Form SSA-454-ICR Continuing Disability Review Report

CONTINUING DISABILITY REVI EW REPORT
SSA-454-ICR
PLEASE READ THIS INFORMATION BEFORE COMPLETING THIS REPORT
The office that reviews your medical condition will use the information in this report.
The information will help that office decide whether you are still disabled. Please
complete as much of this report as you can. We will contact you if we need more
information.
HOW TO COMPLETE THIS REPORT
• Print your answers with a black ink pen.
• If you are assisting someone else, please answer the questions as if

that person were completing the report.

• Print only one letter or number in each box, Leave an empty box between

words.

Example:

Ic l o I N I T I I /N /U / I / N /G / / D / I / S / A / B / I / L / I / T /Y / / R / E / P /O I R /T /
• Print dates like this: Month/Day/Year. For example, you would print

November 10, 2010, like this: 11/10/2010

• Answer "Yes" or "No" questions by marking an "X" inside the "Yes" or "No"
boxes.
Example: Yes

[8]

Yes

D

No

• Provide complete phone numbers including area code.

Example: 410 - 555 - 1212

/ 4 / 1 / 0 /-/ 5 / 5 / 5 /-1 1 / 2 / 1 / 2 /
• If you cannot remember the names of your health care providers, you may be
able to get that information from appointment reminders, medical bills,
prescriptions, or prescription medicine containers.
• A NSWER EVERY QUESTION, unless the report indicates otherwise. If

you need more space to answer any question, please use Section 8 ­
Remarks, on the last page to finish your answer. Write the number of the
question you are answering.
YOU DO NOT NEED TO ASK DOCTORS OR HOSPITALS FOR ANY MEDICAL
RECORDS. The information you give us on this report tells us where to request
your medical and other records. With your permission, we will request your
records .
Form SSA-454-ICR (1 0-201 0)

See Revised Privacy Act Attached
The Privacy Act
Sections 205(a), 223(d), and 1631 (e) (1) of the Social Security Act, as amended,
authorize us to collect this information. The information you provide will be used
to make a decision on the named claimant's claim. While giving us the
information on this report is voluntary, failure to provide all or part of the
requested information could prevent an accurate or timely decision on the named
claimant's claim. We generally use the information you supply for the purpose of
making decisions regarding claims. 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
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 about Social Security records (e.g., to the Government Accountability
Office and 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.

See Revised PRA Attached
The Paperwork Reduction Act
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 60 minutes to read the instructions, gather the facts,
and answer the questions. 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 report.
MAIL THE COMPLETED REPORT IN THE ENCLOSED ENVELOPE OR TAK E IT TO
YOUR LOCAL SOCIAL SECURITY OFFICE, THE NEAREST U.S EMBASSY OR
CONSULATE OFFICE. Office addresses are listed under U.S. Government
agencies in your telephone directory or you may call 1-800-772-1213 (TTY 1-800­
325-0778) for the address.

Form SSA-454-ICR (10-2010)

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Form Approved
OMB No. 0960-0072

Social Security Administration

CONTINUING DISABILITY REVIEW REPORT
SSA will use this form to review your medical condition(s) since the date of your last medical disability decision.
For SSA Use Only - Do not write in this box. WBDOC: Exc

D

Name:
Claim Number:

Own SSN:
Selection date:

2

D

3

D

4

D

5

D

6

D

Date of your last medical disability decision:

000102370304370506070800010237030437050607081010101060012
101112130123456789012345678900123456789012345678920090101
201020280123282810374543718122720090917
SECTION 1 -INFORMATION ABOUT THE DISABLED PERSON
1.A. Are you currently participating in the Ticket to Work Program or working under a plan with a private or state
vocational rehabilitation agency?
D

Yes - STOP - Call the Social Security office at

D

No

1.B. Current Mailing Address (disabled person or representative payee)

D

1.C. Has the mailing address changed?

Yes, add corrections below.

D

No, go to 1.D.

Mailing Address (number, street, apartment, P.O. box, rural route, city, state, ZIP code):

1.D. DA YTIME PHONE NUMBER (If you do not have a phone number where we can reach you, give us a daytime phone number

where we can leave a message.)

Telephone Number:

I I I I-I I I I-I I I I I
(area code)

D

None, go to 1.F.

