Revised SSA-454-BK (Paper Form)

Form SSA-454-BK (XX-XXXX) UF
Discontinue Prior Editions
Social Security Administration

Page 1 of 12
OMB No. 0960-0072

CONTINUING DISABILITY REVIEW REPORT SSA-454-BK
PLEASE READ THIS INFORMATION BEFORE COMPLETING THIS REPORT
The office that reviews your medical condition(s) will use the information you provide in this report to
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, you may contact us
at 1-800-772-1213 (TTY 1-800-325-0778). A Social Security Representative will assist you. Please
have the information available from the bulleted items below when you call us. If you have a continuing
disability review appointment, please have the information available, or the completed report ready
when we contact you. If you cannot speak or understand English, we will provide an interpreter
free of charge.
WHAT YOU NEED TO COMPLETE THIS REPORT
• Name, address, and phone number of a friend or relative (other than your doctors) we can contact
who knows about your medical condition(s), and can help with your case, if needed.
• Name, address, and phone number of any health care providers you have seen within the last 12
months. (You may be able to get that information from the telephone book, Internet, online medical
chart, medical bills, prescriptions, or prescription medicine containers.)
• Any prescription or non-prescription medicines you take or have taken in the last 12 months.
• Name of organization who we can contact that would have medical information about your
condition(s) in the last 12 months. (Such as social services agencies, welfare agencies, attorneys,
prisons, workers’ compensation and insurance companies who have paid you disability benefits.)
• Information about any education since your last disability decision. (See top of Page 3 for date of last
decision.)
• Information about any vocational rehabilitation, employment, or other support services since your last
disability decision. (See top of Page 3 for date of last decision.)
• 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."
• If you need more space to answer any question, please use Section 9 - Remarks, on the last page
to finish your answer. Write the number of the question you are answering.
YOUR MEDICAL RECORDS
YOU DO NOT NEED TO ASK DOCTORS OR HOSPITALS FOR ANY MEDICAL RECORDS.
If you have consented to us obtaining medical records from your providers, we will request your
records directly from them. The information that you give us on this report tells us where to request
your medical and other records.

Form SSA-454-BK (XX-XXXX) UF

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Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 221(i), 223(d), 1614(a), 1631(e), and 1633(c) of the Social Security Act, as amended,
allow 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 determine eligibility for benefits. We may also share your information for
the following purposes, called routine uses:
• To applicants, claimants, prospective applicants or claimants, other than the data subject, their
authorized representatives or representative payees to the extent necessary to pursue Social
Security claims and to representative payees when the information pertains to individuals for whom
they serve as representative payees, for the purpose of assisting Social Security Administration
(SSA) in administering its representative payment responsibilities under the Act and assisting the
representative payees in performing their duties as payees, including receiving and accounting for
benefits for individuals for whom they serve as payees; and
• To private medical and vocational consultants for use in making preparation for, or evaluating the
results of, consultative medical examinations or vocational assessments which they were engaged
to perform by SSA or a State agency acting in accord with sections 221 or 1633 of the Act.
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 additional routine uses is available in our Privacy Act System of Records Notices (SORN)
60-0089, entitled Claims Folders System, as published in the Federal Register (FR) on April 1, 2003,
at 68 FR 15784, and 60-0320, entitled Electronic Disability Claim File, as published in the FR on
December 22, 2003, at 68 FR 71210. Additional information and a full listing of all our SORNs are
available on our website at www.ssa.gov/privacy.
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
regarding this burden estimate or any other aspect of this collection, including suggestions for
reducing this burden to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.
SEND OR BRING THE COMPLETED REPORT TO YOUR LOCAL SOCIAL SECURITY OFFICE, OR
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 REPORT, REMOVE THIS SHEET
AND KEEP IT FOR YOUR RECORDS.

Form SSA-454-BK (XX-XXXX) UF
Discontinue Prior Editions
Social Security Administration

Page 3 of 12
OMB No. 0960-0072

CONTINUING DISABILITY REVIEW REPORT
For SSA Use Only - Do not write in this box.
Date of your last medical disability decision:
SECTION 1 - INFORMATION ABOUT YOU
When a question refers to "you" or "your" it refers to the person receiving disability benefits. If you
are completing this report for someone else, please provide information about them.
1.A. NAME (First, Middle, Last, Suffix)

1.B. SOCIAL SECURITY NUMBER

1.C. In the last 12 months, have you used any other names on your medical or educational records?
Examples include maiden name, other married names, other names, or nickname.
YES
NO
If YES, please list names used
1.D. MAILING ADDRESS (Street or PO Box) Include apartment number if applicable.
CITY

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

1.E. Is your residence address the same as your mailing address?

