Plan for Achieving Self-Support
Name: Chris SSN:
Part I - Your
A. What is your work goal? (Show the specific job you expect to have at the end of the plan. If you are undergoing vocational evaluation to determine a feasible goal, show AVR Evaluation.@ If your goal involves a supported employment position, show the amount of job coaching you expect to need after the plan is completed compared to the amount you currently receive or will receive when you begin working.) My work goal is to become an Office Assistant. I enjoy duties related to the title of Office Clerk such as: counts, weighs, or measures material. Sorts and files records. Stuffs envelopes by hand or with envelope stuffing machine. Conveys messages, and runs errands. Stamps, sorts, and distributes mail. Stamps or numbers forms by hand or machine. Photocopies documents using photocopier. Place cards, forms or other material in storage receptacle such as file cabinet, drawer, or box. Files correspondence, cards, invoices, receipts , and other records in designated or adapted system.
B. Describe the duties you will be expected to perform in this job: As described above.
C. How much do you currently earn (gross) each month in wages or self- employment income? $0/month
How much do you expect to earn each month (gross) after your plan is completed?
How do you expect to find a job by the time your plan is completed?
Anystate University Career Counseling & Job Placement
Vocational Rehabilitation Services.
Networking through Personal & Professional relationships.
School to Work Program
D. If your goal involves self-employment, explain why you believe that operating your own business is more likely to result in self-support than if you worked for someone else. My Goal Does not involve Self-Employment
Part II - Medical/Vocational/Educational Background
A. What is the nature of your disability? My primary disability is Cerebral Palsy.
B. Explain any limitations you have because of your disability (e.g., limited amount of standing
or lifting, etc.) I will use a wheelchair to get around my employment settings. I will need to
do seated work, will not be able to lift heavy objects, and will need adaptations to reach
items above my head. I will need more time to learn the job initially and may perform the
job at a slower rate than my co-workers.
C. List the types of jobs you have had most often in the past few years and those you have had which are similar to your work goal. Also show how long you worked (i.e., how many months or years) in each type of job.
Job Type did you work?
Please refer to Remarks Section -- Summary of Work Experiences
D. Check the block which describes the highest educational level you have completed:
[X] Elementary school  High school graduate or G.E.D.
 Some college  College graduate
 Post graduate courses  Postgraduate degree
 Trade or Vocational School  Other (Specify):
If you completed college, list your major and degree(s) attained; if you completed one or more
courses in a trade or vocational school, list the trade(s) you learned: N/A
E. Describe any other training you have received: The skills I have acquired through my
informal jobs at school, and will be useful in a paid job situation are: following directions,
navigating independently around the school, working independently for an extended time
and organizing items.
F. Have you ever undergone a vocational evaluation?  Yes [X] No
If yes, show the name, address and phone number of the person or organization who conducted the evaluation: Although I have begun a Vocational Evaluation, it is not yet completed.
G. Have you ever had a Plan for Achieving Self-Support before? [X] Yes  No
If yes, please answer the following:
When was your prior plan approved (month/year)? YES 07/28/98
When did it end (month/year)? 06/99
What was your goal in the prior plan? Vocational Evaluation through Community Work Experiences
Why did your prior plan not enable you to become self-supporting? PASS not written for specific work goal.
Why do you believe that this plan will be successful? I have been able to identify an employment consultant willing to provide services in my community. It has been difficult to find an employment consultant able to provide liaison services with my school and community. I continue to have a strong support group, comprised of family, friends and school staff.
H. If someone is helping you prepare this plan, please give their name, address and telephone
number: RSL, Organizational Consultant, Institute on Disabilities at Anystate Univerisity,
XXX Street, Anytown, Anystate 00000, (XXX)-111-0000.
ZYX, Project Coordinator, Institute on Disabilities at the Anystate University, XXX Street, Anytown, Anystate 00000, (XXX) 111-0000.
SMS, Special Educator, Anytown School, XXX School Drive, Anytown, Anystate 00000,
MKW, Nurse, Anytown Schools, (XXX) 111-0000.
