCHORED IN FINAL SLOT.

Source: NEW

ALL CONSENTING (A1=1)

B6. Does your organization currently have a wait list for services?

m Yes 1

m No 0 GO TO B9

NO RESPONSE M GO TO B9

SOFT CHECK: IF B6=M; Your answer helps us ensure we ask only the questions that apply to your organization.

Source: NEW

ALL CONSENTING ORGS WITH WAIT LIST (A1=1 AND B6=1)

B7. How long do Ticketholders typically wait until they start receiving services at your organization? In the boxes below, please report in days, months, or years.

TIME ON WAIT LIST

DROP DOWN OPTIONS: DAYS, MONTHS, YEARS

NO RESPONSE M

SOFT CHECK: IF NO UNIT SELECTED; Please select an option from the drop-down menu.

PROGRAMMER: FOR THIS ITEM, PLEASE CREATE TWO RESPONSE BOXES. THE FIRST WILL CAPTURE THE NUMERIC RESPONSE AND THE SECOND WILL RECORD THE CATEGORIES SHOWN ABOVE, USING A DROP DOWN FORMAT.

Source: NEW

ALL CONSENTING ORGS WITH WAIT LIST (A1=1 AND B6=1)

B8. How many Ticketholders are typically on your organization’s wait list?

NUMBER OF TICKETHOLDERS ON WAITLIST

(RANGE: 0-9999)

NO RESPONSE M

Source: NEW

ALL CONSENTING (A1=1)

B9. In your opinion, what are the most important changes SSA could make to help ENs or VR agencies provide more Ticketholders with the services they need?

Do not include any personal information (such as name, SSN, or date of birth) in your response.

NO RESPONSE M

PROGRAMMER: CREATE OPEN-ENDED TEXT BOX ON SCREEN. ALLOW FOR UP TO 1,000 CHARACTERS

Source: NEW

Section C. Providing Services to Ticketholders

ALL CONSENTING (A1=1)

C_INTRO

The next questions are about delivering services to Ticketholders. Your answers to these questions help the researchers and SSA better understand service provision experiences for Employment Networks and Vocational Rehabilitation providers across the country.

Continue 1

Source: NEW

ALL CONSENTING (A1=1)

C1. About how many Ticketholders served by your organization (or its contracted community partners or affiliates) receive the following services?

Your best understanding of these categories is fine.

PROGRAMMER: CODE ONE PER ROW

Select one per row

	Nearly all receive	Many receive	Some receive	Few receive	None receive
a. Career planning/counseling	1 m	2 m	3 m	4 m	5 m
b. Support requesting job accommodations/assistive technology from employer	1 m	2 m	3 m	4 m	5 m
c. Funding for job accommodations/assistive technology	1 m	2 m	3 m	4 m	5 m
d. Assist with technology and computer skills	1 m	2 m	3 m	4 m	5 m
e. Job coaching	1 m	2 m	3 m	4 m	5 m
f. Job training	1 m	2 m	3 m	4 m	5 m
g. Job development	1 m	2 m	3 m	4 m	5 m
h. Help identifying jobs to apply for	1 m	2 m	3 m	4 m	5 m
i. Resume writing	1 m	2 m	3 m	4 m	5 m
j. Job placement assistance (e.g., interview preparation and filling out applications)	1 m	2 m	3 m	4 m	5 m
k. Direct job placement (for example agreement with employers to place Ticketholders in jobs; hire Ticketholders at your organization)	1 m	2 m	3 m	4 m	5 m
l. Ongoing employment support/job retention	1 m	2 m	3 m	4 m	5 m
m. Help accessing transportation	1 m	2 m	3 m	4 m	5 m
n. Assistance with wage reporting to SSA	1 m	2 m	3 m	4 m	5 m
o. Benefits counseling	1 m	2 m	3 m	4 m	5 m
p. Other service(s), not listed above	1 m	2 m	3 m	4 m	5 m

SOFT CHECK: IF ANY ITEM c1a-c1o=NO RESPONSE; Your answer to this question will help the researchers and SSA better understand how often different types of services are offered to Ticketholders. There are no right or wrong answers – each organization’s experience is different.

