Current Version of SSA-455

Question 3 Can You Work?

Tell us if you have discussed with your doctor whether you can return
to any kind of work, and if so, whether the doctor told you that you can
return to work, even if the work permitted is less physically demanding
and/or less stressful than your usual work. Place an “X” in only 1 box.

Question 4 How Is Your
Health?

We want to know how your overall health now compares to what it was
at the beginning of the report period. You may feel that your health has
gotten worse, has improved, or you may feel that your health is about the
same and has not gotten better or worse. Place an “X” in only 1 box.

Question 5 Treatment By A
Doctor Or Clinic

A “doctor or clinic” can include treatment such as evaluations, checkups,
counseling, providing prescriptions or medicine by a doctor, visiting
nurse, family health center, psychologist, licensed counseling service,
physical therapist, a chiropractor or other licensed health provider.
Treatment may be provided in person or by telephone or other contact.

How To Answer
Question 5.a.

If you have not been treated by a doctor or clinic during the report
period, place an “X” in the box below “NO”, and go on to question 6. If
you have gone to a doctor or clinic during the report period, mark the
box below “yes”, and answer question 5.b.

Question 5.b. Reason For
The Visit

Please start with the most recent visit and then work backwards
in time. Print as much information as will fit, but keep a space between
each word. Try to use the most important or key word(s), such as
Arthritis or Bad Back, or Hypertension or High Blood.
Your medical bills or doctor can provide a short, accurate description.

Date of Visit

Print the month and year you were treated. Complete all 4 boxes. For
example, print September 10, 2003, as 09 03.

Note: If needed, use the “remarks” section on side 2 of the form.

Social Security Administration
Disability Update Report
Information and Completion Instructions
Why We Are
Writing To
You Now

The Social Security Administration must regularly review the cases of
people getting disability benefits to make sure they are still disabled
under our rules. It is time for us to review this case. Enclosed is a
Disability Update Report for you to answer to update us about
you (or the person for whom you are the representative payee), your
health and medical conditions, any recent work activity, or any recent
training.

What To
Do First

Please read the following information, and the instructions for
completing the report form, before you answer the questions.

When to
Respond

Please complete the report, sign it and send it to us in the enclosed
envelope within 30 days. If there is no return envelope with the report,
please send the signed report to us at:

Social Security Administration
P.O. Box 4550
Wilkes-Barre, PA 18767-4550

What We Do
With Your
Answers

We consider the information you give us together with the information
in your claim record to decide if we need to do a full medical review.
We will tell you within 90 days after we receive the completed report
whether or not we need to do a full medical review now.

Question 6.a Have You Been
Hospitalized Or
Had Surgery?

Place an “X” in the box below “NO” if you have not been hospitalized or
not had surgery during the report period. If you have been hospitalized
or had surgery during the report period, then place an “X” in the box
below “YES” and answer question 6.b.

If You Need
Help To
Answer The
Report

It is important that information you give us is accurate. We have tried
to make report questions easy to understand and answer. But, if you
find that you do not understand a question or questions, please contact
us, your authorized representative, a social service agency, your doctor
or clinic, or some other person you trust.

Question 6.b. Reason For
Treatment

Please report your most recent treatment first and then work
backwards in time. Try to provide the most important information.
Keep a space between each word. Your medical bills or doctor can
provide short, accurate words.

If You Need
To Contact
Us

If you need to contact us, please call us toll-free at 1-800-772-1213
or TTY for the hearing impaired at 1-800-325-0778. We can answer
most questions over the telephone. If you prefer to visit or call one of
our offices, please use the 800 number to get the local office address
and telephone number. Please have the Disability Update Report with
you if you call or visit an office. It will help us answer your questions.
Also, if you plan to visit an office, you should call ahead to make an
appointment. This will help us serve you.

We May Need
To Contact
You

Sometimes, we may need more information from you. If so, we will try
to call you. If you do not have a telephone, please give us a number
where we can leave a message for you. Please print the telephone
number in the section provided on the back of the report form.

