Form SSA-454-BK Continuing Disability Review Report

Form SSA-454-BK (04-2019) UF
Discontinue Prior Editions
Social Security Administration

Page 1 of 15
OMB No. 0960-0072

CONTINUING DISABILITY REVIEW REPORT
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 the report as
you can.
IF YOU NEED HELP
You can get help from other people, such as a friend or family member. Please do not ask your health
care provider to complete this report. if you cannot complete the report, a Social Security
Representative will assist you. If you have an appointment, please have the completed report ready
when we contact you.
Note: If you are assisting someone else with this report, please answer the questions as if that person
were completing the report.
HOW TO COMPLETE THIS REPORT
• Print or write clearly.
• Include a ZIP or postal code with each address.
• Provide complete phone numbers, including area code. If a phone number is outside the United
States, provide International Direct Dialing (IDD) code and country code.
• If you cannot remember the names and addresses of your health care providers, you may be able to
get that information from the telephone book, Internet, medical bills, prescriptions, or prescription
medicine containers.
• ANSWER EVERY QUESTION, unless the report indicates otherwise. If you do not know an answer,
or the answer is "none" or "does not apply," please write: "don't know," or "none," or "does not apply."
• 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 question, please use Section 11 - Remarks, on the last page
to finish your answer. Write the number of the question you are answering.
YOUR MEDICAL RECORDS
If you have any of your medical records covering the last 12 months, send or bring them to our office
with this completed report. Please tell us if you want to keep your records so we can return them to
you. If you have a scheduled appointment for an interview, bring your medical records, your
prescription medicine containers (if available), and the completed report with 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 request your records. The information
that you give us on this report tells us where to request your medical and other records.

Form SSA-454-BK (04-2019) UF

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Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 221(i), 223(d), 1614(a)(3), 1631(e)(1), and 1633(c) of the Social Security Act, as
amended, authorize us to collect this information. Furnishing us this information is voluntary. However,
failing to provide all or part of the information may prevent an accurate and timely decision on any
claim filed.
We will use the information to make a determination of eligibility for benefits. We may also share your
information for the following purposes, called routine uses:
1. To third party contacts such as private collection agencies and credit reporting agencies under
contract with the Social Security Administration (SSA) and State motor vehicle agencies for the
purpose of their assisting SSA in recovering overpayments;
2. To State agencies to enable those agencies which have elected Federal administration of their
supplementation programs to monitor changes in applicant/recipient income, special needs, and
circumstances; and
3. To employers or former employers for correcting and reconstructing earnings records and for Social
Security tax purposes.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws.
For example, where authorized, we may use and disclose this information in computer matching
programs, in which our records are compared with other records to establish or verify a person's
eligibility for Federal benefit programs and for repayment of incorrect or delinquent debts under these
programs.
A list of routine uses is available in our Privacy Act System of Records Notices (SORNs) 60-0089,
entitled Claims Folders System; 60-0090, entitled Master Beneficiary Record; 60-0103, entitled
Supplemental Security Income Record and Special Veterans Benefits; and 60-0320, entitled Electronic
Disability Claim File. Additional information and a full listing of all our SORNs are available on our
website at www.socialsecurity.gov/foia/bluebook.
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 (OMB) control number. We estimate that it will take about 60
minutes to read the instructions, gather the facts, and answer the questions. Send only comments
relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.
SEND OR BRING THE COMPLETED REPORT 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.

AFTER COMPLETING THIS FORM, REMOVE THIS SHEET AND KEEP IT FOR YOUR RECORDS.

Form SSA-454-BK (04-2019) UF

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CONTINUING DISABILITY REVIEW REPORT
For SSA Use Only - Do not write in this box.
Date of your last medical disability decision:
Claim Number:
Number Holder:
DIB
DWB
CDB
FZ
Types of Case(s):
TITLE II
DI
DS
DC
BI
(Check all that apply) TITLE XVI

ESRD
BS

HIB
BC

If you are filling out this report for the disabled person, please provide information about him or her.
When a question refers to "you", "your", or the "disabled person", it refers to the person receiving
disability benefits.
SECTION 1 - INFORMATION ABOUT THE DISABLED PERSON
1.A. NAME (First, Middle Initial, Last)
1.B. SOCIAL SECURITY NUMBER
1.C. MAILING ADDRESS (Street or PO Box) Include apartment number if applicable
CITY

STATE/Province ZIP/Postal Code COUNTRY (if not USA)

1.D. RESIDENT ADDRESS (Street or PO Box) Include apartment number if applicable
CITY

STATE/Province ZIP/Postal Code COUNTRY (if not USA)