*Mom , XXX Any Lane, Anytown, Anystate 00000, (XXX) 111-0000.
Do you want us to contact the person who is helping you if we need additional information about your
plan? *[X] Yes  No
Do you want us to send a copy of our decision on your plan to the person who is helping you?
*[X] Yes  No
Part III - Your Plan
List the steps, in sequence, that you will take to reach the goal and show the dates you expect to begin and complete each step. Be sure to show when you expect to purchase the items or services listed in Part IV.
I. Past Steps (Accomplishments to Date)
Performed Job Trial at Local Grocery Store. On 04/22/98.
Transition Planning including employment as part of IEP. From 05/98 to 05/2002.
PASS Submitted 5/98 for approval to SSA.
PASS Approved 07/28/98.
Funds released for PASS 10/98.
Performed school-based Job trials: From 09/98 to 04/99.
Performed Job Trial at Local Market
Performed Job Trial at Grocery Store
Perform on the job training at Local Market. During 04/99.
Perform on the job training at Pizza Restaurant. During 04/99.
Perform on the job training at Shirt Store. During 03/99.
Identify evaluator to complete Vocational Profile. From 10/98 to 11/98.
II. Steps upon approval of PASS Plan
Continue community-based Job Trials: From 11/98 to 06/99
Continue to Gather additional assessment information. From 12/98 to 09/99.
Complete written Vocational Profile Document. From 02/99 to 09/99.
Hold Profile Meeting and Identify specific employers to contact re: hiring Chris. From 03/99 to 09/99.
Revise and Extend PASS to incorporate my vocational goal derived from the Vocational Evaluation as required. From 04/99 to 06/99.
Obtain estimates on van. From 04/99 to 06/99.
Submit this PASS Plan. During 06/99.
Receive retroactive PASS funds for Van down-payment. From 06/99 to 07/99.
Purchase accessible van. From 06/99 to 08/99.
Research and purchase auto insurance. From 04/99 to 08/99.
Set up a maintenance schedule for van. From 08/99 to 06/2001.
Incorporate related curriculum in the Individual Education Plan (IEP). From 09/99 to
Structure classes in related employment area. From 09/99 to 06/2003.
Participate in School to Work Program. From 09/2001 to 06/2003.
Continue Life Skills Training and work with
OT, PT, and Speech Therapists. From 06/99 to 06/2003.
Develop multiple long-term jobs working with local employers and IEP curriculum for School To Work employment .From 09/99 to 06/2003.
Continue on-going tutoring throughout school year and summers.
Obtain part time clerical support position-15-20 hours/week during school summers and increasing to 30-35 hours/week after graduation from high school. From 06/99 to 06/2003.
VII. Receive on the job training. From 06/2002 to 06/2003.
Job Coaching during high school and summers will consist of one-on-one supports, decreasing and increasing as job duties are expanded and will be decreased to one to two hours/week after high school Graduation.
VII. Apply for ST Vocational Rehabilitation Services. From 09/2000 to 10/2000.
VIII. Complete PASS Requirements. As of 06/2001.
Part IV - Plan Expenditures and Disbursements
A. List the items or services you are buying or will need to buy in order to reach your goal. Be as
specific as possible. Where applicable, include brand and model number of the item. (Do not
include expenses you were paying prior to the beginning of your plan; only additional
expenses incurred because of your plan can be approved.) Explain why each is needed to reach
your goal. Also explain why less expensive alternatives will not meet your needs. Part III should
show when you will purchase these items or services.
1. Item/service: Job Development
and On-the-Job Training. Cost: $10,000.00
Vendor/provider: J. J. and Future Contracted Supports
Why needed: To assist me to secure a paid job and establish necessary supports to learn, perform, and maintain the job.
How will you pay for this item (e.g., one-time payment, monthly payment)? No Cost to PASS Plan. ST Vocational Rehabilition and Anytown Schools will be responsible.
How did you determine the cost? Estimate of 200 needed hours @ $50/hour.
