Effective Dates: 05/28/2002 - Present Previous | Next

TN 1 (05-02)

DI 28087.035 Preparation and Routing of Title XVI Child Referrals to the Designated State Agency

A. Introduction - referrals

Use Form SSA-3661-U2 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-832-U5 unless a separate referral is also being made to vocational rehabilitation and VR procedures call for it.

B. Procedure - preparation

The DDS will complete form SSA-3661-U2 after it has completed its disability determinations.

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.

C. Procedure - material to be attached

 

Attach legible copies of the following material:

  1. 1. 

    Form SSA-1994, Cover Sheet (Confidential Information).

  2. 2. 

    Form SSA-831-U5, The Disability Determination.

  3. 3. 

    Form SSA-3820, “Medical History and Disability Report -- Widow, Widower, Surviving Divorced Wife, or Disabled Child”.

  4. 4. 

    Current Medical Reports

  5. 5. 

    Any other information considered useful for social, developmental, educational, medical and rehabilitative services.

D. Procedure - routing

Send original and copy of form SSA-3661-U2 to designated State agency.

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0428087035
DI 28087.035 - Preparation and Routing of Title XVI Child Referrals to the Designated State Agency - 05/28/2002
Batch run: 02/05/2015
Rev:05/28/2002