BASIC (05-02)

DI 26520.030 Completion of Vocational Rehabilitation (VR) Referral Forms

A. Procedure - Form SSA-1407-U4 (Transmittal of Controlled Title II/XVI Referral or Referral to VR)

Use either Form SSA-1407-U4 or some alternative routing form (e.g., a route slip) to refer for VR. If the Form SSA-1407-U4 is used, only items 1, 2, 2a, and 3 of that form need to be completed.

If the claimant moves to another State before adjudication is completed and he/she appears to be a candidate for VR services, enter under “Remarks” on the SSA-1407-U4 “Claimant moved to your State—please consider referral to VR agency.”

NOTE: Disability Determination Services (DDS) addresses may be found in DI 33500.ff. DDS addresses may also be found in the Service Area Directory.

For the purpose of further vocational rehabilitation consideration, the DDS will probably wish to use essential portions of the information or documents obtained in connection with the disability determination. This may be accomplished by transcribing the desired information or making photocopies of the original documents.

B. Procedure - Form SSA-3661-U2 (Transmittal of TITLE XVI Referral to Designated State Agency)

1. Referrals

Form SSA-3661-U2 is used to transmit all under age 16 title XVI disability and blind recipient referrals and additional material to designated State agencies. Do not check the VR referral box on the SSA-831-U5 unless a separate referral is also being made to VR.

2. Preparation

This form should be completed by the DDS after it has completed its disability determination.

Item

Explanation

1

Enter the name and address of the appropriate designated State agency.

2

Enter the child's SSN.

3

Enter the child's name.

4

Enter the child's date of birth.

5

Check “M” or “F.”

6

Enter the three digit DDS code (SA code).

7

Enter the child's full address.

8

Check “A” or “B.” Do not check “B” unless a separate referral is also being made to vocational rehabilitation.

9

Enter the full name and relationship of the adult responsible for the child.

10

Enter the responsible adult's address.

11

Enter any special information you feel the designated State agency might find useful including the identification of any referral of a child denied SSI benefits. (Referral of denied children should be made only if the designated State agency requests them.)

12

The form should be signed by the individual making the referral.

13

Enter the date of the referral.

15-18

To be completed and sent to SSA by the designated State agency only when it determines that the child's impairment(s) has diminished to the extent that it may no longer be disabling.

3. SSA-1407-U4 and SSA-3661-U2 Attachment Chart

Attach legible copies of the following material:

Attachments

SSA-1407-U4

SSA-3661-U2

SSA-1994, Cover Sheet

X

X

SSA-831-U5 or SSA-833-U5

X

X

SSA-3368-BK