1.E. DAYTIME PHONE NUMBER, including area code, and the IDD and country codes if you live
outside the USA or Canada.
Phone Number:
Check this box if you have a phone or a number where we can leave a message

1.F. ALTERNATE PHONE NUMBER, including area code where we may reach you, if any.
Alternate Phone Number:
YES
NO
1.G. Can you speak and understand English?
If NO, what language do you prefer?
If you cannot speak and understand English, we will provide an interpreter free of charge.
1.H. Have you used any other names on your medical or educational records in the last 12 months?
Examples are maiden name, other married names, or nickname.
YES
NO
If YES, please list
SECTION 2 - CONTACTS
Give the name of a friend or relative (other than your doctors) we can contact who knows about your
medical conditions, and can help you with your case.
2.A. NAME (First, Middle Initial, Last)

2.B. Relationship to Disabled Person

2.C. MAILING ADDRESS (Street or PO Box) Include apartment number if applicable
CITY

STATE/Province ZIP/Postal Code COUNTRY (if not USA)

2.D. DAYTIME PHONE NUMBER (as described in 1.E. above)

Form SSA-454-BK (04-2019) UF

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SECTION 2 - CONTACTS (Continued)
2.E. Can this person speak and understand English?
If NO, what language is preferred?
2.F. Who is completing this report?

YES

NO

The disabled person listed in 1.A. (Go to Section 3 - Medical Condition(s))
The person listed in 2.A. (Go to Section 3 - Medical Condition(s))
Someone else (Complete the rest of Section 2 below)

2.G. NAME (First, Middle Initial, Last)

2.H. Relationship to Disabled Person

2.I. DAYTIME PHONE NUMBER (as described in 1.E. above)
2.J. MAILING ADDRESS (Street or PO Box) Include apartment number if applicable
CITY

STATE/Province ZIP/Postal Code COUNTRY (if not USA)

SECTION 3 - MEDICAL CONDITION(S)
3.A. If you are an adult (age 18 or older), list the physical and/or mental condition(s) (including
emotional or learning problems) that limit your ability to work. If you are completing this report for a
child (under age 18), list the physical and/or mental condition(s) (including emotional and learning
problems) that limit the child's ability to do the same things as other children the same age. List
each physical and/or mental condition separately.
1.
2.
3.
4.
If you need more space go to Section 11 - Remarks
3.B. What is your height without shoes?
OR
feet
3.C. What is your weight without shoes?

inches

centimeters (if outside USA)
OR

pounds
kilograms (if outside USA)
3.D. Do you use an assistive device (for example: eye glasses, hearing aids, braces, canes,
crutch(es), walker, wheelchair, service animal?
Always
Sometimes
Never
If ALWAYS OR SOMETIMES, please describe what kind, when, and how you use it.

If you need more space, use Section 11 - Remarks

Form SSA-454-BK (04-2019) UF

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SECTION 4 - MEDICAL TREATMENT
Within the last 12 months, have you seen a doctor or other health care professional, or received
treatment at a hospital or clinic, or do you have a future appointment scheduled:
YES
4.A. For any physical conditions?
4.B. For any mental condition(s) (including emotional or learning problems)?
YES

NO
NO

If you answered "NO" to both 4.A. and 4.B., go to Section 5 - Other Medical Information on
page 9
4.C. Tell us who may have medical records covering the last 12 months about any of your physical or
mental condition(s) (including emotional or learning problems). This includes doctors' offices, hospitals
(including emergency room visits), clinics, and other health care facilities. Tell us about your next
appointment, if you have one scheduled.
NAME OF FACILITY OR OFFICE

NAME OF HEALTHCARE PROFESSIONAL
THAT TREATED YOU

ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE
PROFESSIONAL ABOVE
PHONE NUMBER
PATIENT ID# (if known)
MAILING ADDRESS
CITY

STATE/Province ZIP/Postal Code COUNTRY (if not USA)

Dates of Treatment (within the last 12 months)
1. Office, Clinic or Outpatient
Visits

2. Emergency Room
Visits List the most 3. Overnight Hospitals Stays
recent date first

First visit

A.

A. Date in

Date out

Last visit

B.

B. Date in

Date out

Next Scheduled Appointment
(if any)

C.

C. Date in

Date out

What medical conditions were treated or evaluated?

What treatment did you receive for the above conditions? (Do not describe medicines or tests in this
box.)

Form SSA-454-BK (04-2019) UF

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SECTION 4 - MEDICAL TREATMENT (Continued)
Check the boxes below for any tests this provider performed or sent you to within the last 12
months, or has scheduled you to take. Please give the dates for past and future tests. If you need to
list more tests, use Section 11 - Remarks.
Check this box if no tests by this provider or at this facility.