Source: APOR, 17 – rev

ALL CONSENTING REPORTING OTHER SERVICES DELIVERED (A1=1 AND C1P=1, 2, OR 3)

C1q. What is/are the other service(s) your organization (or its contracted community partners) provides to Ticketholders?

Do not include any personal information (such as name, SSN, date of birth) in your response.

OTHER SERVICE(S) PROVIDED (STRING 500)

NO RESPONSE M

Source: APOR, 17 – rev

ALL CONSENTING EN PROVIDING ON-GOING EMPLOYMENT SUPPORT (A1=1 AND C1L=1 OR 2 OR 3)

C2. For how long do staff at your organization typically provide ongoing employment support or job retention services after a Ticketholder starts a job?

On average, is it…

DURATION OF ONGOING EMPLOYMENT SUPPORT

DROP DOWN OPTION: DAYS, MONTHS, YEARS

NO RESPONSE M

Source: NEW

ALL CONSENTING (A1=1)

C3. Some organizations deliver employment services in-person, some deliver services remotely, and some use a mix of approaches.

Does your organization offer services remotely?

Remote service delivery includes using virtual platforms (Zoom, MS Teams, Google Meet), email, telephone calls, and text messaging.

m Yes 1

m No 0 GO TO C5

NO RESPONSE M GO TO C5

SOFT CHECK: IF C3=NO RESPONSE; Your answer to this question helps researchers and SSA better understand the ways in which services are delivered. Each organization’s experience is important to the evaluation. Please consider providing a response to this question.

Source: NEW

ALL CONSENTING OFFERING REMOTE SERVICES (A1=1 AND C3=1)

C4. What share of Ticketholders do you serve entirely in-person, entirely remotely, or through a mix of in-person and remote services?

	% of Ticketholders
Percent of Ticketholders receiving ALL services in-person
Percent of Ticketholders receiving ALL services remotely
Percentage of Ticketholders receiving a MIX of in-person and remote services
TOTAL	[SUM]

PROGRAMMER: SUM RESPONSES FROM C4a-C4c. PROGRAMMER: RANGE FOR GRID IS 0-100

Source: NEW

ALL CONSENTING (A1=1)

C5. Which statement best describes your organization’s current staffing level and capacity to provide timely and quality services to Ticketholders?

Select one only

m We are fully staffed and are at full capacity 1

m We are fully staffed and have the capacity to serve more Ticketholders 2

m We have staff vacancies and do not have the capacity to serve more Ticketholders at this time 3

m We have staff vacancies but have the capacity to serve more Ticketholders 4

NO RESPONSE M

Source: CSAVR, Pg. 1

ALL CONSENTING (A1=1)

[FILL “EN” IF EN_TYPE=1 OR 2, FILL “VR agency” IF EN_TYPE=3]

C6. How challenging are each of the following for your organization, as part of the Ticket to Work program?

If your organization does not encounter a given challenge, select “not a challenge.”

PROGRAMMER: CODE ONE PER ROW

Select one per row

	Not a challenge	Somewhat of a challenge	Very challenging
a. Recruiting Ticketholders	1 m	2 m	3 m
b. Assigning Tickets	1 m	2 m	3 m
c. Explaining to Ticketholders the advantages of working with an [EN/VR agency]	1 m	2 m	3 m
d. Ticketholders’ ability to access services (remotely or in person)	1 m	2 m	3 m
e. Ticketholders’ responsiveness to contacts from staff at your organization	1 m	2 m	3 m
f. Identifying Ticketholders likely to generate payments	1 m	2 m	3 m

Source: REO, D5

ALL CONSENTING (A1=1)

C7. How challenging are each of the following service delivery issues for your organization?

If your organization does not encounter a given challenge, select “not a challenge.”

