Current Pilot Version of the SSA-454-ICR

CONTINUING DISABILITY REVIEW REPORT
SSA-454-ICR
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 this report as you can. We will contact you if we need more
information.
HOW TO COMPLETE THIS REPORT

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Print your answers with a black ink pen.
If you are assisting someone else, please answer the questions as if
that person were completing the report.
Print only one letter or number in each box. Leave an empty box between
words.
Example:
C O N T I N U I N G

D I S A B I L I T Y

R E P O R T

Print dates like this: Month/Day/Year. For example, you would print
November 10, 2009, like this: 11/10/2009
1 1 / 1 0 / 2 0 0 9
Answer “Yes” or “No” questions by marking an “X” inside the “Yes” or “No”
boxes.
Example: Yes

X

Yes
No

Provide complete phone numbers including area code.
Example: 410 - 555 - 1212
4 1 0

-

5 5 5

-

1 2 1 2

If you cannot remember the names of your health care providers, you may be
able to get that information from appointment reminders, medical bills,
prescriptions, or prescription medicine containers.
ANSWER EVERY QUESTION, unless the report indicates otherwise. If
you need more space to answer any question, please use Section 8 Remarks, on the last page to finish your answer. Write the number of the
question you are answering.

YOU DO NOT NEED TO ASK DOCTORS OR HOSPITALS FOR ANY MEDICAL
RECORDS. The information you give us on this report tells us where to request
your medical and other records. With your permission, we will request your
records.
Form SSA-454-ICR (07-2010)

The Privacy Act
Sections 205(a), 223(d), and 1631(e) (1) of the Social Security Act, as amended,
authorize us to collect this information. The information you provide will be used
to make a decision on the named claimant’s claim. While giving us the
information on this report is voluntary, failure to provide all or part of the
requested information could prevent an accurate or timely decision on the named
claimant’s claim. We generally use the information you supply for the purpose of
making decisions regarding claims. 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
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); (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 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.
The Paperwork Reduction Act
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. 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 report.
MAIL THE COMPLETED REPORT IN THE ENCLOSED ENVELOPE OR TAKE IT 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 1-800325-0778) for the address.

AFTER COMPLETING THIS REPORT, REMOVE THIS SHEET AND KEEP IT
FOR YOUR RECORDS
Form SSA-454-ICR (07-2010)

Form Approved
OMB No. 0960-0072

Social Security Administration

CONTINUING DISABILITY REVIEW REPORT
SSA will use this form to review your medical condition(s) since the date of your last medical disability decision.
For SSA Use Only - Do not write in this box.

WBDOC: Exc

1

2

3

Selection date:
Claim Number:
Date of your last medical disability decision:

000102370304370506070800010237030437050607081010101060012
101112130123456789012345678900123456789012345678920090101
201020280123282810374543718122720090917
IMPORTANT
Are you currently participating in the
Ticket to Work Program or working under
a plan with a private or State Vocational
Rehabilitation Agency?

No

Continue with 1.A.

Yes

STOP!! Call the Social Security office at

SECTION 1 – INFORMATION ABOUT THE DISABLED PERSON
1.A. Social Security Number, Name, and Address of Disabled Person

▼

If your Name and Address are correct, skip to 1.C. If your Name or Address is
not correct as shown, write an "X" in this box and enter corrections below:

1.B. Enter Name or Address Corrections Here (Go to 1.C. if the above information is correct)
Full Name (First, Middle Initial, Last)

Mailing Address (number, street, apartment, PO box, rural route):

State:

City:

ZIP Code:

1.C. DAYTIME PHONE NUMBER

(If you do not have a phone number where we can reach you, give us a daytime phone number
where we can leave a message.)

Telephone Number:

(area code)

-

None - check here if we cannot contact you by phone.

(phone number)

1.D. ALTERNATE PHONE NUMBER
Telephone Number:

(area code)

-

None - check here if we cannot contact you by phone.

(phone number)

1.E. In the last 12 months, have you used any other names on your medical or educational
records?
Form SSA-454-ICR (07-2010)

454-ICR 1

Yes

No

SECTION 2 - MEDICAL CONDITIONS
2.A. If you are an adult (age 18 or older), list all of the physical and/or mental conditions that limit your
ability to work. If you are completing this form for a child (under age 18), list all of the physical and/or
mental conditions that limit the child’s ability to do the same things as other children of the same age.
List each physical and/or mental condition (including emotional or learning problems) separately.
1.
2.
3.
4.
5.
2.B. Do you have more than 5 medical conditions?