KIND OF TEST

DATES OF TEST(S)

KIND OF TEST

EKG (heart test)

EEG (brain wave test)

Treadmill (exercise test)

HIV Test

Cardiac Catheterization

Blood Test (not HIV)

Biopsy (list body part)

X-Ray (list body part)

Hearing test

MRI/CT Scan (list body part)

DATES OF TEST(S)

Speech/Language Test
Vision Test

Other

Breathing test

If you do not have any more doctors or hospitals to describe, go to
Section 5 - Medicines on page 11.
4.D. Tell us who may have medical records covering the last 12 months about any of your physical or
mental condition(s) (including emotional or learning problems). This includes doctors' offices, hospitals
(including emergency room visits), clinics, and other health care facilities. Tell us about your next
appointment, if you have one scheduled.
NAME OF FACILITY OR OFFICE

NAME OF HEALTHCARE PROFESSIONAL
THAT TREATED YOU

ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE
PROFESSIONAL ABOVE
PHONE NUMBER
PATIENT ID# (if known)
MAILING ADDRESS
CITY

STATE/Province ZIP/Postal Code COUNTRY (if not USA)

Dates of Treatment (within the last 12 months)
1. Office, Clinic or Outpatient
Visits

2. Emergency Room
Visits List the most 3. Overnight Hospitals Stays
recent date first

First visit

A.

A. Date in

Date out

Last visit

B.

B. Date in

Date out

Next Scheduled Appointment
(if any)

C.

C. Date in

Date out

Form SSA-454-BK (04-2019) UF

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SECTION 4 - MEDICAL TREATMENT (Continued)
What medical conditions were treated or evaluated?

What treatment did you receive for the above conditions? (Do not describe medicines or tests in this
box.)

Check the boxes below for any tests this provider performed or sent you to within the last 12
months, or has scheduled you to take. Please give the dates for past and future tests. If you need to
list more tests, use Section 11 - Remarks.
Check this box if no tests by this provider or at this facility.

KIND OF TEST

DATES OF TEST(S)

KIND OF TEST

EKG (heart test)

EEG (brain wave test)

Treadmill (exercise test)

HIV Test

Cardiac Catheterization

Blood Test (not HIV)

Biopsy (list body part)

X-Ray (list body part)

Hearing test

MRI/CT Scan (list body part)

DATES OF TEST(S)

Speech/Language Test
Vision Test

Other

Breathing test

If you do not have any more doctors or hospitals to describe, go to
Section 5 - Medicines on page 11.
4.E. Tell us who may have medical records covering the last 12 months about any of your physical or
mental condition(s) (including emotional or learning problems). This includes doctors' offices, hospitals
(including emergency room visits), clinics, and other health care facilities. Tell us about your next
appointment, if you have one scheduled.
NAME OF FACILITY OR OFFICE

NAME OF HEALTHCARE PROFESSIONAL
THAT TREATED YOU

ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE
PROFESSIONAL ABOVE
PHONE NUMBER
PATIENT ID# (if known)
MAILING ADDRESS
CITY

STATE/Province ZIP/Postal Code COUNTRY (if not USA)

Form SSA-454-BK (04-2019) UF

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SECTION 4 - MEDICAL TREATMENT (Continued)
Dates of Treatment (within the last 12 months)
1. Office, Clinic or Outpatient
Visits

2. Emergency Room
Visits List the most 3. Overnight Hospitals Stays
recent date first

First visit

A.

A. Date in

Date out

Last visit

B.

B. Date in

Date out

Next Scheduled Appointment
(if any)

C.

C. Date in

Date out

What medical conditions were treated or evaluated?

What treatment did you receive for the above conditions? (Do not describe medicines or tests in this
box.)

Check the boxes below for any tests this provider performed or sent you to within the last 12
months, or has scheduled you to take. Please give the dates for past and future tests. If you need to
list more tests, use Section 11 - Remarks.
Check this box if no tests by this provider or at this facility.

KIND OF TEST

DATES OF TEST(S)

KIND OF TEST

EKG (heart test)

EEG (brain wave test)

Treadmill (exercise test)

HIV Test

Cardiac Catheterization

Blood Test (not HIV)

Biopsy (list body part)

X-Ray (list body part)

Hearing test

MRI/CT Scan (list body part)

DATES OF TEST(S)

Speech/Language Test
Vision Test

Other

Breathing test

If you do not have any more doctors or hospitals to describe, go to
Section 5 - Medicines on page 11.
4.F. Tell us who may have medical records covering the last 12 months about any of your physical or
mental condition(s) (including emotional or learning problems). This includes doctors' offices, hospitals
(including emergency room visits), clinics, and other health care facilities. Tell us about your next
appointment, if you have one scheduled.

