Form SSA-455 Disability Update Report

See Revised Privacy Act
Statement

See Revised Paperwork
Reduction Act Statement

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
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 0960-0555. 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.

∗

DATE:

Disability Update Report
Social Security Administration, P.O. Box

FORM APPROVED
OMB NO. 0960-0511

, Wilkes-Barre, PA 18767

PAYEE’S NAME AND ADDRESS

REPORT PERIOD
From:
BENEFICIARY

To The Present

PSC:
TELEPHONE NUMBER

1.

a. Since

CLAIM NUMBER

YES

, have you worked for someone

NO

➤

or been self-employed?

b. If you answered “YES” to 1.a., please complete the information below.
WORK ENDED
Month
Year

WORK BEGAN
Month
Year

Most
Recent
Work

2.

1.

$

,

2.

$

,

3.

$

,

Have you attended any school or work training program(s)
since

3.

YES

NO

?
to the present...(Please place an “X” in one box only):

Since

my doctor and I
have not discussed
whether I can work.

4.

MONTHLY EARNINGS
Dollars Only, No Cents

my doctor
told me I
cannot work.

my doctor
told me I
can work.

Place an “X” in only one box which best describes your health
now as compared to
BETTER

Form SSA-455-OCR-SM (10-2003)

.
SAME
Continued on the Reverse

WORSE

➤

FOR SSA USE ONLY

AC?

5.

a. Have you gone to a doctor or clinic for treatment
(including evaluations, checkups, counseling,
prescriptions, or medicine) since
?

YES

NO

➤

b. If you answered “YES” to 5.a., please list:
Reason For Visit:
Most
Recent
Visit

Month

Year

1.
2.
3.

6.

a. Have you been hospitalized or had surgery
since

?

YES

NO

➤

b. If you answered “YES” to 6.a., please list:
Most
Recent

Reason For Hospitalization or Surgery:

Month

Year

1.
2.
3.

REMARKS: If you use this space to further answer questions 1. through 6.,
place an “X” in the box to the right and print on the lines below.

SIGN HERE

➧

Form SSA-455-OCR-SM (10-2003)

TODAY’S DATE
TELEPHONE NUMBER (include Area Code)

SSA will insert the following revised Privacy Act Statement into the form at its next
scheduled reprinting:
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.
The information you furnish on this report is voluntary. However, failure to provide us with the requested
information could prevent us from making an accurate and timely decision on your claim.
We rarely use this information you supply for any purpose other than for reviewing your claim for Social
Security 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.
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 are available in our Systems of Records Notices entitled,
Claims Folders Systems (60-0089) and the Master Beneficiary Record (60-0090). These notices, additional
information regarding this form, routine uses of information, and our programs and systems are available online at www.socialsecurity.gov or at your local Social Security office.