YES

NO - Complete RESIDENT
ADDRESS below

RESIDENT ADDRESS (Include apartment number if applicable.)
CITY

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

1.F. DAYTIME PHONE NUMBER(S) where we can call to speak with you, or leave a message, if needed.
(Include area code, or IDD and country code if outside the USA or Canada.)
Secondary:
Primary:
(If available)

1.G. EMAIL ADDRESS
YES
1.H. 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.

NO

YES
NO
1.I. Can you read and understand English?
YES
NO
1.J. Can you write more than your name in English?
SECTION 2 – SOMEONE WE CAN CONTACT
Please provide the name of someone (other than your doctors) we can contact who knows about
your medical condition(s), and can help with your case and can help us reach you if you become
unavailable. Examples include a family member, friend, or neighbor.
2.A. NAME (First, Middle Initial, Last)

2.B. Relationship to Person in 1.A.

Form SSA-454-BK (XX-XXXX) UF

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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.F. above)
YES

2.E. Can this person speak and understand English?
(If NO, what language is preferred?)

NO

SECTION 3 - MEDICAL INFORMATION
Please provide us with general medical information to assist us with any records requests. We will
use this information to see what additional questions or forms we may need to send you.
3.A. Separately list each physical and/or mental health condition that limits your ability to work. If under
age 18, list the physical and/or mental health condition(s) that limit the child’s ability to do the same
things as other children the same age.
1.
2.
3.
4.
5.
If you need more space to list additional conditions go to Section 9 – Remarks
3.B. What is your height?

OR
feet

inches

3.C. What is your weight?

centimeters
OR

pounds
kilograms
3.D. Within the last 12 months, have you seen or received treatment from a health care provider (doctor,
hospital, clinic, psychiatrists, nurse practitioners, therapists, physical therapists, or other medical
professionals)?
NO (Go to 3.F.)
YES (Complete the following section below.)
You may find this information on medical bills or the internet. If you don’t have the full street address,
give as much as you can. Example: “On Main St next to the Courthouse.”
1. NAME OF FACILITY OR OFFICE

NAME OF HEALTH CARE PROVIDER THAT TREATED YOU

What medical conditions were treated or evaluated?

PHONE NUMBER

DATE LAST SEEN
(IF KNOWN)

MM / YYYY

STREET ADDRESS
CITY

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

Form SSA-454-BK (XX-XXXX) UF

2. NAME OF FACILITY OR OFFICE

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NAME OF HEALTH CARE PROVIDER THAT TREATED YOU

What medical conditions were treated or evaluated?

PHONE NUMBER

DATE LAST SEEN
(IF KNOWN)

MM / YYYY

STREET ADDRESS
CITY
3. NAME OF FACILITY OR OFFICE

STATE/Province ZIP/Postal Code COUNTRY (if not USA)
NAME OF HEALTH CARE PROVIDER THAT TREATED YOU

What medical conditions were treated or evaluated?

PHONE NUMBER

DATE LAST SEEN
(IF KNOWN)

MM / YYYY

STREET ADDRESS
CITY
4. NAME OF FACILITY OR OFFICE

STATE/Province ZIP/Postal Code COUNTRY (if not USA)
NAME OF HEALTH CARE PROVIDER THAT TREATED YOU

What medical conditions were treated or evaluated?

PHONE NUMBER

DATE LAST SEEN
(IF KNOWN)

MM / YYYY

STREET ADDRESS
CITY
5. NAME OF FACILITY OR OFFICE

STATE/Province ZIP/Postal Code COUNTRY (if not USA)
NAME OF HEALTH CARE PROVIDER THAT TREATED YOU

What medical conditions were treated or evaluated?