Form SSA-454-BK (04-2019) UF

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SECTION 4 - MEDICAL TREATMENT (Continued)
NAME OF FACILITY OR OFFICE
NAME OF HEALTHCARE PROFESSIONAL
THAT TREATED YOU
ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE
PROFESSIONAL ABOVE
PHONE NUMBER
PATIENT ID# (if known)
MAILING ADDRESS
CITY

STATE/Province ZIP/Postal Code COUNTRY (if not USA)

Dates of Treatment (within the last 12 months)
1. Office, Clinic or Outpatient
Visits

2. Emergency Room
Visits List the most 3. Overnight Hospitals Stays
recent date first

First visit

A.

A. Date in

Date out

Last visit

B.

B. Date in

Date out

Next Scheduled Appointment
(if any)

C.

C. Date in

Date out

What medical conditions were treated or evaluated?

What treatment did you receive for the above conditions? (Do not describe medicines or tests in this
box.)

Check the boxes below for any tests this provider performed or sent you to within the last 12
months, or has scheduled you to take. Please give the dates for past and future tests. If you need to
list more tests, use Section 11 - Remarks.
Check this box if no tests by this provider or at this facility.

KIND OF TEST

DATES OF TEST(S)

KIND OF TEST

EKG (heart test)

EEG (brain wave test)

Treadmill (exercise test)

HIV Test

Cardiac Catheterization

Blood Test (not HIV)

Biopsy (list body part)

X-Ray (list body part)

Hearing test

MRI/CT Scan (list body part)

Speech/Language Test
Vision Test
Breathing test

Other

DATES OF TEST(S)

Form SSA-454-BK (04-2019) UF

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SECTION 4 - MEDICAL TREATMENT (Continued)
If you do not have any more doctors or hospitals to describe, go to
Section 5 - Medicines on page 11.
4.G. Tell us who may have medical records covering the last 12 months about any of your physical or
mental condition(s) (including emotional or learning problems). This includes doctors' offices, hospitals
(including emergency room visits), clinics, and other health care facilities. Tell us about your next
appointment, if you have one scheduled.
NAME OF FACILITY OR OFFICE

NAME OF HEALTHCARE PROFESSIONAL
THAT TREATED YOU

ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE
PROFESSIONAL ABOVE
PHONE NUMBER
PATIENT ID# (if known)
MAILING ADDRESS
CITY

STATE/Province ZIP/Postal Code COUNTRY (if not USA)

Dates of Treatment (within the last 12 months)
1. Office, Clinic or Outpatient
Visits

2. Emergency Room
Visits List the most 3. Overnight Hospitals Stays
recent date first

First visit

A.

A. Date in

Date out

Last visit

B.

B. Date in

Date out

Next Scheduled Appointment
(if any)

C.

C. Date in

Date out

What medical conditions were treated or evaluated?

What treatment did you receive for the above conditions? (Do not describe medicines or tests in this
box.)

Check the boxes below for any tests this provider performed or sent you to within the last 12
months, or has scheduled you to take. Please give the dates for past and future tests. If you need to
list more tests, use Section 11 - Remarks.
Check this box if no tests by this provider or at this facility.

Form SSA-454-BK (04-2019) UF

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SECTION 4 - MEDICAL TREATMENT (Continued)
KIND OF TEST

DATES OF TEST(S)

KIND OF TEST

EKG (heart test)

EEG (brain wave test)

Treadmill (exercise test)

HIV Test

Cardiac Catheterization

Blood Test (not HIV)

Biopsy (list body part)

X-Ray (list body part)

Hearing test

MRI/CT Scan (list body part)

DATES OF TEST(S)

Speech/Language Test
Vision Test

Other

Breathing test

If you need to list more doctors or hospitals use Section 11 - Remarks and
give the same detailed information as above for each one you list.
SECTION 5 - MEDICINES
5. Are you now taking, or have you taken in the last 12 months, any prescription or non-prescription
medicines?
YES (Complete the following information. Look at your medicine containers, if necessary.)
NO (Go to section 6 - Other Medical Information on page 12.)
NAME OF MEDICINE

IF PRESCRIBED,
GIVE NAME OF DOCTOR

REASON FOR MEDICINE

If you need to list other medicines use Section 11 - Remarks.
If you are under age 18, Skip to Section 11 - Remarks.

