Form SSA-3441-BK Disability Report--Appeal

DISABILITY REPORT - APPEAL - Form SSA-3441-BK
READ ALL OF THIS INFORMATION BEFORE YOU BEGIN
COMPLETING THIS FORM
We will use the information that you give us on this form to update your disability report
information for your appeal. We will use the form to update your disability information since
you last completed a disability report. Please complete as much of the form as you can. If
you need help, your interviewer will help you finish it. If you have an appointment for an
interview by telephone, have the form ready to discuss with us when we call you. If you have
an appointment for an interview in our office, bring the completed form with you or mail it
ahead of time, if you were told to do so. If you have access to the Internet, you may access the
Disability Report Form - Appeal instructions at http://www.ssa.gov/online/ssa-3441.html.

HOW TO COMPLETE THIS FORM

• Print or write clearly.
• DO NOT LEAVE ANSWERS BLANK. If you do not know the answers, or the answer
•
•
•
•
•

is "none" or "does not apply," please write: "don't know," or "none," or "does not apply."
IN SECTION 3, PUT INFORMATION ON ONLY ONE DOCTOR/HMO/
THERAPIST/OTHER/HOSPITAL/CLINIC IN EACH SPACE.
Each address should include a ZIP code. Each telephone number should include an area code.
DO NOT ASK A DOCTOR OR HOSPITAL TO COMPLETE THIS FORM.
However, you can get help from other people, like a friend or family member.
Be sure to explain an answer if the question asks for an explanation, or if you want to give
additional information.
If you need more space to answer any questions or want to tell us more about an answer,
please use Section 10 - REMARKS on Page 7, and show the number of the question being
answered.
ABOUT YOUR MEDICAL RECORDS

If you have any medical records or copies of prescriptions at home, send them to our office with
your completed form or, if you are having an interview in our office, bring them and any
medicine containers with you. If you need the records back, tell us and we will photocopy them
and return them to you.
YOU DO NOT NEED TO ASK DOCTORS OR HOSPITALS FOR ANY MEDICAL
RECORDS THAT YOU DO NOT ALREADY HAVE. With your permission, we will do that
for you. The information we ask for on this form tells us to whom we should send a request for
medical and other records. If you cannot remember the names and addresses of your medical
sources, you may be able to get that information from the telephone book, medical bills,
prescriptions, or prescription containers.

Disability Report - Appeal SSA-3441-BK

If you are filling out the form for someone else, please provide information about him or her.
When a question refers to "you," "your," or the "Disabled Person," it refers to the person who
is applying for or has been entitled to disability benefits.

The Privacy Act
See Revised Privacy Act Statement Attached
We are authorized to collect the information on this form under sections 205(a) and (b), 223(d), and
1631(e)(1) of the Social Security Act. We will use the information you provide on this form to
make a decision on your claim or case. Your response to this request is voluntary. However, failure
to provide all or part of the information could prevent us from making an accurate and timely
decision on your claim or case.
We rarely use the information you supply for any purpose other than for determining your living
arrangements. However, we may use it for the administration and integrity of Social Security
programs. We may also disclose information to another person or to another agency in accordance
with approved routine uses, which include but are not limited to the following: (1) to enable a third
party or an agency to assist Social Security in establishing rights to Special Veterans Benefits; (2)
to comply with Federal laws requiring the release of information from Social Security records (e.g.,
to the 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, audit, or investigative activities necessary to assure the integrity of Social
Security programs.
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.
Additional information regarding this form, routine uses of information, and our programs and
systems, is available on-line at www.socialsecurity.gov or at any local Social Security office.

The Paperwork Reduction Act
See Revised PRA Statement Attached
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 45 minutes to read the instructions, gather the facts, and answer the questions.
SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. The office is listed under U. S. Government agencies in your telephone directory
or you may call Social Security at 1 800 772 1213 (TTY 1 800 325 0778). You may send
comments on our time estimate above to: SSA, 6401 Security Boulevard, Baltimore, MD
21235-6401. Send only comments relating to our time estimate to this address, not the
completed form.
AFTER COMPLETING THIS FORM, REMOVE THIS SHEET AND KEEP IT
FOR YOUR RECORDS.

Form Approved
OMB No. 0960-0144

SOCIAL SECURITY ADMINISTRATION

DISABILITY REPORT - APPEAL
For SSA Use Only
Do not write in this box.

-

Related SSN
Individual
is filing:

-

Number Holder
Date of Last
Disability Report

Reconsideration

Request for Review by Federal
Reconsideration for Disability Cessation
Reviewing Official

Request for ALJ Hearing

SECTION 1 - INFORMATION ABOUT THE DISABLED PERSON
A. NAME (First, Middle Initial, Last)

B. SOCIAL SECURITY NUMBER

-

-

C. DAYTIME TELEPHONE NUMBER (If you do not have a number where we can reach you, give us a
daytime number where we can leave a message.)

