Form SSA-454-BK Continuing Disability Review Report

CONTINUING DISABILITY REVIEW REPORT SSA-454-BK
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 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, a Social Security
Representative will assist you. If you have an appointment, please have the completed report ready
when we contact you.
Note: If you are assisting someone else with this report, please answer the questions as if that
person were completing the report.
HOW TO COMPLETE THIS REPORT
•

Print or write clearly.

•

Include a ZIP or postal code with each address.

•

Provide complete phone numbers, including area code. If a phone number is outside the United
States, provide International Direct Dialing (IDD) code and country code.

•

If you cannot remember the names and addresses of your health care providers, you may be
able to get that information from the telephone book, Internet, medical bills, prescriptions, or
prescription medicine containers.

•

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."

•

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 question, please use Section 11 - Remarks, on the last
page to finish your answer. Write the number of the question you are answering.
YOUR MEDICAL RECORDS

If you have any of your medical records covering the last 12 months, send or bring them to our
office with this completed report. Please tell us if you want to keep your records so we can return
them to you. If you have a scheduled appointment for an interview, bring your medical records, your
prescription medicine containers (if available), and the completed report with 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 request your records. The
information that you give us on this report tells us where to request your medical and other records.
Form SSA-454-BK (04-2014) ef (04-2014)
Destroy Prior Editions

Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 223(d), and 1631(e)(1) of the Social Security Act, as amended, authorize us to
collect this information. We will use the information you provide to make a decision on the named
claimant’s claim. Furnishing us this information is voluntary. However, failing to provide us with all
or part of the information could prevent an accurate or timely decision on the named claimant’s
claim.
We rarely use the information you supply for any purpose other than to make a decision on the
named claimant’s claim. 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 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 System of Records Notices entitled, Supplemental Security Income
Record and Special Veterans Benefits (60-0103), Claims Folders System (60-0089), Master
Beneficiary Record (60-0090), and Electronic Disability Claim File (60-0320). Additional
information about this and other system of records notices and our programs are available from
our Internet website 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. We estimate that it will take about 60 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 21235-0001.
SEND OR BRING THE COMPLETED REPORT 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
1-800-325-0778) for the address.

AFTER COMPLETING THIS FORM, REMOVE THIS SHEET AND KEEP IT FOR YOUR RECORDS.

Form SSA-454-BK (04-2014) ef (04-2014)

Form Approved
OMB No. 0960-0072

SOCIAL SECURITY ADMINISTRATION

CONTINUING DISABILITY REVIEW REPORT
For SSA Use Only - Do not write in this box.
Date of your last medical disability decision:
Claim Number:

Number Holder:

Type(s) of Case(s):

TITLE II

DIB

DWB

CDB

FZ

ESRD

HIB

(Check all that apply.) TITLE XVI

DI
DS
DC
BI
BS
BC
If you are filling out this report for the disabled person, please provide information about him or her.
When a question refers to "you", "your", or the "disabled person", it refers to the person receiving
disability benefits.
SECTION 1 - INFORMATION ABOUT THE DISABLED PERSON
1.B. SOCIAL SECURITY NUMBER

1.A. NAME (First, Middle Initial, Last)

1.C. MAILING ADDRESS (Street or PO Box) Include apartment number if applicable
CITY

ZIP/Postal Code COUNTRY (if not
USA)

STATE/Province

Deleted: ¶

1.D. DAYTIME PHONE NUMBER, including area code, and the IDD and country codes if you live
outside the USA or Canada.
Phone Number:
Check this box if you have a phone or a number where we can leave a message
1.E. ALTERNATE PHONE NUMBER, including area code where we may reach you, if any.
Alternate Phone Number:
1.F. Can you speak and understand English?

YES

NO

If NO, what language do you prefer?
If you cannot speak and understand English, we will provide an interpreter free of charge.
1.G. Can you read and understand English?

YES

NO

Commented [Mockup1]: Modify numbering

1.H. Can you write more than your name in English?