2. Item/service: Van Cost: $12,000.00
Vendor/provider: Local Chevrolet Dealer with local Surgical Supply
Why needed: Provide safe transportation to work.
How will you pay for this item (e.g., one-time payment, monthly payment)? Monthly payments
How did you determine the cost? Received two estimates and made determination on the package best suited to my needs. I have decided to use a company from this area to ensure available service. An out of state company may be cheaper at time of purchase but will not be able to provide me with needed service without having to travel great distances. The cost of shipping the conversion and other additions was also considered. Payments for a five-year period will be approximately $790.00. Maintenance will be low as the van and equipment will be under warranty. I will be sharing the cost of the van with my brother Louis whom is also developing a PASS. The total van cost with all modifications is $35,000.00
3. Item/service: Van Insurance
Why needed: Insurance required by state law and bank requirement
How will you pay for this item (e.g., one-time payment, monthly payment)? Quarterly
How did you determine the cost? Phone Estimate
Insurance Costs will not be charged to the PASS Plan -- will be responsibility of family.
4. Item/service: Operational Costs, Gas, Maintenance and Tags Cost: $90.00/month
Vendor/provider: Local Service Stations
Why needed: Vehicle Maintenance to and from work
How will you pay for this item (e.g., one-time payment, monthly payment)? Weekly
How did you determine the cost? Estimated rural distances to employers. Costs will not be charged to the PASS Plan -- will be responsibility of family.
B. If you propose to purchase, lease or rent a vehicle, please provide the
1. Do you currently have a valid driver=s license?  Yes [x] No
If no, Part III must include the steps necessary to attain a driver's license. My disability will not allow me to attain a driver's license. I plan to contract with family members to perform this service.
Explain why alternate forms of transportation (e.g., public transportation, cabs, having friends or relatives drive you) will not allow you to reach your goal? My family and I live 21+ miles from the nearest town of # population. The nearest community with increased vocational opportunities is 45+ miles away. Public forms of transportation are not available to me. It is not reasonable to request assistance from neighbors due to inconvenience and my transportation needs.
If you are proposing to purchase a vehicle, explain why renting or leasing are not sufficient.
Because of special accommodations.
4. If you are proposing to purchase a new vehicle, explain why purchasing a reliable used vehicle is not sufficient. My family and I have not been able to find a used van that will adapt to our needs.
5. Explain why you chose the particular vehicle rather than a less expensive model. Low mileage, adaptable used conversion vans are difficult to find. It may cost more to adapt a used vehicle to my needs.
C. If you propose to purchase computer equipment or other expensive equipment, please explain why a less expensive alternative (e.g., rental or purchase of less expensive equipment) will not allow you to reach your goal. Explain why you need the capabilities of the particular computer/equipment you identified. Also, if you attend (or will attend) a school with a computer lab for student use, explain why use of that facility is not sufficient to meet your needs. I am not proposing to purchase any expensive equipment.
D. If you indicated in Part II that you have a college degree or specialized training, and your plan
includes additional education or training, explain why the education/training you already received is not sufficient to allow you to be self-supporting. N/A
Part V - Income/Resource Exclusion
A. List any items you already own (e.g., equipment or property) which you will use to reach your goal. Show the value of each item and explain why you need each of the items to attain your goal. 1. Wheelchair, for mobility and access to employment, Value = $1,800.00
B. What money do you already have saved to pay for the expenses listed in Part IV? (Include cash on hand or money in a bank account)? $2768.00 saved in a bank account.
C. Other than the earnings shown in Part I, what income do you receive (or expect to receive)? (Show how much you receive and how frequently you receive or expect to receive it.) $250.00 Adoption subsidy. +$148.00 Survivor's Benefits
D. How much of this money will you use each month to pay for the expenses listed in Part IV?
E. Do you plan to save any or all of this money for a future purchase which is necessary to complete your goal? [X] Yes  No
If yes, explain how you will keep the money separate from other money you have. (If you will keep the savings in a separate bank account, give the name and address of the bank and the account number.): Local State Bank, XXX Street, Anytown, Anystate, 00000.