(phone number)

1.E. IALTERNATE PHONE NUMBER

Telephone Number:

I I I I-I I I I-I I I I I
(area code)

(phone number)

1.F. Has your name changed or have you used any other names in the last 12 months on
your medical or education records?
If yes, add other names used to Section 8 - Remarks
Form SSA-454-ICR (10-2010)

454-ICR 1

D

Yes

D

No

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SECTION 2 - MEDICAL CONDITIONS
2.A. If you are an adult (age 18 or older), list all of the physical and/or mental conditions that limit your

ability to work. If you are completing this form for a child (under age 18), list all of the physical and/or

mental conditions that limit the child's ability to do the same things as other children of the same age.

List each physical and/or mental condition (including emotional or learning problems) separately.

1.

I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I

2.

I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I

3.

I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I

4.

I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I

5.

I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I

6.

I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I

7.

I I I I I I I I I I I I I I I I I· I I I I I I I I I I I I I I I I I I
Do you have more than 7 medical conditions?

D

Yes

Any physical condition(s)?

D

Yes

Any mental condition(s) (including emotional or learning problems)?

D

Yes

2.B.

D

No

If yes, add the additional conditions to Section 8 - Remarks
SECTION 3 - MEDICAL RECORDS
3.A. Have you seen a doctor or other health care professional or received treatment at a hospital

or clinic in the last 12 months, or do you have a future appointment scheduled for:

D
D

No
No

. If you answered "No" to both questions in 3.A,
o to 3.0.
3.B. Tell us who may have medical records covering the last 12 months about any of your physical or mental

condition(s). This includes doctors' offices, hospitals (including emergency room visits), clinics, and other

health care facilities.

(1) Name of Hospital, Clinic, Doctor or other Health Care Professional:

I II I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I

Telephone Number:

City:

State:

I I I I-I I I I-I I I II I I I I I I I I I I I I I I I I I I I
(area code)

(phone number)

Form SSA-454-ICR (10-2010)

454-ICR 2

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(2) Name of Hospital, Clinic, Doctor or other Health Care Professional:

I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I

Telephone Number:

City:

State:

I I I I-I I I I-I I I I I I I I I I I I I I I I I I I I I I I I
(area code)

(phone number)

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(3) Name of Hospital, Clinic, Doctor or other Health Care Professional :

I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I

Telephone Number:

City:

State:

I I I I-I I I I-I I I I I I I I I I I I I I I I I I I I I I I I
(area code)

(phone number)

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(4) Name of Hospital, Clinic, Doctor or other Health Care Professional:

I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I

Telephone Number:

City:

State:

I I I I-I I I I-I I I I I I I I I I I I I I I I I I I I I I I I
(area code)

(phone number)

CD

(5) Name of Hospital, Clinic, Doctor or other Health Care Professional:

I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I

Telephone Number:

City:

State:

I I I I-I I I I-I I I I I I I I I I I I I I I I I I I I I I I I
(area code)

(phone number)

3.C. Have you seen more than 5 medical providers in the last 12 months?
If yes, someone will contact you for the additional information.
Does anyone else have medical information about your condition(s) covering the last 12

months, or are you scheduled to see anyone else? (This includes workers' compensation,

3.0. insurance companies who have paid you disability benefits, prisons, attorneys, and welfare.)

CD

D

Yes

D

No

D

Yes

D

No

D

Yes

D

No

If yes, someone will contact you for the additional information.
SECTION 4 - WORK, EDUCATION AND TRAINING

Complete this section only if you are 18 or older

4.A. Since

have you worked?

4.8. Since

have you received any education?

4.C.

D

Yes, go to 4.C.

D

No, go to 4.0.

If you answered Yes in 4.8, what year did you last attend any school? (for example: 2010)

4.0. Since

have you received any type of specialized job,

trade or vocational training?
Form SSA-454-ICR (10-2010)

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454-ICR 3

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D

Yes

D

No

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SECTION 5 - VOCATIONAL REHABILITATION, EMPLOYMENT, OR OTHER SUPPORT SERVICES

Complete this section only if you are 18 or older

5.

Since
, 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 (PASS);
• an Individualized Education Program (lEP) through an educational institution (if a student age18-21); or
• any program providing vocational rehabilitation, employment services, or other support services to help you go to
work? D

Yes

D

No
SECTION 6 - TESTS AND MEDICINES

6.A. Have you had any medical tests in the last 12 months, or do you have any tests
scheduled for your condition? If yes, someone will contact you for the information .
6.B. Are you now taking, or have you taken in the last 12
months, any prescription or non-prescription
D
Yes, go to 6.C.
medicines?
6.C. List your medicines below. Look at your medicine containers, if necessary.

