SSA-454-BK--Currently Approved Version

CONTINUING DISABILITY REVIEW REPORT
FORM SSA-454-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 do your continuing disability review. We will use the form to
update your disability information since the date of your last medical disability decision. 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 your appointment is 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.
Reminder: If you are filling out the form for someone else, please provide the information about him or her. When a
question refers to “you,” “your,” or the “Disabled Person,” it refers to the person who is receiving disability benefits.
HOW TO COMPLETE THIS FORM
•
•
•
•
•
•
•

Print or write clearly.
Unless otherwise indicated, 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 FOR 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, please use SECTION 10 - REMARKS, on Page 14, 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 that 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.

FORM

SSA 454-BK

(4-2006)

ef (04-2006) (Destroy Prior Editions)

The Privacy Act
The Social Security Administration is authorized to collect the information on this form under sections 205(a), 223(d), and
1631(e)(1) of the Social Security Act. The information on this form is needed by Social Security to make a decision on
your case. While giving us the information on this form is voluntary, failure to provide all or part of the requested
information could prevent an accurate or timely decision on your case. Although the information you furnish is almost
never used for any purpose other than making a determination about your disability, such information may be disclosed by
the Social Security Administration as follows: (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); and
(3) to facilitate statistical research and such activities necessary to assure the integrity and improvement of the Social
Security programs (e.g., to the Bureau of the Census and private concerns under contract to Social Security).
We may also use information that you give us when we match records by computer. Matching programs compare our
records with those of other Federal, State, or local government agencies. Many agencies may use matching programs to find
or prove that a person qualifies for benefits paid by the Federal government. The law allows us to do this even if you do not
agree to it.
Explanations about these and other reasons why information you provide us may be used or given out are available in Social
Security offices. If you want to learn more about this, contact any Social Security office.

The 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 60 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. 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

SSA 454-BK

(4-2006)

ef (04-2006) (Destroy Prior Editions)

Form Approved
OMB No. 0960-0072

SOCIAL SECURITY ADMINISTRATION

CONTINUING DISABILITY REVIEW REPORT
SSA will use this form to review your illnesses, injuries, or
conditions since the date of your last medical disability decision.

-

Related SSN
Type(s) of Case(s):
(Check all that apply.)

-

For SSA Use Only
Do not write in this box.
Date of your last medical disability decision:

Number Holder

TITLE II
TITLE XVI

DIB
DI

DWB
DS

CDB
DC

FZ
BI

ESRD
BS

HIB
BC

If you are currently participating in the Ticket to Work Program or working
under a plan with a private or State Vocational Rehabilitation Agency, contact
the Social Security Administration before completing this form.
SECTION 1- INFORMATION ABOUT THE DISABLED PERSON
1.A. NAME (first, middle, last)
1.B. SOCIAL SECURITY NUMBER

-

1.C.

-

DAYTIME PHONE NUMBER (If you do not have a phone 1.D. E-MAIL ADDRESS (optional)
number where we can reach you, give us a daytime
phone number where we can leave a message. )

(

)

(area code)

Your number

-

Message number
None

(phone number)

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

RELATIONSHIP

ADDRESS (number, street, apt., PO Box, rural route)

DAYTIME PHONE NUMBER

CITY

(

STATE ZIP

(area code)

-

1.F. Can you speak and understand English?

)

YES

(phone number)

NO

If "no," what is your preferred language?
NOTE: If you cannot speak and understand English, we will provide an interpreter, free of charge.
If you cannot speak and understand English, is there someone we may contact who speaks and
understands English and will give you messages?
YES
NO
If "yes," and this is the same person as in "1.E." above, write "SAME" below. If "yes," but this is a different
person, complete the information below.)
NAME
RELATIONSHIP
ADDRESS (number, street, apt., PO Box, rural route)
CITY

DAYTIME PHONE NUMBER

(

STATE ZIP

)

(area code)

-

(phone number)

1.G. If you are age 18 or older, can you read and understand 1.H. If you are age 18 or older, can you write
more than your name in English?
English?
YES
NO
YES
NO
1.I. What is your height without shoes?
1.J. What is your weight without shoes?

FORM

SSA 454-BK

(4-2006) ef (04-2006)

(Destroy Prior Editions)

PAGE 1

SECTION 2- INFORMATION ABOUT YOUR ILLNESSES, INJURIES, OR CONDITIONS
2.A. If you are an adult (age 18 or older), what are the disabling illnesses, injuries, or conditions that limit your
ability to work? If you are a child (under age 18), what are the disabling illnesses, injuries, or conditions
that limit your ability to do the same things as other children of the same age?