PROGRAMMER: CODE ONE PER ROW

Select one per row

	Not a challenge	Somewhat of a challenge	Very challenging
a. Responsiveness of local SSA field offices (e.g., to provide Benefits Planning Query (BPQY), clarify a Ticketholder issue)	1 m	2 m	3 m
b. Responsiveness of Area Work Incentives Counselor (AWIC)	1 m	2 m	3 m
c. Responsiveness of state agencies (e.g., to verify benefits)	1 m	2 m	3 m
d. Referring Ticketholders to other assistance programs or services	1 m	2 m	3 m
e. Referring Ticketholders to other Ticket Act programs	1 m	2 m	3 m
f. Effectiveness of case management software or other management information system for service delivery	1 m	2 m	3 m
g. Understanding and effectively navigating SSA work support provisions	1 m	2 m	3 m

Source: REO, D5

ALL CONSENTING (A1=1)

C8. How challenging are each of the following administrative issues for your organization?

If your organization does not encounter a given challenge, select “not a challenge.”

PROGRAMMER: CODE ONE PER ROW

Select one per row

	Not a challenge	Somewhat of a challenge	Very challenging
a. Tracking Ticketholders’ data, such as job placement and retention	1 m	2 m	3 m
b. Meeting federal systems and security requirements (e.g., FedRAMP)	1 m	2 m	3 m
c. Completing earnings reporting necessary to receive payment from SSA	1 m	2 m	3 m
d. Lack of or limited financial resources for your organization	1 m	2 m	3 m
e. Lack of or limited nonfinancial resources (such as space or equipment) for your organization	1 m	2 m	3 m
f. Responsiveness of Ticket Program Manager (for example, to communication, payment requests)	1 m	2 m	3 m
g. E-PAY process	1 m	2 m	3 m
h. Manual payment process	1 m	2 m	3 m

Source: REO, D5

ALL CONSENTING (A1=1)

C9. Are there any other challenges your organization faces in administering the Ticket to Work program and providing services to Ticketholders?

If so, provide a brief description of the challenge below. If not, please select “no other challenges.”

Do not include any personal information (such as name, SSN, date of birth) in your response.

1 m No other challenges

PROGRAMMER: CREATE OPEN-ENDED TEXT BOX ON SCREEN. ALLOW FOR UP TO 1,000 CHARACTERS

Source: REO, D5, REV

ALL CONSENTING (A1=1)

C10. In your opinion, what are the most important changes SSA could make to help more Ticketholders find work, stay working, and reduce their dependence on cash benefit programs?

Do not include any personal information (such as name, SSN, or date of birth) in your response.

NO RESPONSE M

PROGRAMMER: CREATE OPEN-ENDED TEXT BOX ON SCREEN. ALLOW FOR UP TO 1,000 CHARACTERS

Source: NEW

Section D. Influence of Services on Ticketholders

ALL CONSENTING (A1=1)

D_INTRO. Questions in this section ask about the ways that Ticket to Work (TTW) services affect the lives of the people receiving those services. There are no right or wrong answers. The information provided will help the researchers and SSA better understand service provision for Ticketholders across the country.

m Continue 1

ALL CONSENTING (A1=1)

D1. Thinking about your organization’s experience serving Ticketholders, how effective are the following Ticket to Work program services in helping Ticketholders obtain and maintain employment?

PROGRAMMER: CODE ONE PER ROW

Select one per row

	Not at all effective	Somewhat ineffective	Neither effective nor effective	Somewhat effective	Extremely effective
a. Career planning or counseling	1 m	2 m	3 m	4 m	5 m
b. Support requesting job accommodations/assistive technology from employer	1 m	2 m	3 m	4 m	5 m
c. Funding for job accommodations/assistive technology	1 m	2 m	3 m	4 m	5 m
d. Help with technology and computer skills	1 m	2 m	3 m	4 m	5 m
e. Job coaching	1 m	2 m	3 m	4 m	5 m
f. Job training	1 m	2 m	3 m	4 m	5 m
g. Job development	1 m	2 m	3 m	4 m	5 m
h. Identify jobs to apply to	1 m	2 m	3 m	4 m	5 m
i. Resume writing	1 m	2 m	3 m	4 m	5 m
j. Job placement assistance (e.g., interview preparation and filling out applications)	1 m	2 m	3 m	4 m	5 m
k. Direct hiring for a job (e.g., direct placement, or hiring to be employed at their EN)	1 m	2 m	3 m	4 m	5 m
l. Ongoing employment support/job retention	1 m	2 m	3 m	4 m	5 m
m. Help accessing transportation	1 m	2 m	3 m	4 m	5 m
n. Education about wage reporting to SSA	1 m	2 m	3 m	4 m	5 m
o. Benefits counseling	1 m	2 m	3 m	4 m	5 m

PROGRAMMER: RANDOMIZE THE SEQUENCE OF THE RESPONSE OPTIONS IN ITEM D1a-D1o.