PHONE NUMBER

DATE LAST SEEN
(IF KNOWN)

MM / YYYY

STREET ADDRESS
CITY

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

Form SSA-454-BK (XX-XXXX) UF

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If you need to list more facilities or doctors, use Section 9 – Remarks.
3.E. Within the last 12 months, did any of the providers listed in 3.D. order any medical tests for you?
(Include tests already performed and those scheduled in the future, and the healthcare provider that
scheduled them.)
NO (Go to 3.F.)
YES (Complete the following section below.) – If you need more space, use Section 9 – Remarks.
TEST

NAME OF HEALTHCARE PROVIDER

Blood test (not HIV)
Breathing test
Cardiac catheterization
EEG (brain wave test)
EKG (heart test)
Hearing test
HIV test
Speech/language test
Treadmill (exercise test)
Vision test
Psychological/IQ test
Biopsy (list body part):
MRI/CT scan (list body part):
X-ray (list body part):
Other – please specify:
3.F. Within the last 12 months, have you taken or are you now taking any prescription or non-prescription
medicines?
NO (Go to 3.G.)
YES (Complete the following section below.) – Look at your medicine containers, if necessary.
If you need more space, use Section 9 – Remarks.
NAME OF MEDICINE
1.
2.
3.
4.
5.
6.

IF PRESCRIBED, GIVE
DOCTOR NAME

REASON FOR MEDICINE
(IF KNOWN)

Form SSA-454-BK (XX-XXXX) UF

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3.G. Do you use an assistive device?
NO (Go to Section 4)
YES (Complete the following section below.) If you need more space,
use Section 9 – Remarks.

DEVICE

FREQUENCY OF USE

Braces
Canes
Crutches
Eyeglasses
Hearing aid
Screen reader

Always
Always
Always
Always
Always
Always

Sometimes
Sometimes
Sometimes
Sometimes
Sometimes
Sometimes

Walker
Wheelchair
Other:

Always
Always

Sometimes
Sometimes

Always

Sometimes

NAME OF HEALTH CARE
PROVIDER, IF PRESCRIBED

3.H. Is the person receiving disability benefits listed in 1.A. under age 14?
NO (Go to Section 4)
YES (Go to Section 10)
SECTION 4 – WORK INFORMATION
Complete only if you are age 14 years old or older
Please tell us if you have worked since the date of your last medical disability decision. If we have
any additional questions about your work, we may contact you.
4.A. Since the date of your last medical disability decision have you worked? (See date on top of Page 3.)
NO (Go to 4.B.)
YES (Complete following section below.)
Are you currently working?
No
Yes
Select all types of work you had since your last medical disability decision:
Wages from employer
Self-employment
4.B. Is the person receiving disability benefits listed in 1.A. under age 18?
NO (Go to Section 5)
YES (Go to Section 10)

Form SSA-454-BK (XX-XXXX) UF

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SECTION 5 – SUPPORT SERVICES
Complete only if you are age 18 years or older
Please provide the information about your participation in support services. Examples of support
services can include:
• An Individualized Education Program (IEP) through a school (if a student age 18-21)
• An individualized work plan with an employment network under the Ticket to Work Program
• A Plan to Achieve Self-Support (PASS)
• An individualized plan for employment with a vocational rehabilitation agency or any
other organization.
5.A. Since the date of your last medical disability decision, have you participated or are you participating in
any support services mentioned above or any other vocational rehabilitation, employment services, or
other support services to help you return to work? (See date on top of Page 3.)
NO (Go to Section 6)
YES (Complete the following section below.)
FACILITY OR ORGANIZATION NAME

PHONE NUMBER

COUNSELOR, INSTRUCTOR, OR JOB COACH NAME
MAILING ADDRESS (Street or PO Box) (Include Suite, Building, etc.)
CITY

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

5.B. Are you still participating in the plan or program? (Select answer below)
YES - Date began:

MM / YYYY

Expected completion date:

NO - Date began:

MM / YYYY

Date stopped:

MM / YYYY

MM / YYYY

Reason stopped:
5.C. What types of services, tests, or evaluation were provided?
Select all that apply:
Vision test

Psychological/IQ test

Work classes

Hearing test

Work Evaluation

Other - Please explain:
SECTION 6 - OTHER MEDICAL INFORMATION
Complete only if you are age 18 years or older
Please provide the contact information for anyone else or any other organization that may have
medical information about your physical or mental health condition(s) that you did not list in
Questions 3.D. or 5.A.
6. Within the last 12 months, does anyone else (other than your medical providers) have your medical
information or are you scheduled to see anyone else? Examples include places like social services
agencies, welfare agencies, attorneys, prisons, workers’ compensation, insurance companies who have
paid you disability benefits.
NO (Go to Section 7)
YES (Complete the following section below.)

