Soar Data Form Muskegon County Page 2
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2Applicant ID # __ __ __ __ __
14. Representative payee provided?
Yes
No
Pending
15. If denied, was a reconsideration or appeal filed?
Yes
No
16. If homeless at time of application, date applicant was housed
(mm/dd/yyyy)
B: SOAR – Initiated Reconsideration or Appeal
1.
Did SOAR staff initiate the reconsideration or appeal?
Yes
No
2.
Did SOAR staff submit SSA 1696 Appointment of Representative form?
Yes
No
3.
Were medical records collected and submitted?
Yes
No
4.
Was a medical summary report written and submitted?
Yes
No
5.
Was an expedited hearing requested?
Yes
No
6.
Was a review on record requested?
Yes
No
7.
Did applicant have an attorney?
Yes
No
8.
Date of hearing decision or review on record:
___ / ___ / ____
(mm/dd/yyyy)
9.
Outcome of hearing or review on record:
Approved
Denied
10. Approved for SSI?
Yes
No
11. Approved for SSDI?
Yes
No
12. Representative payee needed?
Yes
No
13. Representative payee provided?
Yes
No
Pending
C: Pending Applications (Those Not Initiated Using SOAR)
1.
Date of first contact with applicant whose claim was pending:
___ / ___ / ____
(mm/dd/yyyy)
2.
When you began working with applicant, was application pending at the:
a. Initial Level?
Yes (Go to Q. 3)
No
b. Reconsideration Level?
Yes (Go to Q. 4)
No
c. Administrative Law Judge (ALJ) hearing level?
Yes (Go to Q. 5)
No
3.
Initial level
a.
Date of initial decision
___ / ___ / ____
(mm/dd/yyyy)
b.
Outcome of initial decision (If approved, go to Q. 6)
Approved
Denied
c.
If denied, was a request for reconsideration filed?
Yes
No
4.
Reconsideration Level
(mm/dd/yyyy)
a. Date of reconsideraton
b. Outcome of reconsideration (If approved, go to Q. 6)
Approved
Denied
c. If denied, was an appeal for an Administrative Law Judge (ALJ)
Yes
No
hearing filed?
5.
Administrative Law Judge (ALJ) hearing level
a. Date of ALJ hearing decision
___ / ___ / ____
(mm/dd/yyyy)
b. Outcome of ALJ hearing decision
Approved
Denied
6.
Approved for SSI?
Yes
No
7.
Approved for SSDI?
Yes
No
8.
Representative payee needed?
Yes
No
9.
Representative payee provided?
Yes
No
Pending
M171 Rev. 3/01/10
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