2.B. Has there been a change (for better or worse) in your illnesses, injuries, or conditions listed in SECTION
2.A., since the date of your last medical disability decision (see date on top right side of Page 1)?
YES (Describe specific changes below and give dates when these changes started.)
NO

If you need more space, use SECTION 10 - REMARKS.
SECTION 3- INFORMATION ABOUT YOUR MEDICAL RECORDS
3.A. Within the last 12 months, have you seen a doctor/hospital/clinic or anyone else for your illnesses,
injuries, or conditions?
YES

NO

Do you have a future appointment with a doctor/hospital/clinic or anyone else for your illnesses, injuries,
or conditions?
YES

NO

3.B. Within the last 12 months, have you seen a doctor/hospital/clinic or anyone else for emotional or mental
problems?
YES

NO

Do you have a future appointment with a doctor/hospital/clinic or anyone else for emotional or mental
problems?
YES

NO

If you answered "No" to both 3.A. and 3.B., do not complete the rest of
SECTION 3; skip to SECTION 4.

FORM

SSA 454-BK

(4-2006)

ef (04-2006)

PAGE 2

SECTION 3- INFORMATION ABOUT YOUR MEDICAL RECORDS, continued
3.C. List other names, if any, that you have used on your medical records within the last 12 months.

3.D. List each DOCTOR/HMO/THERAPIST/OTHER PERSON who has treated you within the last 12
months. Also, provide this information for any future appointment(s).
1. NAME
DATES
ADDRESS

First Visit (within last 12 months)
STATE

CITY

ZIP

Last Visit

PHONE

(

)

(area code)

-

PATIENT ID# (if known)

Next Appointment

(phone number)

Reasons for visits

What treatment was received?

2. NAME
DATES
First Visit (within last 12 months)

ADDRESS
STATE

CITY

ZIP

Last Visit

PHONE

(

)

(area code)

-

PATIENT ID# (if known)

Next Appointment

(phone number)

Reasons for visits

What treatment was received?

FORM SSA 454-BK (4-2006) ef (04-2006)

PAGE 3

SECTION 3- INFORMATION ABOUT YOUR MEDICAL RECORDS, continued

DOCTOR/HMO/THERAPIST/OTHER
3. NAME

DATES
First Visit (within last 12 months)

ADDRESS
ZIP

STATE

CITY

Last Visit

PHONE

(

)

(area code)

PATIENT ID# (if known)

-

Next Appointment

(phone number)

Reasons for visits

What treatment was received?

If you need more space, use SECTION 10 - REMARKS.
3.E. List each HOSPITAL/CLINIC where you received treatment within the last 12 months. Also, provide this
information for any future appointment(s).
1. NAME

PHONE

(

)

(area code)

(phone number)

PATIENT ID # (if known) NEXT APPOINTMENT

ADDRESS

CITY

-

STATE

ZIP

What doctor(s) do you regularly see here?

TYPE OF VISIT

DATES (within the last 12 months)
Date In

Date Out

First Visit

Last Visit

REASON FOR VISIT(S)

TREATMENT RECEIVED

REASON FOR VISIT(S)

TREATMENT RECEIVED

REASON FOR VISIT(S)

TREATMENT RECEIVED

Inpatient Stays
(stayed at least
overnight)

Outpatient Visits
(sent home the
same day)

Date(s) of Visit(s)

Emergency Room
Visits

FORM SSA 454-BK (4-2006) ef (04-2006)

PAGE 4

SECTION 3- INFORMATION ABOUT YOUR MEDICAL RECORDS, continued

HOSPITAL/CLINIC
2. NAME

PHONE

(

)

(area code)

(phone number)

PATIENT ID # (if known) NEXT APPOINTMENT

ADDRESS

CITY

-

STATE

ZIP

What doctor(s) do you regularly see here?

TYPE OF VISIT

DATES (within the last 12 months)
Date In

Date Out

First Visit

Last Visit

REASON FOR VISIT(S)

TREATMENT RECEIVED

REASON FOR VISIT(S)

TREATMENT RECEIVED

REASON FOR VISIT(S)

TREATMENT RECEIVED

Inpatient Stays
(stayed at least
overnight)

Outpatient Visits
(sent home the
same day)

Date(s) of Visit(s)

Emergency Room
Visits
3. NAME

PHONE

(

)

(area code)

ADDRESS

CITY

(phone number)

PATIENT ID # (if known) NEXT APPOINTMENT

STATE

ZIP

What doctor(s) do you regularly see here?