If We Don’t
Hear From You

If you do not complete and return the report promptly, or tell us why
you cannot respond, we may stop sending payments to you. If it is
necessary to stop your payments, we will send you another letter
telling you what we plan to do.

Date of
Treatment

Print the month and year you were hospitalized or had surgery. Be
sure to use all four spaces. If you were hospitalized more than one
month, print last month you were hospitalized.
Note: If needed, use the “remarks” section on side 2 of the form.

Remarks
Section
Signature, Date
and Telephone
Sections
Form SSa-455-ocr-sm (02-2009)

If you need more room to answer questions 1.b., 5.b. and/or 6.b., or
there are any other facts or statements you want us to consider, place
an “X” in the box and write in this section. If necessary, use an extra
piece of paper.
Please sign the report form as you usually sign your name. Please
provide a telephone number where you can be reached during the day.

4

Form SSa-455-ocr-sm (02-2009)

Continued on the Reverse

If We Do A
Full Medical
Review

If we decide to do a full medical review of your case, you can give us
any information which you believe shows that you are still disabled,
such as medical reports and letters from your doctors about your
health. Then, we look at all your information in your case, including the
new information you give us, and decide whether you continue to be
disabled under our rules.

Appeals And
Continued
Benefits

When we review your case, we may find that you are no longer disabled
under our rules, and your payments may stop. If your payments stop,
you can appeal our decision or you can ask us to continue to make
payments while you appeal.

If You Want
To Work

Do you want to work, but worry about losing your payments or
Medicare before you can support yourself? We want to help you go to
work when you are ready. But, work and earnings may affect your
benefits. Your local Social Security office can tell you more about work
incentives, and how work and earnings can affect your benefits.

The Privacy
And
Paperwork
Reduction
Acts

Sections 205(a) and 1631(e)(1)(A) and (B) of the Social Security Act, as amended, and
Social Security regulations at 20 C.F.R. 404.1589 and 416.989 authorize us to collect
this information. The information you provide will be used to further document your
claim and permit a determination about continuing disability.

The Disability Update Report is a scannable form which can be “read”
electronically. To help us process your report, please follow these
instructions when you answer the questions on the report
form:
1. use black ink or a #2 pencil.
2. keep your numbers, letters, and “x’s” inside the
boxes.
3. numbers: Try to make your numbers look like these:

0 1 2 3 4 5 6 7 8 9
4. Letters: Print in Capitals. Try to make your letters look
like these:

A B C D E F G H I J K L M
N O P Q R S T U V W X Y Z
5: Money Amounts: Show dollars only. Do not use dollar signs
($), and do not show cents. For example, show $1,540.30 like this:
Dollars Only, No Cents

0 1 ,540

The information you furnish on this report is voluntary. However, if you do not
provide the requested information, a decision based on the evidence in your case can
result in a determination that your disability has ceased.
We rarely ever use the information you supply on this report for any purpose other
than making a determination relating to your disability. However, we may use it
for the administration and integrity of the Social Security programs. We may also
disclose information to another person or to another agency as follows:
1. To enable a third party or an agency to assist Social Security in establishing
rights to Social Security benefits and/or coverage;
2. To comply with federal laws requiring the release of information from
Social Security records (e.g., to the Government Accountability Office and
Department of Veterans’ Affairs);
3. To make determinations for eligibility in similar health and income
maintenance programs at the Federal, state and local level; and
4. To facilitate statistical research and audit activities necessary to assure
the integrity and improvement of the Social Security programs (e.g., to the
Bureau of the Census and private concerns under contract to Social Security).
We may also use the information you provide in computer matching programs.
Matching programs compare our records with records kept by other Federal, State or
local government agencies. Information from these matching programs can be used to
establish or verify a person’s eligibility for Federally funded or administered benefit
programs and for repayment of payments or delinquent debts under these programs.
Explanations about these and other reasons why information you provide us may be
used or given out are available in Social Security offices or on-line at www.ssa.gov. If
you want to learn more about this, contact any Social Security office.
Paperwork Reduction Act Statement – This information collection meets
the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork
Reduction Act of 1995. You do not need to answer these questions unless we display a
valid Office of Management and Budget control number. We estimate that it will take
about 15 minutes to read the instructions, gather the facts, and answer the questions.
Send only comments on our time estimate above to: SSA, 1338 Annex Building, 6401
Security Boulevard, Baltimore, MD 21235-6401