Source: NGPL, C1, mod

ALL CONSENTING (A1=1)

D2. There are many reasons why organizations may not receive payments from SSA for some Ticketholders.

For each of the reasons shown below, select “yes” if it is a typical reason for your organization not receiving payment for services provided to a Ticketholder or “no” if it is not.

PROGRAMMER: CODE ONE PER ROW

Select one per row

	YES	NO
a. Ticketholders are not responsive to contacts from our organization	1 m	0 m
b. Ticketholders’ health is a barrier to work	1 m	0 m
c. Ticketholders do not have employment goals that would generate payments	1 m	0 m
d. Ticketholders do not provide the necessary paperwork (e.g. paystubs) to SSA to generate payment for my organization	1 m	0 m
e. The time needed for SSA to review work activity and cease benefits results in delayed outcome payments	1 m	0 m

PROGRAMMER: RANDOMIZE THE SEQUENCE OF THE RESPONSE OPTIONS IN ITEM D2a-D2e.

Source: NEW

ALL CONSENTING (A1=1)

D3. If SSA could make one change to the TTW program that would allow your organization to better serve Ticketholders, what would it be?

Do not include any personal information (such as name, SSN, or date of birth) in your response.

PROGRAMMER: CREATE OPEN-ENDED TEXT BOX ON SCREEN. ALLOW FOR UP TO 1,000 CHARACTERS.

Source: NEW

Section E. Partnership Plus

ALL CONSENTING AND IN PARTNERSHIP PLUS (A1=1 AND A20=1)

E_INTRO. Questions in this section ask about the ways that Ticket to Work (TTW) services affect the lives of the people receiving those services. There are no right or wrong answers.

The information provided will help the researchers and SSA better understand service provision for Ticketholders across the country.

m Continue 1

Source: NEW

ALL CONSENTING, NON-VR EN, IN PARTNERSHIP PLUS (A1=1 AND EN_TYPE=2 AND A20=1)

E1. Below is a list of reasons why some organizations decide to participate in Partnership Plus. For each, select “yes” if it applies to your organization or “no” if it does not.

If you do not have information about this decision, please consult with other staff at your organization. If there are no other reasons, then leave “other reason not listed above” blank.

Select one per row

	YES This is a reason	NO This is not a reason
a. To fulfill the need that Ticketholders have for additional support after VR case closure	1 m	0 m
b. To formalize an existing relationship with a VR agency	1 m	0 m
c. To increase or sustain referrals from a VR agency	1 m	0 m
d. To reduce the time required to obtain Ticket payments	1 m	0 m
e. To access the funding provided by Partnership Plus for follow-on supports to Ticketholders	1 m	0 m
f. Other reason not listed above.	1 m	0 m

PROGRAMMER: CODE ONE PER ROW. KEEP E1F ANCHORED IN THE FINAL ROW.

Source: NEW

ALL CONSENTING NON-VR EN, WITH OTHER REASONS IN PARTNERSHIP PLUS (A1=1 AND E1f=1)

E1g. What is/are the other reason(s) your organizations decided to participate in Partnership Plus?

Do not include any personal information (such as name, SSN, date of birth) in your response.

OTHER REASON(S) IN PARTNERSHIP PLUS

(STRING 150)

NO RESPONSE M

Source: NEW

ALL CONSENTING VR ONLY, IN PARTNERSHIP PLUS (A1=1 AND EN_TYPE=3 AND A20=1)

E2. Below is a list of reasons why some organizations decide to participate in Partnership Plus. For each, select “yes” if it applies to your organization or “no” if it does not.