Form SSA-454-BK (XX-XXXX) UF

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NAME OR ORGANIZATION

PHONE NUMBER

MAILING ADDRESS
CITY

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

NAME OF CONTACT PERSON
Date of First Contact
(in last 12 months)

CLAIM NUMBER (if any)
Date of Last Contact
(in last 12 months)

Date of Next Contact
(if any)

Reason(s) for Contacts
If you need to list other people or organizations use Section 9 - Remarks and give the same detailed
information as above for each one you list.
SECTION 7 – EDUCATION, TRAINING, AND LITERACY
Complete only if you are age 18 years or older
Please provide any information about your education, training, and literacy since your last
disability decision.
7.A. Have you received any education since your last disability decision? (See date at the top of Page 3.)
NO, (Go to 7.B.)
YES (Complete the following section below.)
NAME OF SCHOOL

DATE(S) OF ATTENDANCE
/
/
to
MM YYYY
MM YYYY

MAILING ADDRESS
CITY

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

TYPE OF PROGRAM/DEGREE

Date Completed (or scheduled to be completed)
/
MM YYYY
7.B. Have you received any type of training (specialized job, trade, or vocational training) since your last
disability decision? (See date at top of Page 3.)
NO (Go to 7.C.)
YES (Complete the following section below.)
NAME OF TRAINING FACILITY

PHONE NUMBER

MAILING ADDRESS
CITY
TYPE OF PROGRAM

STATE/Province ZIP/Postal Code COUNTRY (if not USA)
Date Completed (or scheduled to be completed)
/
MM YYYY

Form SSA-454-BK (XX-XXXX) UF

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7.C. What written language do you use every day in most situations (at home, work, school, in community,
etc.)?
7.D. READING - In the language you identified in 7.C., can you read a simple message, such as a
YES
NO
shopping list or short and simple notes?
7.E. WRITING - In the language you identified in 7.C., can you write a simple message, such as a shopping
YES
NO
list or short simple notes?
If you need to list other education information or training facilities use Section 9 - Remarks and
provide the same detailed information as above.
SECTION 8 - DAILY ACTIVITIES
Complete only if you are age 18 years or older.
Please tell us how your conditions affect your everyday life. This will help us further understand
your medical condition(s).
8.A. Describe what you do in a typical day. Please focus on how your medical condition(s) affect your daily
activities. If you need more space, use Section 9 – Remarks. Claims Specialists will mention to respondents
that this question is optional

8.B. Do you have hobbies or interests? If you need more space, use Section 9 – Remarks.
YES

NO

Claims Specialists will mention to respondents
that this question is optional

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

8.C. Do your medical conditions cause you to have difficulties doing any of the following?
YES
NO
If YES, please select any tasks that you need help with or have difficulty doing.
Dressing
Taking medicine
Doing chores (inside/outside of house)
Bathing
Preparing meals
Driving or using public transportation
Caring for hair
Feeding self
Understanding or following directions
Walking
Shopping
Managing money
Standing
Lifting objects
Getting along with people
Sitting
Using arms
Using hands or fingers
Concentrating
Remembering
Seeing, hearing, or speaking
Please explain anything you marked you need help with or have difficulty doing:

If you need more space, use Section 9 – Remarks.

Form SSA-454-BK (XX-XXXX) UF

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SECTION 9 - 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 provide the additional information requested in those sections. Be sure to note the section
(and question number) to which you are referring.

Form SSA-454-BK (XX-XXXX) UF

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SECTION 10 – WHO IS COMPLETING THIS REPORT
Date Report Completed (month, day, year)
Who is completing this report?
The person listed in 1.A.
The person listed in 2.A.
Someone else (Complete the following section below)
NAME (First, Middle Initial, Last)

Relationship to Person in 1.A.

DAYTIME PHONE NUMBER where we may reach you or leave a message, if needed. (Include the area
code, IDD and country codes if you live outside the USA or Canada.)
MAILING ADDRESS (Street or PO Box) Include apartment number if applicable.
CITY

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