CALIFORNIA BRIDGES TO YOUTH SELF-SUFFICIENCY (BRIDGES)
INFORMED CONSENT AND RELEASE OF INFORMATION
Name: ____________________________________ SSN: ____________________
Date of Birth: ____________________
Please check the school district where you receive services:
Irvine USD
Capistrano USD
Vallejo City USD
Newport-Mesa USD
Riverside COE
Whittier UHSD
Saddleback Valley USD
I understand that the Bridges Project is a five (5) year State of California Department of
Rehabilitation (CDOR) and Social Security Administration (SSA) research study testing ways to
help youth with disabilities gain access to services and support that are necessary to get and
keep a job. I also understand that in order to participate in the Bridges project, I must be an
active participant.
I hereby authorize the school district checked above, CDOR, and SSA to release/exchange
records and information about me for the purpose of the study. Information to be released
includes disability, educational/employment, financial, social and health information. I
understand that the information the school district checked above, CDOR, and SSA collect about
me is confidential and protected under the Privacy Act.
SSA will share the information with an evaluation team, in order to learn how well the Bridges
Project worked and the best way in which to help youth people with disabilities find and keep
work. I understand SSA will share this information with other organizations involved in the
Bridges Project and, as required, under the Social Security Act, with State agencies that make
disability decisions.
I understand this information and my work can affect my application for Social Security Disability
Insurance Benefits, and/or Supplemental Security Income payments, or my continuing eligibility.
I also understand that it is my continuing responsibility to report earnings information, income
and other changes (that may effect my benefits) directly to the SSA office. Finally, I know that
a school district staff representative will be available to help me understand Social Security
benefits and provide resources to help me plan for the future.
I know that I do not have to take part in this project. There is no penalty for not volunteering or
dropping out whenever I choose. My signature below indicates that I want to be part of the
project. I understand that I can withdraw my consent at any time. If not ended sooner, my
authorization to share information shall terminate at the completion of Bridges Project September 30, 2008.
____________________________________________________
Applicant’s Signature
____________________________________________________
Parent/Guardian (required for youth under 18)
_____________
Date
_____________
Date
I have read materials to the applicant, and I believe that he/she understands it.
____________________________________________________
School District Representative
Bridgesinfchoice.doc
2003
_____________
Date
Privacy Act Language – Informed Consent
SSA is allowed to collect the information asked for while you participate in the Bridges
Project, under section 1110(b) of the Social Security Act (the Act). We use the information
to decide what services would best help you. You do not have to give us this information.
However, if you do not, we will be unable to offer you services.
There are certain situations authorized by Federal law in which SSA may release the
information you give us through the Bridges Project. For example, we release the
information to a congressional office in response to an inquiry that office may make at your
request, or to the national evaluation team hired by SSA to evaluate the all of the states that
participate in the Project.
Explanations about these and other reasons why information you provide us may be used or
given out are available in Social Security Offices. If you want to learn more about this,
contact any Social Security Office.
Bridgesinfchoice.doc
2003