F. What are your current living expenses each month (e.g., rent, food, utilities,
If the amount of income you will have available for living expenses after making payments or saving money for your plan expenses is less than your current living expenses, explain how you will pay for those living expenses. The amount of income I will have available is the same with or without a PASS.
G. Do you expect any other person or organization (e.g., Vocational Rehabilitation) to pay for or
reimburse you for any part of the items and services listed in Part IV or to provide any other items or services you will need?
[X] Yes  No If yes, please provide details as follows:
When will the item or Who will pay Item/service Amount service be purchased?
Vocational Rehab, Van Lift for $ 5,500 as of 9/1999.
JTPA Support, Conversion Package for $10,510 as of 9/1999.
Institute on Disabilities, PASS Consult for $ 2,500 as of 6/1999.
United Cerebral Palsey, Vocational Services for $14,000 as of 9/1999.
Part VI - Remarks
By ZYX, on behalf of Chris.
In the job trials Chris has participated in he has exhibited a strong work ethic. He especially enjoys tasks and environments that are new. He is not distracted by new environments and working with unfamiliar people. Chris has a good attention to detail and has the capability to be a very meticulous worker if he likes what he is doing. His O.T. and aide witnessed his best performance when he is seated, due to lack of balance. Chris is a compassionate young man. When he visits a local nursing home to volunteer, he attempts to communicate with residents in the halls and reaches out to touch their hands. Chris is a social young man and likes interacting with people in general but seems to especially like spending time with older males. Chris really enjoys being able to do things for himself. His interests include: computers, pets, jewelry, and physical activities like lifting weights.
Chris uses a wheelchair and a walker to move throughout an environment. His stamina is good. He has a fantastic memory and can navigate through large buildings independently. Crag can transition into a vehicle by using his walker. Chris's speech is sometimes difficult to understand even by people who know him well. He and his support staff are currently researching augmentative communication devices for more effective methods of communication. Chris needs support in the event that he has a seizure. He does lose consciousness and may slide out of his wheelchair.
Job Trial Summaries:
Pizza Restaurant: Chris washed tables. Although he followed a prescribed pattern for washing the tables he was not thorough enough to remove all food from the table. Chris appeared bored with the task and seemed to dislike wearing the rubber gloves and putting his hands in the bleach water used to clean the tables. However, he did seem to enjoy cleaning pool tables. He was quite thorough removing all debris from the table, and again was able to follow a prescribed pattern for cleaning the table. He used a roller brush to perform the task.
Local Gym Training: Chris performed a job trial assembling bicycle breaks as a consultant learner for a training. During the 30-minute trial he worked with people whom he had never met before, in an unfamiliar place, performing an unfamiliar task. Several people whom he knew (his mom, brother, aide and teacher were in the room at the time of his trial but were not interacting with him). There were many other distractions in the room as well; three other consultant learners were also performing the task simultaneously and 20 people were participating in the training. Chris remained focused on the task at hand. He had some difficulty performing some of the assembly steps which required fine motor coordination, e.g. picking up a break shoe by grasping it between the index finger and thumb. Chris persisted through these steps attempting to perform the task independently. He was meticulous in performance of each step. His speed was slow but it was unclear if it was caused by his thoroughness or the difficulty with the fine motor requirements of the task.
Local Cafe: Chris practiced rolling silverware at the Anytown Cafe for 1-2 hours. Although he was able to roll one utensil in a napkin, he was unable to roll all three pieces at a time and keep the napkin tight due to lack of dexterity. The business is small and congested, this made it difficult for Chris to move around the business with his wheelchair. Chris exhibits dulled sensitivity to temperatures; it may not be wise to employ Chris in eating establishments where safety could be an issue.
Shirt Store: Chris folded tee shirts for two hours. He was able to follow the prescribed steps shown to him by the owner. He folded the shirts neatly, smoothing out the wrinkles as he worked, and he sorted the shirts by color. Chris's performance was better folding the smaller shirts than the larger shirts since he could reach all the sides of the smaller shirt. Accommodations would have made it easier to complete tasks efficiently in a sitting position.