Yes

No

3.A. For any physical condition(s)?

Yes

No

3.B. For any mental condition(s) (including emotional or learning problems)?

Yes

No

SECTION 3 - MEDICAL RECORDS
Have you seen a doctor or other health care professional or received treatment at a hospital
or clinic within the last 12 months, or do you have a future appointment scheduled?

If you answered "no" to both 3.A and 3.B, go to
Section 4 - Work, Education and Training
3.C. Tell us who may have medical records covering the last 12 months about any of your physical or mental
condition(s). This includes doctors' offices, hospitals (including emergency room visits), clinics, and other
health care facilities.
(1) Name of Hospital, Clinic, Doctor or other Health Care Professional:

City and State in which you saw this medical provider:

Telephone Number:

(area code)

(phone number)

Form SSA-454-ICR (07-2010)

454-ICR 2

(2) Name of Hospital, Clinic, Doctor or other Health Care Professional:

Telephone Number:

(area code)

City and State in which you saw this medical provider:

(phone number)

(3) Name of Hospital, Clinic, Doctor or other Health Care Professional:

Telephone Number:

(area code)

City and State in which you saw this medical provider:

(phone number)

(4) Name of Hospital, Clinic, Doctor or other Health Care Professional:

Telephone Number:

(area code)

City and State in which you saw this medical provider:

(phone number)

(5) Name of Hospital, Clinic, Doctor or other Health Care Professional:

Telephone Number:

(area code)

City and State in which you saw this medical provider:

(phone number)

3.D. Have you seen other medical providers within the last 12 months?

Yes

No

3.E. Does anyone else have medical information about your condition(s) covering the last 12
months, or are you scheduled to see anyone else? (This includes workers’ compensation,
insurance companies who have paid you disability benefits, prisons, attorneys, and welfare.)

Yes

No

SECTION 4 - WORK, EDUCATION AND TRAINING
Complete this section only if you are 18 or older
4.A. Since

have you worked?

Yes

No

4.B. Since

have you received any education?

Yes

No

4.C. What year did you last attend any school? (for example 1982)
4.D. Since

have you received any type of specialized job,

trade or vocational training?
Form SSA-454-ICR (07-2010)

454-ICR 3

Y Y Y Y

Yes

No

SECTION 5 - VOCATIONAL REHABILITATION, EMPLOYMENT, OR OTHER SUPPORT SERVICES
Complete this section only if you are 18 or older
5.

Since
, have you participated, or are you participating in:
an individual 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;
an individualized education program through an educational institution (if a student age18-21); or
any program providing vocational rehabilitation, employment services, or other support services to help you go to
work?
No
Yes
SECTION 6 - MEDICINES

6.A. Are you now taking, or have you taken in the last 12 months, any prescription or nonprescription medicines?

Yes

6.B. If you answered yes, please list your medicines below. Look at your medicine containers, if necessary.
1.
2.
3.
4.
5.
6.
7.
8.
9.
SECTION 7 - DAILY ACTIVITIES
Use remarks section if more space is needed
7.A. Describe what you do in a typical day (for example: I get up around 7 a.m., take a shower, eat breakfast,
check emails, etc.)

Form SSA-454-ICR (07-2010)

454-ICR 4

No

7.B. Do you have difficulty doing any of the following?
Dressing

Yes

No

Bathing

Yes

No

Caring for hair

Yes

No

Taking medicine

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/following
directions

Yes

No

Completing tasks

Yes

No

Getting along with
people

Yes

No

Form SSA-454-ICR (07-2010)

Please explain any "Yes" answers here. ▼

454-ICR 5

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

Always

Never

Sometimes

If ALWAYS or SOMETIMES, please describe what kind, when, and how you use it.

7.D. Do you have hobbies or interests?

Yes

No

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

SECTION 8 - 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 medical condition(s) 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.

SECTION 9 - CONTACTS
9.A. Give the name of someone (other than your doctors) we can contact who knows about your medical
conditions, and can help you with your case.
Full Name (First, Middle Initial, Last):

Daytime Telephone Number:

(area code)

Relationship to Disabled Person:

(phone number)

9.B. When was this report completed (month / day / year)?
9.C. Who completed this report?
The disabled person
The person named in 9.A. above
Someone else (go to question 9.D.)
9.D. Give the name of the person who completed this report.
Full Name (First, Middle Initial, Last):

Daytime Telephone Number:

-

Relationship to Disabled Person:

-

Form SSA-454-ICR (07-2010)

454-ICR 6

M M

/

D D

/

Y Y Y Y