North Carolina Coalition to End Homelessness

PO Box 27692
Raleigh, NC 27611
Tel: 919-755-4393

SOAR Outcome Reporting Tool

Use this form to keep us updated on your cases! If you have completed or are currently working on a disability application with an individual, please let us know!
 
This information is essential to the successful implementation of SOAR in North Carolina. If you have any questions regarding this form, please contact Emily Carmody at (919) 755-4393 or email Emily
 
Be sure to complete all required fields marked *

SOAR Caseworker Information

First Name*
Last Name*
What county do you work in?*
Company*
Work Phone*
Email*
Certified SOAR Worker

Applicant Information

First Two Letters of First Name*
First Two Letters of Last Name*
Date of Birth (mm/dd/yyyy)*
Gender
Veteran?

SSI and SSDI Application Information

Level of Application
Is this an update to a previously submitted outcome?
Protective Filing Date (mm/dd/yyyy)
Length of time homeless (as of Protective Filing Date-- #years or months)
Did you file an SSI and SSDI application? (remember-- you should file for both!)
If no application was filed, why not?
Was the application given the SSA "Homeless Flag"?
If no, why not?
Did you become the 1696 Representative?
Date disability report and application for SSI/SSDI completed (mm/dd/yyyy)
Date medical records and/or medical summary report submitted to DDS (mm/dd/yyy)

Determination Information

Date of DDS Determination (mm/dd/yyyy) If presumptive disability decision, enter date of presumptive decision.
Outcome of DDS Determination
Was the case reassigned to a SOAR DDS Examiner? (If you are unsure, please contact NCCEH.)
SSI Approved?
SSI Benefit Amount Awarded? (monthly)
SSDI Approved?
SSDI Benefit Amount Awarded? (monthly)
Total Amount of Back Pay Awarded?
Medicaid Approved?
Medicare Approved?
Rep. Payee Needed?
Rep. Payee Provided?
Consultative Exam Required?
Date Housed (mm/dd/yyyy)

Comments

Anything else you would like us to know about?

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