No personal Information will be gathered.

Do you receive Social Security benefits?	Yes No
Do you receive SSDI?	Yes No
Do you receive Medicare?	Yes No
Do you receive SSI?	Yes No
Do you have Medicaid?	Yes No
Do you have a Ticket to Work?	Yes No
Did you assign your Ticket to an Employment Network/VR?	Yes No
If you are a person with a disability are you currently working?	Yes No
If you are not working do you want to work?	Yes No
Are you willing to work if it means your Social Security cash benefits will be reduced or even stop if you can keep your Health Coverage?	Yes No
Have you talked to someone from a Work Incentive Planning Assistance program about how working will affect your Social Security and other benefits?	Yes No