Current SSA-4570

Form SSA-4570 (08-2023)
Discontinue Prior Editions
Social Security Administration

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OMB No. 0960-0768

Protection and Advocacy for Beneficiaries of Social Security (PABSS)
Annual Performance Report
Reporting Period: From

PABSS Grant
Award Number:

To

State:
Agency Name:

Agency
Address:

PABSS Coordinator:
Report Prepared By:
Telephone Number:

Fax Number:

Email Address:
Date Submitted:
Part 1 - Quantitative Statistics
Section A: Individuals and Service Requests
1. Information and Referral (I&R)
How many individuals received I&R under PABSS funding during the reporting period?
2. PABSS Service Requests
a. How many individuals had open PABSS service requests at the start of the reporting period?
b. Indicate the number of PABSS service requests added during the reporting period:
c. Total number of PABSS service requests closed during the reporting period:
3. Please provide counts of individuals served by Race
a. American Indian or Alaska Native:
b. Asian:
c. Black or African American:
d. Native Hawaiian or Other Pacific Islander:
e. White:

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4. Please provide counts of individuals served by Ethnicity
a. Hispanic or Latino:
b. Not Hispanic or Latino:
5. Provide counts of individuals served during the reporting period who were:
Age 14 to 25
6. Beneficiary Services (provide counts by type of benefit)
a. Supplemental Security Income (SSI) eligible:
b. Social Security Disability (SSDI) eligible:
c. Eligible for both SSI and SSDI:
Section B: PABSS Service Request Source of Concern
1. Provide counts of PABSS service requests and the area of concern in the reporting period.
a. Education:
b. Employment discrimination:
c. Employment Services (Vocational Rehabilitation (VR),
Employment Networks (EN) and other employment supports):
d. Employment Support (Assistive Technology, supportive employment, sheltered
work, reasonable accommodations):
e. Employment – other issues:
f. Entitlements, Health Insurance and Benefits Planning:
g. Healthcare (includes personal health service issues):
h. Housing:
i. Support Services (other than employment):
j. Transition Services:
k. Transportation:
Total PABSS service requests during the reporting period:

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Section C: Closed Service Requests
1. PABSS Case Resolution - show case resolution type in the reporting period.
a. Issue Resolved in Individual’s Favor:
b. Issue Partially Resolved in Individual’s Favor:
c. Issue not resolved in Individual’s Favor:
d. Issue Lacked legal merit, complaint withdrawn or not pursued by the individual:
2. PABSS Outcome for the individuals served (provide counts) during the reporting period.
a. Individual gained or maintained access to Employment Services from an EN, VR
agency or other employment support provider:
b. Individual obtained, regained, or maintained employment:
c. Individual obtained access to Support Services (indirectly related to employment):
3. What was the highest intervention strategy used?
a. Short Term/Technical assistance:
b. Informal Resolution:
c. Investigation/Monitoring:
d. Negotiation, Mediation or Alternative Dispute Resolution:
e. Administrative Remedies:
f. Legal Remedy/Litigation:
g. Class Action Suits:
h. Systemic/Policy Activities:

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Part 2 - Narrative Reporting
A. Description of Progress and Status Update - Provide a brief overview of overall project status, staff
changes, staff training or other major developments with regard to the PABSS program for the reporting
period. This can include a description of PABSS priorities and services and organizational updates.

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B. Service Request Summaries - Provide summaries of three Issues/Service Requests undertaken as part
of the PABSS project. Describe the issue or problem, the PABSS intervention, and the outcome. If
involved in systems advocacy, please include a description here.

C. Outreach Narrative - Describe the agency's outreach efforts, including the number of outreach
presentations during the reporting period by PABSS staff. Highlight efforts to reach youth, minority
populations and veterans. Describe media activities, including radio and TV appearances; newspaper,
magazine and journal articles; Public Services Announcements or videos; and social media efforts.
Please include PABSS participation on local boards and statewide networks.

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D. Challenges - Describe any challenges the PABSS program experienced during the reporting period.
Describe efforts to resolve these challenges.

E. Inclusion Activities - Describe efforts to address the needs of individuals with disabilities from diverse
ethnic and racial communities and under-served populations.