Form SSA-454-BK (04-2019) UF

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SECTION 6 - OTHER MEDICAL INFORMATION
Complete only if you are age 18 years or older
6. Does anyone else have medical information about your physical or mental condition(s) (including
emotional and learning problems) covering the last 12 months, or are you scheduled to see anyone
else? (This may include places such as workers' compensation, vocational rehabilitation, insurance
companies who have paid you disability benefits, prisons, attorneys, social service agencies and
welfare agencies.)
YES (Complete the following information.)
NO (Go to SECTION 7 - Education and Training.)
NAME OR ORGANIZATION

PHONE NUMBER

MAILING ADDRESS
CITY

STATE/Province ZIP/Postal Code COUNTRY (if not USA)

NAME OF CONTACT PERSON

CLAIM NUMBER (if any)

Date First Contact (in last 12 months) Date Last Contact (in last 12 months) Date Next Contact (if any)
Reason(s) for Contacts
If you need to list other people or organizations use Section 11 - Remarks and give the same
detailed information as above for each one you list.
SECTION 7 - EDUCATION AND TRAINING
Complete only if you are age 18 years or older
7.A. Have you received any education since your last disability decision? (See date at top of Page 3.)
YES (Complete the information below.)

NO (Go to question 7.B. below.)

If YES, what year did you last attend any school?
Please describe the education you received.
7.B. Have you received any type of specialized job, trade, or vocational training since your last
disability decision? (See date at top of Page 3.)
YES (Complete the information below.)
NO
NAME OF TRAINING FACILITY

PHONE NUMBER

MAILING ADDRESS
CITY

STATE/Province ZIP/Postal Code COUNTRY (if not USA)

TYPE OF PROGRAM

Date Completed (or scheduled to be completed)

If you need to list other education information or training facilities use
Section 11 - Remarks and give the same detailed information as above.

Form SSA-454-BK (04-2019) UF

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SECTION 8 - VOCATIONAL REHABILITATION, EMPLOYMENT, OR OTHER SUPPORT SERVICES
Complete only if you are age 18 years or older.
8.A. Since the date of your last medical disability decision (see date on top of Page 3), have you
participated, or are you participating, in:
• an individualized 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 (IEP) through a school (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 (Complete the information below.)

NO (Go to Section 9 - Daily Activities)

If YES, what year did you last attend any school?
NAME OF ORGANIZATION OR SCHOOL
NAME OF COUNSELOR, INSTRUCTOR OR JOB COACH

PHONE NUMBER

MAILING ADDRESS
CITY

STATE/Province ZIP/Postal Code COUNTRY (if not USA)

8.B. When did you start participating in the plan or program?
8.C. Are you still participating in the plan or program?
YES, I am scheduled to complete the plan or program on:
(date to be completed)
NO, I completed the plan or program on:
(date completed)
NO, I stopped participating in the plan before completing it because:

8.D. What types of services, tests, or evaluations were provided (for example: intelligence or
psychological testing, vision or hearing tests, physical exam, work evaluations, or classes?)

If you need to list another plan or program use Section 11 - Remarks and
give the same detailed information as above

Form SSA-454-BK (04-2019) UF

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SECTION 9 - DAILY ACTIVITIES
Complete only if you are age 18 years or older.
9.A. Describe what you do in a typical day (for example: I get up around 7 A.M., take a shower, eat
breakfast, etc.).

If you need more space, go to Section 11 - Remarks
9.B. Do you have hobbies or interests?
YES

NO

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

9.C. Do you ever have difficulty doing any of the following? (Please explain any "Yes" answers.)
YES
NO
Dressing
YES
NO
Bathing
YES
NO
Caring for hair
YES
NO
Taking medicines
YES
NO
Preparing Meals
YES
NO
Feeding Self
YES
NO
Doing chores (inside/outside house)
YES
NO
Driving or using public transportation
YES
NO
Shopping
YES
NO
Managing money
YES
NO
Walking
YES
NO
Standing
YES
NO
Lifting Objects
YES
NO
Using arms
YES
NO
Using hands or fingers
YES
NO
Sitting
YES
NO
Seeing, hearing, or speaking
YES
NO
Concentrating
YES
NO
Remembering
YES
NO
Understanding or following directions
YES
NO
Completing tasks
YES
NO
Getting along with people

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SECTION 10 - WORK
Complete only if you are age 14 years or older.
10. Since the date of your last medical disability decision have you worked? (see date at top of Page 3)
YES (If yes, we may contact you for additional information)

NO

SECTION 11 - REMARKS
Please write any additional information you did not give in earlier parts of this report. If you did not have enough space in
the sections of this report to write the requested information, please use this space to tell us the additional requested in
those sections. Be sure to show the section to which you are referring.

Date Report Completed (MM/DD/YYYY)