Form SSa-455-ocr-sm (02-2009)

general
instructions
- how to
complete
“scannable”
forms

2

6. Dates: Put a number in each box. For example, show September
9, 2003, like this:
Month

Year

0 9 03
7. The Report Period: The “report period” is the period of
time for which we need information. It is described at the top of
the report form to the right of your name, and again in questions 1
through 6. Usually, the report period is the last 24 months, but it
may be less. It is important that you keep the report period
in mind when answering the questions.

Question 1.a. Have You
Worked?

how to fill out the report form

If you have not worked during the report period, place an “X” in the
box below “no”, and go on to question 2. If you have worked, mark the
box below “yes”, and answer question 1.b.

Question 1.b. When You
Worked And
Your Monthly
Earnings

Describe your most recent work activity first. Print the months
and years you began and ended working in the boxes under “Work
Began” and “Work Ended.” If you are working now, print the
current month and year in the first set of boxes under “Work Ended.”
Print your gross monthly earnings for the periods you worked in the
boxes.

Question 2 School Or Work
Training

Place an “X” in the box below “YES” if you have attended school and/or
a training program during the report period; otherwise, mark the box
below “NO”. This could include high school equivalency programs,
college courses, vocational evaluation or retraining programs, but
generally would not include group therapy or hobbies.

Form SSa-455-ocr-sm (02-2009)

3

Continued on the Reverse

∗

DATE:

Disability Update Report
Social Security Administration, P.O. Box

FORM APPROVED
OMB NO. 0960-0511

, Wilkes-Barre, PA 18767

PAYEE’S NAME AND ADDRESS

REPORT PERIOD
From:
BENEFICIARY

To The Present

PSC:
TELEPHONE NUMBER

1.

a. Since

CLAIM NUMBER

YES

, have you worked for someone

NO

➤

or been self-employed?

b. If you answered “YES” to 1.a., please complete the information below.
WORK ENDED
Month
Year

WORK BEGAN
Month
Year

Most
Recent
Work

2.

1.

$

,

2.

$

,

3.

$

,

Have you attended any school or work training program(s)
since

3.

YES

NO

?
to the present...(Please place an “X” in one box only):

Since

my doctor and I
have not discussed
whether I can work.

4.

MONTHLY EARNINGS
Dollars Only, No Cents

my doctor
told me I
cannot work.

my doctor
told me I
can work.

Place an “X” in only one box which best describes your health
now as compared to
BETTER

Form SSA-455-OCR-SM (10-2003)

.
SAME
Continued on the Reverse

WORSE

➤

FOR SSA USE ONLY

AC?

5.

a. Have you gone to a doctor or clinic for treatment
(including evaluations, checkups, counseling,
prescriptions, or medicine) since
?

YES

NO

➤

b. If you answered “YES” to 5.a., please list:
Reason For Visit:
Most
Recent
Visit

Month

Year

1.
2.
3.

6.

a. Have you been hospitalized or had surgery
since

?

YES

NO

➤

b. If you answered “YES” to 6.a., please list:
Most
Recent

Reason For Hospitalization or Surgery:

Month

Year

1.
2.
3.

REMARKS: If you use this space to further answer questions 1. through 6.,
place an “X” in the box to the right and print on the lines below.

SIGN HERE

➧

Form SSA-455-OCR-SM (10-2003)

TODAY’S DATE
TELEPHONE NUMBER (include Area Code)