(

)

-

Area Code

Your Number

Message Number

None

Number

D. Give the name of a friend or relative that we can contact (other than your doctors) who
knows about your illnesses, injuries, or conditions and can help you with your claim or
case.
NAME

RELATIONSHIP

ADDRESS
(Number, Street, Apt. No.(If any), P.O. Box, or Rural Route)

City

State

ZIP

(
)
DAYTIME
Area
Code
PHONE

Number

SECTION 2 - INFORMATION ABOUT YOUR ILLNESSES, INJURIES, OR CONDITIONS
A. Has there been any change (for better or worse) in your illnesses, injuries, or conditions
Yes
No
since you last completed a disability report?
If "Yes," please describe in detail:

Approximate date the
changes occurred:
Month

Day

Year

B. Do you have any new physical or mental limitations as a result of your illnesses, injuries,
or conditions since you last completed a disability report?
Yes
No
If "Yes," please describe in detail:

Approximate date the
changes occurred:
Month

Form SSA-3441-BK (08-2010) ef (08-2010) Destroy Prior Editions

PAGE 1

Day

Year

C. Do you have any new illnesses, injuries, or conditions since you last completed a
Yes
No
disability report?
If "Yes," please describe in detail:

Approximate date the
changes occurred:
Month

Day

Year

If you need more space, use Section 10 - REMARKS.
SECTION 3 - INFORMATION ABOUT YOUR MEDICAL RECORDS
A. Since you last completed a disability report, have you seen or will you see a
doctor/hospital/clinic or anyone else for the illnesses, injuries, or conditions that limit
your ability to work?
YES
NO
B. Since you last completed a disability report, have you seen or will you see a
doctor/hospital/clinic or anyone else for emotional or mental problems that limit your
YES
NO
ability to work?
C. List other names you have used on your medical records.

If you answered "NO" to both A and B, go to Section 4 - MEDICATIONS.

Tell us who may have medical records or other information about your illnesses, injuries, or
conditions since you last completed a disability report.
D. List each DOCTOR/HMO/THERAPIST/OTHER. Include your next appointment.
1. NAME

DATES
FIRST VISIT

STREET ADDRESS

CITY

STATE

LAST VISIT

ZIP

PHONE

(

)

Area Code

-

PATIENT ID # (If known)

Phone Number

REASONS FOR VISITS

WHAT TREATMENT DID YOU RECEIVE?

Form SSA-3441-BK (08-2010) ef (08-2010)

PAGE 2

NEXT APPOINTMENT

2. NAME

DATES
FIRST VISIT

STREET ADDRESS

CITY

STATE

ZIP

LAST VISIT

PHONE

(

)

PATIENT ID # (If known)

-

Area Code

NEXT APPOINTMENT

Phone Number

REASONS FOR VISITS

WHAT TREATMENT DID YOU RECEIVE?

If you need more space, use Section 10 - REMARKS.
E . List each HOSPITAL/CLINIC. Include your next appointment.
HOSPITAL/CLINIC

TYPE OF VISIT

NAME

INPATIENT
STAYS

DATES
DATE IN

DATE OUT

DATE FIRST VISIT

DATE LAST VISIT

(Stayed at least overnight)

STREET ADDRESS
OUTPATIENT
VISITS

STATE ZIP

CITY

(Sent home same day)

PHONE

(

)

EMERGENCY
ROOM VISITS

-

Area Code

DATES OF VISITS

Phone Number

Next appointment

Your hospital/clinic number

Reasons for visits

What treatment did you receive?

What doctors do you see at this hospital/clinic on a regular basis?

If you need more space, use Section 10 - REMARKS.
Form SSA-3441-BK (08-2010) ef (08-2010)

PAGE 3

F. Since you last completed a disability report, does anyone else have medical records
or information about your illnesses, injuries, or conditions (for example, Workers'
Compensation, insurance companies, prisons, attorneys, or welfare agency), or are you
YES
NO
scheduled to see anyone else?
If "YES," complete information below:
NAME

DATES

STREET ADDRESS

FIRST VISIT

CITY

STATE

ZIP

LAST VISIT

PHONE

(

)

Area Code

NEXT APPOINTMENT

Phone Number

CLAIM NUMBER (if any)
REASONS FOR VISITS

If you need more space, use Section 10 - REMARKS.
SECTION 4 - MEDICATIONS
Are you currently taking any medications for your illnesses, injuries or conditions?
If "YES," please tell us the following: ( Look at your medicine containers, if necessary.)

NAME OF MEDICINE

IF PRESCRIBED, GIVE
NAME OF DOCTOR

REASON FOR MEDICINE

YES

SIDE EFFECTS YOU
HAVE

If you need more space, use Section 10 - REMARKS.
Form SSA-3441-BK (08-2010) ef (08-2010)

PAGE 4

NO

SECTION 5 - TESTS
Since you last completed a disability report, have you had any medical tests for illnesses,
injuries, or conditions or do you have any such tests scheduled?
YES
NO
If "YES," please tell us the following: (Give approximate dates, if necessary.)

