Name: Updated 9-2019
BHDDH DIVISION OF DEVELOPMENTAL DISABILITIES
ISP ATTACHMENT FORM FOR BENEFITS PLANNING AND EMPLOYMENT
What information on Social Security Work Incentives, have you received? This includes information a family
member or rep payee received on your behalf. Check all that apply.
I received (check all that apply):
❑ SSA Working While Disabled Pamphlet
❑ Myths & Facts: Social Security Benefits & Work
❑ Sherlock Plan information
I attended (check all that apply):
❑ A group work incentive information session
❑ An individual counseling session for a benefits plan
I have secured employment and have a benefits plan written by a Certified Work Incentives Counselor
(CWIC)?
If YES, date of plan: __________________ If NO, I have declined a benefits plan _____________
Working age adults (age 18+) must choose one of the following statements:
❑ I am employed and choose to: Check all that apply.
❑ Retain current integrated job.
❑ Advance in current integrated job (more hours, raise, new skills, promotion, etc.)
❑ Get a new integrated job.
❑ Get an additional integrated job.
❑ Maintain a job in a non-integrated employment setting.
▪ Complete separate Request for Variance for Segregated Employment and submit
separately.
❑ I am Retired – I am at least 62 or will be this ISP year.
▪ Employment goals are not required, but plan must address retirement activities.
❑ I am currently not working in integrated employment, but I’m interested and choose to: Check all
that apply.
❑ I want to obtain integrated employment.
❑ Explore interests in integrated employment or in community settings through an
Employment Path, Discovery, or other time‐limited service.
❑ I’m enrolled in Post-Secondary Education or a Vocational Training Program.
❑ Not pursue integrated employment at this time due to need to stabilize health (including
behavioral health).
❑ Other: please explain___________________________________________________
❑ I am not interested in employment
▪ Complete Request for Variance for Day Only Services and submit separately.
Status with Office of Rehabilitation Services (ORS)
❑ I want ORS services
Application Date:_________
❑ I am currently receiving ORS Services
❑ I went to ORS in the past, now closed
❑ Other/Not Applicable, please explain:
