Individual Self-Sufficiency Planning (Issp)

INDIVIDUAL SELF-SUFFICIENCY PLANNING (ISSP) INFORMED CONSENT AND RELEASE OF INFORMATION

NAME ______SSN: ______

MH#______

I understand that the ISSP Project is a five (5) year State Department of Rehabilitation (DR) and Social Security Administration (SSA) research study testing ways to help people with disabilities get the necessary services and items that they need to get and keep a job. Vocational Rehabilitation Services (VRS) is the San Mateo County Human Services Agency designated to provide services. Included in the ISSP Project is the SSI Work Incentives Demonstration Project, which will test the effectiveness of altering certain SSI program rules as incentives to work. I understand that in order to participate in the SSI demonstration project, I must be an active participant in the ISSP Project.

I hereby waive my right to confidentiality and authorize VRS, DR, and SSA to release/exchange records or information in their possession obtained in the course of psychiatric and/or drug and/or alcohol diagnoses and treatment for the purpose of the study. Information to be released includes disability, educational/employment, financial, social and health information. I further authorize DR and their contractors to obtain information about my past and current history of employment, and use of social and health services in order to evaluate the research study. I understand this information will be kept confidential by the researchers. I understand that the information VRS, DR, and SSA collect about me is confidential and will be protected under the Privacy Act. SSA will share the information with Virginia Commonwealth University, a university under contract to SSA, to evaluate the ISSP Project and to learn how well the ISSP Project worked and the best way in which to help people with disabilities to find and keep work. I understand SSA will share this information with other organizations involved in the ISSP Project and, as required, under the Social Security Act, with State agencies that make disability decisions. I understand this information and my work can affect my application for Social Security Disability Insurance Benefits, and/or Supplemental Security Income payments, or my continuing eligibility. I further recognize that it is my responsibility to continue reporting earnings information, related income changes, and any other pertinent information which could affect my SSI eligibility directly to the SSA office. A VRS staff representative will be available to help me understand Social Security issues and provide resources to help me plan my return to work. A VRS staff representative explained the SSI waiver rules to me.

I know that I do not have to take part in this Project, including the SSI demonstration project. There is no penalty for not volunteering or dropping out whenever I choose. My signature below indicates that I want to be part of the Project, including the SSI demonstration project. My consent is subject to revocation at any time. If not earlier

Isspinfchoice.doc 2001 revoked, this authorization shall terminate at the completion of ISSP Project - September 30, 2003.

______Applicant’s Signature Date ______Parent/Guardian Date

I have read materials to the applicant, and I believe that he/she understands it.

______VRS Staff Representative Date

Privacy Act Language – Informed Consent

SSA is allowed to collect the information asked for while you participate in the State Partnership Initiative, including the SSI demonstration project, under section 1110(b) of the Social Security Act (the Act). We use the information to decide what services would best help you. You do not have to give us this information. However, if you do not, we will be unable to offer you services.

There are certain situations authorized by Federal law in which SSA may release the information you give us through the ISSP Project. For example, we release the information to a congressional office in response to an inquiry that office may make at your request, or to Virginia Commonwealth University, a private university hired by SSA to evaluate the ISSP Project.

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 any Social Security Office.

Isspinfchoice.doc 2001