D

D

Yes

D

No

No, go to 7.A.

1.

I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I

2.

I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I

3.

I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I

4.

I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I

5.

I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I

6.

I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I

7.

I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I

6.0. Are you taking more than 7 medicines?

If yes, add them to Section 8 - Remarks

D

Yes

SECTION 7 - DAILY ACTIVITIES
7.A. Describe what you do in a typical day (for example: I get up around 7 a.m., take a shower, eat breakfast,
check emails)

Form SSA-454-ICR (10-2010)

Use Section 8 - Remarks if more space is needed
I 454-ICR 4 I

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No

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7.B. IDo you have difficulty doing any of the following?
Dressing
Bathing
Caring for hair
Taking medicine
Preparing meals
Feeding self
Doing chores
(inside/outside house)
Driving or using public
transportation
Shopping
Managing money
Walking
Standing
Lifting objects
Using arms
Using hands or fingers
Sitting
Seeing, hearing, or
speaking
Concentrating
Remembering
Understanding/following
directions
Completing tasks
Getting along with
people

D
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D
D
D
D
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D
D
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D
D
D
D
D
D
D
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Form SSA-454-ICR (10-2010)

Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes

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Explain "Yes" answers here.

No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No

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454-ICR 5

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Do you use an assistive device (for example: eye glasses,
7.C. hearing aids, braces, canes, crutch(es), walker, wheelchair)?

.

D

Always

D

Sometimes

D

Never

If Always or Sometimes, please describe what kind , when, and how you use it.

7.0. Do you have hobbies or interests?

D

Yes

D

No

If Yes, please describe what they are and how much time you spend doing them .

SECTION 8 - REMARKS
Please provide any additional information you did not show in earlier sections of this form . You may also attach any medical
records, copies of prescriptions, or any other records about your medical condition(s) you have at home that you wish to
give us. When you are finished, or if you don't have anything to add, be sure to complete Section 9 - Contacts.

SECTION 9 - CONTACTS
9.A. Give the name of someone (other than your doctors) we can contact who knows about your medical
conditions, and can hel ou with our case.
Full Name (First, Middle Initial, Last):

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Daytime Telephone Number:

Relationship to Disabled Person:

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I I I I I I I I I I I I I I I I I I I I I

(area code)

(phone number)

9.B. IWho completed this report?
D

The disabled person (go to 9.0.)

D

The person listed in 9.A. above (go to 9.0.)

D

Someone else (go to 9.C.)

9.C. IGive the name of the person who completed this report.
Full Name (First, Middle Initial, Last):

111111111111 D

111111111111111111111

Daytime Telephone Number:

Relationship to Disabled Person:

I I I I - I I I 1- r----rl1---'-1""-'11

I I I I 1 1 1 I 1 I I I I I I I I I I I I

9.0.

When was this report completed (month / day / year)?

Form SSA-454-ICR (10-2010)

454-ICR 6

SSA will insert the following revised Privacy Act and PRA Statements into the form at its next
scheduled reprinting:
The Privacy Act
Collection and Use of Personal Information
Sections 205(a), 223(d), and 1631(e)(1) of the Social Security Act, as amended, authorize us to
collect this information. The information you provide will be used to make a decision on the
named claimant’s claim.
The information you furnish on this form is voluntary. However, failure to provide this
requested information could prevent an accurate and timely decision on the named claimant’s
claim.
We rarely use the information you supply for any purpose other than for making a determination
about your continuing entitlement to benefits. 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
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, audit, or investigative activities necessary to assure
the integrity and improvement of 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.
A complete list of routine uses for this information is available in our Systems of Records
Notices entitled, Claims Folder Systems, 60-0089 and Master Beneficiary Record, 60-0090.
These notices, additional information regarding this form, and information regarding our
programs and systems, are available on-line at www.socialsecurity.gov or at your local Social
Security office.

The Paperwork Reduction Act
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 30 minutes to read the instructions, gather the facts, and answer the questions. 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 report.
MAIL THE COMPLETED REPORT IN THE ENCLOSED ENVELOPE OR TAKE IT
TO YOUR LOCAL SOCIAL SECURITY OFFICE, THE NEAREST U.S. EMBASSY, OR
CONSULATE OFFICE. You can find your local Social Security office through SSA’s
website at www.socialsecurity.gov. Offices addresses 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).