If you do not have information about this decision, please consult with other staff at your organization.

PROGRAMMER: CODE ONE PER ROW

Select one per row

	YES This is a reason	NO This is not a reason
a. Interest in formalizing an existing relationship with EN(s).	1 m	0 m
b. Limited capacity to provide services after case closure.	1 m	0 m
c. Limited capacity to follow up or keep in touch with Ticketholders.	1 m	0 m
d. Other reason, not listed above.	1 m	0 m

Source: NEW

ALL CONSENTING NON VR EN, NOT IN PARTNERSHIP PLUS (A1=1 AND EN_TYPE=2 AND A20=0)

E3. Below is a list of reasons why some organizations decide not to participate in Partnership Plus.

For each, select “yes” if it applies to your organization or “no” if it does not.

If you do not have information about this decision, please consult with other staff at your organization.

PROGRAMMER: CODE ONE PER ROW

Select one per row

	YES This was a factor	NO This was not a factor
a. Unfamiliarity with requirements/benefits of Partnership Plus	1 m	0 m
b. Could not identify a VR agency interested in a partnership	1 m	0 m
c. Our payments would be lower than if we provided all services to the Ticketholder.	1 m	0 m
d. Our organization would not be able to keep in touch with Ticketholder after case closure	1 m	0 m
e. Other reason – not listed above.	1 m	0 m

Source: NEW

ALL CONSENTING NON-EN VR NOT IN PARTNERSHIP PLUS (A1=1 AND EN_TYPE=3 AND A20=0)

E4. Below is a list of factors that influence some organizations decision to not participate in Partnership Plus.

For each, please select “yes” if it applies to your organization or “no” if it does not.

If you do not have information about this decision, please consult with other staff at your organization.

Select one per row

	YES This is a reason	NO This is not a reason
a. Inadequate staff capacity to negotiate and maintain agreements.	1 m	0 m
b. Lack of familiarity with requirements or benefits of Partnership Plus.	1 m	0 m
c. Could not identify EN(s) interested in a partnership.	1 m	0 m
d. Concern that our VR agency would lose reimbursement dollars for Ticketholders who work.	1 m	0 m
e. Other reason(s) not listed above.	1 m	0 m

PROGRAMMER: CODE ONE PER ROW. ensure that a27E IS ANCHORED IN FINAL ROW.

Source: NEW

Section F. Closing

ALL CONSENTING (A1=1)

F1. Is there anything that we have not asked that SSA should know about running an effective EN?

Do not include any personal information (such as name, SSN, or date of birth) in your response.

PROGRAMMER: CREATE OPEN-ENDED TEXT BOX ON SCREEN. ALLOW FOR UP TO 1,000 CHARACTERS.

Source: NEW

ALL CONSENTING (A1=1)

F2. Thank you for the time you have spent answering these questions. Mathematica will mail you a $40 gift card to thank you for completing this survey.

The information below helps us know where to send the check.

Your Name: (STRING 50)

Street Address 1: (STRING 200)

Street Address 2: (STRING 50)

City: STRING 150)

State: PROGRAMMER: USE DROP DOWN

Zip: (STRING 10)

SOFT CHECK: IF ANY FIELDS IN F2=NO RESPONSE; This information is not required, however we will need it to be able to send you the $40 check for completing the survey. If you do not wish to provide this information, or do not want to receive the $40 check, you may leave this blank and continue to the next question.

ALL CONSENTING (A1=1)

F3. If we have any questions about the information you have provided in the survey, may we contact you by phone?

If you agree to be contacted, please provide the best telephone number to reach you at below.

TELEPHONE NUMBER

NO RESPONSE M

ALL CONSENTING (A1=1)

CLOSING SCREEN

Thank you for completing this survey.

We appreciate your time and the information you have provided. If you have any questions, please contact the survey director at Mathematica, Holly Matulewicz, at XXX-XXX-XXXX.

For more information about the Ticket-to-Work evaluation, go to: www.xxx.ssa.gov.

PROGRAMMER: Please ensure the logo maintains the alt-text provided in the specifications. Please hyperlink the SSA logo to the study website at: www.xxx.ssa.gov.