TYPE OF VISIT

DATES (within the last 12 months)
Date In

Date Out

First Visit

Last Visit

REASON FOR VISIT(S)

TREATMENT RECEIVED

REASON FOR VISIT(S)

TREATMENT RECEIVED

REASON FOR VISIT(S)

TREATMENT RECEIVED

Inpatient Stays
(stayed at least
overnight)

Outpatient Visits
(sent home the
same day)

Date(s) of Visit(s)

Emergency Room
Visits

If you need more space, use SECTION 10 - REMARKS.
FORM SSA 454-BK (4-2006) ef (04-2006)

PAGE 5

SECTION 3- INFORMATION ABOUT YOUR MEDICAL RECORDS, continued
If you are under age 18, do not complete question 3.F. or SECTION 4; skip to SECTION 5 - TESTS.

3.F. Does anyone else (for example, Workers' Compensation, insurance company, prisons, attorneys, or
welfare agency) have medical records or information about your illnesses, injuries, or conditions, within
the last 12 months? Also, provide this information if you are scheduled to see anyone in the future.
YES

NO (Skip to SECTION 4.)

(Complete the following information.)

NAME
DATES
FIRST VISIT(within the last 12 months)

ADDRESS
STATE

CITY

ZIP

LAST VISIT

PHONE

(

)

NEXT APPOINTMENT

-

(area code)

(phone number)

CLAIM NUMBER (if any)

NAME OF CONTACT PERSON

REASONS FOR VISITS

If you need more space, use SECTION 10 - REMARKS.
SECTION 4 - MEDICATIONS
Are you taking any medications for your illnesses, injuries, or conditions?
YES (Complete the following information. Look at your medicine containers, if necessary.)
NO (Skip to SECTION 5.)

NAME OF MEDICINE

IF PRESCRIBED, GIVE
NAME OF DOCTOR

REASON FOR
MEDICINE

If you need more space, use SECTION 10 - REMARKS.

FORM SSA 454-BK (4-2006) ef (04-2006)

PAGE 6

ANY SIDE EFFECTS
YOU HAVE

SECTION 5 - TESTS
Within the last 12 months, have you had any of the following tests for your illnesses, injuries, or conditions?
Also, provide this information if you are scheduled for tests in the future.
YES (Complete the following information, give approximate dates, if necessary.)
NO (Skip to SECTION 6.)

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

KIND OF TEST

WHERE DONE?
(name of facility)

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.

FORM SSA 454-BK (4-2006) ef (04-2006)

PAGE 7

WHO SENT YOU
FOR THIS TEST?

SECTION 6 - EDUCATION/TRAINING INFORMATION
Complete SECTION 6 if you are age 18 years old or older.

6.A. Check the highest grade of school completed.

School:
None K

College:
1

2

3

4

5

6

7

8

9

10

11

12 GED

1

2

3

4 or more

Approximate date completed:

6.B. Since the date of your last medical disability decision (see date on top right side of Page 1), have you
completed or will you complete any type of special job training, trade or vocational school?
YES (Complete the following information.)

NO

NAME OF SCHOOL

PHONE

ADDRESS

CITY

STATE

(

ZIP

TYPE OF PROGRAM

APPROXIMATE DATE COMPLETED (or will complete)

If you need more space, use SECTION 10 - REMARKS.

FORM SSA 454-BK (4-2006) ef (04-2006)

)

(area code)

PAGE 8

(phone number)

SECTION 7 - UPDATED WORK INFORMATION
If you are under age 14, skip to SECTION 10 - REMARKS.
If you are age 14 or older, complete SECTION 7.A., and as appropriate, B., C., and D. only. Then skip to
SECTION 10 - REMARKS.
If you are age 16 or older, complete all of SECTION 7.

7.A. ARE YOU WORKING NOW?
Full-time (Skip to Question 7.D.)

Part-time (Skip to Question 7.D.)
Not working now (Continue to Question 7.B.)

7.B. If you are not working now, did you work since the date 7.C. If you are not working now, do you believe
that your medical condition has improved?
of your last medical disability decision (see date on
top right side of Page 1).
YES (Go to Question 7.C.)

YES

NO (Skip to Question 7.E.)

NO

7.D. If you have worked at any time since the date of your last medical disability decision (see date on top
right side of Page 1), complete the following information for each job you have done. List the most recent
job first.
JOB 1

JOB 2

JOB TITLE
(example: cook)

TYPE OF BUSINESS
(example: restaurant)

JOB DESCRIPTION

DATES
WORKED
(month and year)

FROM:
TO:

HOURS PER DAY
DAYS PER WEEK
RATE OF PAY
(per hour, day, week, month,
or year)

REASON YOU STOPPED
WORK

If you need more space, use SECTION 10 - REMARKS.