WHEN WAS/WILL
TEST BE DONE?
(Month, day, year)

KIND OF TEST

WHERE DONE?
(Name of Facility)

WHO SENT YOU FOR
THIS TEST?

EKG (HEART TEST)
TREADMILL (EXERCISE TEST)
CARDIAC CATHETERIZATION
BIOPSY -- Name of body part
HEARING TEST
SPEECH/LANGUAGE TEST
VISION TEST
IQ TESTING
EEG (BRAIN WAVE TEST)
HIV TEST
BLOOD TEST (NOT HIV)
BREATHING TEST
X-RAY -- Name of body part
MRI/CT SCAN -- Name of body
part

If you need more space, use Section 10 - REMARKS.
SECTION 6 - UPDATED WORK INFORMATION
Have you worked since you last completed a disability report?

YES

NO

If "YES," you will be asked to give details on a separate form.

SECTION 7 - INFORMATION ABOUT YOUR ACTIVITIES
A. How do your illnesses, injuries, or conditions affect your ability to care for your personal
needs?

Form SSA-3441-BK (08-2010) ef (08-2010)

PAGE 5

B. What changes have occurred in your daily activities since you last completed a
disability report?
If none, show "NONE."

If you need more space, use Section 10 - REMARKS.
SECTION 8 - EDUCATION/TRAINING INFORMATION
Have you completed any type of special job training, trade or vocational school since you
last completed a disability report?
YES
NO
If "YES," describe what type:

Approximate date completed:
SECTION 9 - VOCATIONAL REHABILITATION, EMPLOYMENT, OTHER SUPPORT
SERVICES INFORMATION, OR INDIVIDUALIZED EDUCATION PROGRAM
Since you last completed a disability report, have you participated, or are you participating in:
•

an individual work plan with an employment network under the Ticket to Work Program;

•

an individualized plan for employment with a vocational rehabilitation agency or any other organization;

•

a Plan to Achieve Self-Support;

•

an individualized education program through an educational institution (if a student age 18-21); or

•

any program providing vocational rehabilitation, employment services, or other support services to help
you go to work?
YES
NO

If "YES," complete the following information:
NAME OF ORGANIZATION OR SCHOOL
NAME OF COUNSELOR OR INSTRUCTOR
ADDRESS
(Number, Street, Apt. No.(if any), P.O. Box, or Rural Route)

City

(

DAYTIME PHONE NUMBER

)

State

Number

Area Code

DATES SEEN
TYPE OF SERVICES,
TESTS, OR EVALUATIONS
PERFORMED
Form SSA-3441-BK (08-2010) ef (08-2010)

TO

(IQ, vision, physicals, hearing, workshops, classes, etc.)
PAGE 6

ZIP

SECTION 10 - REMARKS
Use this section for any additional information you did not show in earlier parts of this
form. When you are finished with this section (or if you don't have anything to add), be
sure to go to the next page and complete the blocks there.

Form SSA-3441-BK (08-2010) ef (08-2010)

PAGE 7

SECTION 10 - REMARKS

Name of person completing this form if other than the disabled
person (Please print)

Date Form Completed (Month, day, year)

E-Mail Address of person completing this form (optional)

If the person completing this form is other than the disabled person or the person identified in Section 1. Item D.,
please complete the following information.
Relationship to Disabled Person
Daytime Telephone Number

(
Address (Number and street)

City

)

State

ZIP

Form SSA-3441-BK (08-2010) ef (08-2010)

PAGE 8

SSA will insert the following revised Privacy Act and PRA Statements into the form at its next
scheduled reprinting:
The Privacy Act
Sections 205(a), 223(d), and 1631(e)(1) of the Social Security Act authorize us to collect the
information on this form. We will use the information you provide on this form to make a
decision on your claim or case. Your response to this request is voluntary. However, failure to
provide all or part of the information could prevent us from making an accurate and timely
decision on your claim or case.
We rarely use the information you supply for any purpose other than for determining your living
arrangements. However, we may use it for the administration and integrity of Social Security
programs. We may also disclose information to another person or to another agency in
accordance with approved routine uses, which include but are not limited to the following: (1) to
enable a third party or an agency to assist Social Security in establishing rights to Special
Veterans Benefits; (2) to comply with Federal laws requiring the release of information from
Social Security records (e.g., to the 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, audit, or investigative activities necessary to assure
the integrity of Social Security programs.
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.
Additional information regarding this form, routine uses of information, and our programs and
systems, is available online at www.socialsecurity.gov or at any local 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 45 minutes to read the instructions, gather
the facts, and answer the questions. SED OR BRIG THE COMPLETED FORM TO
YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your local Social Security
office through SSA’s website at www.socialsecurity.gov. Offices are also listed under U. S.
Government agencies in your telephone directory or you may call Social Security at 1-800772-1213 (TTY 1-800-325-0778). You may send comments on our time estimate above to: SSA,
6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time
estimate to this address, not the completed form.