The SSA-1407-U4 is a form which is used to refer individuals to the State VR agency.
When making a referral to VR, prepare an original and two copies of the SSA-1407-U4
as follows:
Item 1 |
- |
State of residence of the individual |
Item 2 |
- |
Enter the individual's own SSN |
Item 2A |
- |
If CDB or DWB, enter SSN of primary beneficiary |
Item 3 |
- |
Enter the individual's name |
Item 4 |
- |
Enter month, day and year of birth |
Item 5 |
- |
Check appropriate box |
Item 6 |
- |
Check appropriate block |
Item 7 |
- |
Show the number of years of formal education |
Item 8 |
- |
Enter the DDS code for the State of residence |
Item 9 |
- |
Enter the individual's full address and the DO code |
Item 10 |
- |
Check block A |
Item 11 |
- |
Show by checks all payments allowed (SSDI) |
Item 12 |
- |
Check one box indicating individual's primary impairment |
Item 13 |
- |
If the folder contains a copy of the individual's plan for self-support, check the
block and attach a copy of the plan
|
Item 14 |
- |
Enter a description of all material sent to VR agency, e.g., Medical Report from Dr.
Smith dated 7/6/76
|
Item 15 |
- |
Enter any special information the VR agency might find useful, e.g., an urgent need
for a particular VR service
|
Item 16 |
- |
Signature of the examiner who makes the referral |
Item 17 |
- |
Date of referral |
1. Attachments to the SSA-1407-U4
-
a.
Form SSA-1994, Cover Sheet (Confidential Information)
-
b.
A copy of the determination (SSA-831-U5 SSA-832-U5 or SSA-833-U5 and SSA-834-U4)
-
c.
Form SSA-3368-BK, SSA-3369-BK, SSA-3820-BK, SSA-3441-BK (Photocopy)
-
d.
Current medical reports (photocopy)
-
e.
Vocational evaluation reports (photocopy)
-
f.
Any other material which may be useful to the VR agency (photocopy)
2. Routing of the SSA-1407-U4
Send the original and one copy with attachments to the mailroom by OF-41. Insert the
remark, “Send to (name of State) VR agency.” Place the remaining copy in the folder. The Privacy Act requires accounting for all
routine disclosure. The folder copy of the SSA-1407-U4 satisfies this requirement.