Local Market and Grocery Store Chain: Chris performed the task of facing shelves in both grocery stores. He was able to work independently for at least 30 minutes. Chris organized the shelves neatly ensuring all labels faced forward and rotated merchandise. Chris exhibited pride in his work at this site.
Part VII - Agreement
If my plan is approved, I agree to:
o Comply with all of the terms and conditions of the plan as approved by the Social Security
o Report any changes in my plan to SSA Immediately;
o Keep records and receipts of all expenditures I make under the plan until the next review of my
plan at which time I will provide them to SSA;
o Use the Income or resources set aside under the plan only to buy the items or services approved by SSA.
I realize that if I do not comply with the terms of the plan or if I use the Income or resources set aside under my plan for any other purpose, SSA will count the income or resources that were excluded and I may have to repay the additional SSI I received. I also realize that SSA may not approve any expenditure for which I do not submit receipts or other proof of payment.
I know that anyone who makes or causes to be made a false statement or representation of material fact in an application for use in determining a right to payment under the Social Security Act commits a crime punishable under Federal Law and/or State Law. I affirm that all the information I have given on this form is true.
Signature __________________ Date____________________
Privacy Act Statement
The Social Security Administration is allowed to collect the information on this form under section 1631 (e) of the Social Security Act. We need this information to determine if we can approve you plan for achieving self-support. Giving us this information is voluntary. However, without it, we may not be able to approve you plan. Social Security will not use the information for any other purpose.
We would give out the facts on this form without your consent only in certain situations. For example, we give out this information if a Federal law requires us to or if your Congressional Representative or Senator needs the information to answer questions, you ask them.
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor and you are not required to respond to, a collection of information unless it displays a valid OMB control number.
TIME IT TAKES TO COMPLETE THIS FORM
We estimate that it will take you about 45 minutes to complete this form. This includes the time it will take to read the instructions, gather the necessary facts and fill out the form. If you have comments or suggestions on this estimate, write to the Social Security Administration, ATTN: Reports Clearance Officer, 1-A-21 Operations Bldg., Baltimore, MD 21235. Send only comments relating to our Atime it takes@ estimate to the office listed above. All requests for Social Security cards and other claims-related information should be sent to your local Social Security office, whose address is listed under Social Security Administration in the U.S. Government section of your telephone directory.
RECEIPT FOR YOUR PLAN FOR ACHIEVING SELF-SUPPORT
We received the plan for achieving self-support which you submitted. We will process your plan as soon as possible.
You should hear from us within _______ days. We will send you a letter telling you if your plan is approved. We will notify you if we need additional information before making a decision on your plan. We may ask you to modify your plan.
YOUR REPORTING AND RECORD KEEPING RESPONSIBILITIES
If we approve your plan, you must tell Social Security about any changes to your plan. You must tell us if:
o Your medical condition improves.
o You are unable to follow your plan.
o You decide not to pursue your goal or decide to pursue a different goal.
o You decide that you do not need to pay for any of the expenses you listed in your plan.
o Someone else pays for any of your plan expenses.
o You use the income or resources we exclude for a purpose other than the expenses specified in your plan.
o There are any other changes to your plan.
You must tell us about any of these things within 10 days following the month in which it happens. If you do not report any of these things, we may stop your plan.
You should also tell us if you decide that you need to pay for other expenses not listed in you plan in order to reach your goal. We may be able to modify your plan or change the amount of income we exclude so you can pay for the additional expenses.
YOU MUST KEEP RECEIPTS OR CANCELED CHECKS TO SHOW WHAT EXPENSES YOU PAID FOR AS PART OF THE PLAN. You need to keep these receipts or canceled checks until we contact you to find out if you are still following your plan. When we contact you, we will ask to see the receipts or canceled checks. If you are not following the plan, you may have to pay back the some or all of the SSI you received.