FORM SSA 454-BK (4-2006) ef (04-2006)

PAGE 9

JOB 3

SECTION 7 - UPDATED WORK INFORMATION, continued
7.E. If you are not working, do you believe that you are able to work?
No, I don't believe that I am able to work at this time.
Yes, and I believe that I do not have limitations or restrictions on my ability to work.
Yes, but I believe that I have limitations or restrictions on my ability to work. (Please explain.)

7.F. Has your doctor(s) told you that you are able to work?
No

(Skip to Section 8.)

Did not say (Skip to Section 8.)
Yes, and my doctor(s) did not place limitations or restrictions on my ability to work.
Yes, but my doctor(s) placed limitations or restrictions on my ability to work. (Please
explain. If the same as 7.E., write "same" here.)

7.G. What is the name(s) of the doctor(s) who said you were 7.H. According to your doctor, when were/are you
able to work?
able to begin work?

(Please make sure that this doctor(s) is listed in SECTION 3.)

If you need more space, use SECTION 10 - REMARKS.
SECTION 8 - VOCATIONAL REHABILITATION, EMPLOYMENT, or
OTHER SUPPORT SERVICES INFORMATION
Complete SECTION 8 if you are age 18 years old or older.
8.A. Since the date of your last medical disability decision (see date on top right side of Page 1), have you
participated, or are you participating, in the Ticket to Work Program, a plan with a private or State
Vocational Rehabilitation Services, an employment network, or any other support services to help you go to
work?
YES (Complete the following information.)
NO (Skip to SECTION 9.)
NAME OF ORGANIZATION

NAME OF COUNSELOR

ADDRESS

CITY

PHONE

STATE

ZIP

(

(area code)

FORM SSA 454-BK (4-2006) ef (04-2006)

)

PAGE 10

(phone number)

8.B. When did you start participating in the plan?

8.C. Are you still participating in the plan?
YES

NO. I completed the plan
(date completed)

NO. I stopped participating in the plan before completing it. (Please explain why you are
no longer participating.)

8.D. Types of services or tests provided (for example: intelligence or psychological testing, vision, physicals,
hearing, workshops, schools, colleges):

If you need more space, use SECTION 10 - REMARKS.
SECTION 9 - INFORMATION ABOUT YOUR DAILY ACTIVITIES
Complete SECTION 9 if you are age 18 years old or older.
9.A. Describe what you do in a typical day.

FORM SSA 454-BK (4-2006) ef (04-2006)

PAGE 11

SECTION 9 - INFORMATION ABOUT YOUR DAILY ACTIVITIES, continued
9.B. Do you have difficulty doing any of the following? (Please explain any "Yes" answers.)
Dressing

No

Yes

Bathing

No

Yes

Caring for hair

No

Yes

Taking medicine

No

Yes

Preparing meals

No

Yes

Feeding self

No

Yes

Doing chores (inside/outside house)

No

Yes

Driving or using public transportation

No

Yes

Shopping

No

Yes

Managing money

No

Yes

Walking

No

Yes

Standing

No

Yes

Lifting objects

No

Yes

Using arms

No

Yes

Using hands or fingers

No

Yes

Sitting

No

Yes

Seeing, hearing, or speaking

No

Yes

FORM SSA 454-BK (4-2006) ef (04-2006)

PAGE 12

SECTION 9 - INFORMATION ABOUT YOUR DAILY ACTIVITIES, continued
9.B. (continued) Do you have difficulty doing any of the following? (Please explain any "Yes" answers.)
Concentrating

No

Yes

Remembering

No

Yes

Understanding/following directions

No

Yes

Completing tasks

No

Yes

Getting along with people

No

Yes

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

NO

YES

(Please describe what kind, when and how you use it.)

9.D. Do you have hobbies or interests?
NO

YES

(Please describe what they are and how much time you spend doing them.)

If you need more space, use SECTION 10 - REMARKS.

FORM SSA 454-BK (4-2006) ef (04-2006)

PAGE 13

SECTION 10 - REMARKS
Please provide any additional information you did not show in earlier parts of this form. You may also attach
any medical records, copies of prescriptions, or any other records about your current illnesses, injuries, or
conditions 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 the information below.

Date Form Completed (month, day, year)

If the person completing this form is NOT the disabled person, please complete the following
information.
Name (please print)

Address (number and street)

City

E-mail address (optional)
State

ZIP

Relationship to disabled person
-

FORM SSA 454-BK (4-2006) ef (04-2006)

PAGE 14