Form SSA-455 Disability Update Report

FORM APPROVED
OMB NO. 0960-0511

SOCIAL SECURITY ADMINISTRATION

DISABILITY UPDATE REPORT
Privacy Act Statement
Collection and Use of Personal Information
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. We will use the information you provide to
further document your claim and permit a determination about continuing disability.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the information may prevent
an accurate and timely decision on any claim filed.
We rarely use the information you supply us for any purpose other than for the reasons explained above. However, we
may use the information for the administration of our programs including sharing information:
1. To comply with Federal laws requiring the release of information from our records (e.g., to the Government
Accountability Office and Department of Veterans Affairs);
2. To facilitate statistical research, audit, or investigative activities necessary to assure the integrity and improvement of
our programs (e.g., to the Bureau of the Census and to private entities under contract with us).
A complete list of when we may share your information with others, called routine uses, is available in our Privacy Act
Systems of Records Notices entitled, Claims Folders Systems (60-0089) and the Master Beneficiary Record (60-0090).
Additional information about this and other system of records notices and our programs are available online at
www.socialsecurity.gov or at your local Social Security office.
We may share the information you provide to other health agencies through computer matching programs. Matching
programs compare our records with records kept by other Federal, State or local government agencies. We use the
information from these programs to establish or verify a person’s eligibility for federally funded or administered benefit
programs and for repayment of incorrect payments or delinquent debts under these programs.
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. The OMB control number for this collection is
0960-0511. We estimate that it will take 15 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.

Name and Address

Claim Number

1. Within the last 2 years have you worked for someone or been self-employed?
Yes

No

If yes, please complete the information below.
Work Began
(month/year)

Work Ended
(month/year)

Monthly
Earnings

1.

/

/

$

2.

/

/

$

3.

/

/

$

Form SSA-455 (08-2014)

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2.

Check the block which best describes your health within the last 2 years:
Better

3.

Same

Worse

Within the last 2 years has your doctor told you that you can return to work?
Yes

4.

No

Within the last 2 years have you attended any school or work training program(s)?
Yes

No

5.

Would you be interested in receiving rehabilitation or other services that could help you get back to
work?
Yes
No

6.

Within the last 2 years have you been hospitalized or had any surgery?
Yes

No

If yes, please list below:
Date: (month/year)

Reason
1.
2.
3.
7.

Within the last 2 years have you gone to a doctor or clinic for your condition?
Yes

No

If yes, show the date and the reason for the visit.
1. Date
Reason
2. Date
Reason
3. Date
Reason
I declare under penalty of perjury that I have examined all the information on this form, and on any
accompanying statements or forms, and it is true and correct to the best of my knowledge. I understand
that anyone who knowingly gives a false or misleading statement about a material fact in this information,
or causes someone else to do so, commits a crime and may be sent to prison, or may face other
penalties, or both.
Sign
Here
Form SSA-455 (08-2014)

Date

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Telephone Number