YES

NO

Commented [Mockup2]: Add these questions

1.I. Have you used any other names on your medical or educational records in the last 12 months?
Examples are maiden name, other married names, or nickname.
YES
NO
If YES, please list
SECTION 2 - CONTACTS
Give the name of a friend or relative (other than your doctors) we can contact who knows about
your medical conditions, and can help you with your case.
2.A. NAME (First, Middle Initial, Last)

2.B. Relationship to Disabled

2.C. MAILING ADDRESS (Street or PO Box) Include apartment number if applicable
Form SSA-454-BK (04-2014) ef (04-2014)

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Deleted: G

CITY

STATE/Province

Form SSA-454-BK (04-2014) ef (04-2014)

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ZIP/Postal Code

COUNTRY (if not USA)

SECTION 2 - CONTACTS (Continued)
2.D. DAYTIME PHONE NUMBER (as described in 1.D. above)
2.E. Can this person speak and understand English?
If NO, what language is preferred?

YES

NO

2.F. Who is completing this report?
The disabled person listed in 1.A. (Go to Section 3 - Medical Condition(s))
The person listed in 2.A. (Go to Section 3 - Medical Condition(s))
Someone else (Complete the rest of Section 2 below)
2.G. NAME (First, Middle Initial, Last)

2.H. Relationship to Disabled

2.I. DAYTIME PHONE NUMBER (as described in 1.D. above)
2.J. MAILING ADDRESS (Street or PO Box) Include apartment number if applicable
CITY

STATE/Province

ZIP/Postal Code

COUNTRY (if not USA)

SECTION 3 - MEDICAL CONDITION(S)
3.A. If you are an adult (age 18 or older), list the physical and/or mental condition(s) (including
emotional or learning problems) that limit your ability to work. If you are completing this report
for a child (under age 18), list the physical and/or mental condition(s) (including emotional and
learning problems) that limit the child's ability to do the same things as other children the same
age. List each physical and/or mental condition separately.
1.
2.
3.
4.

If you need more space go to Section 11 - Remarks
3.B. What is your height without shoes?

OR
feet

inches

centimeters (if outside USA)

OR

3.C. What is your weight without shoes?
pounds

kilograms (if outside USA)

3.D. Do you use an assistive device (for example: eye glasses, hearing aids, braces, canes,
crutch(es), walker, wheelchair, service animal)?
Always
Sometimes
Never
If ALWAYS OR SOMETIMES, please describe what kind, when, and how you use it.

If you need more space, use SECTION 11 - Remarks
Form SSA-454-BK (04-2014) ef (04-2014)

Page 3

SECTION 4 - MEDICAL TREATMENT
Within the last 12 months, have you seen a doctor or other health care professional, or received
treatment at a hospital or clinic, or do you have a future appointment scheduled:
4.A. For any physical conditions?
Yes
No
4.B. For any mental condition(s) (including emotional or learning problems)
Yes
No
If you answered "No" to both 4.A. and 4.B., go to Section 5 - Other medical Information
on page 9
4.C. Tell us who may have medical records covering the last 12 months about any of your physical
or mental condition(s) (including emotional or learning problems). This includes doctors'
offices, hospitals (including emergency room visits), clinics, and other health care
facilities. Tell us about your next appointment, if you have one scheduled.
NAME OF FACILITY OR OFFICE

NAME OF HEALTHCARE PROFESSIONAL THAT TREATED YOU

ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE
PROFESSIONAL ABOVE
PHONE NUMBER

PATIENT ID# (if known)

MAILING ADDRESS
STATE/Province

CITY

ZIP/Postal Code

COUNTRY (if not USA)

Dates of Treatment (within the last 12 months)
1. Office, Clinic or
2. Emergency Room Visits 3. Overnight Hospitals Stays
Outpatient visits
List the most recent date first
First visit

A.

Last visit
Next Scheduled Appointment B.
(if any)

C.

A. Date in

Date out

B. Date in

Date out

C. Date in

Date out

What medical conditions were treated or evaluated?

What treatment did you receive for the above conditions? (Do not describe medicines or tests in
this box.)

Form SSA-454-BK (04-2014) ef (04-2014)

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SECTION 4 - MEDICAL TREATMENT (continued)
Check the boxes below for any tests this provider performed or sent you to within the last 12
months, or has scheduled you to take. Please give the dates for past and future tests. If you need
to list more tests, use Section 11 - Remarks.
Check this box if no tests by this provider or at this facility.
KIND OF TEST

DATES OF TEST(S)

KIND OF TEST

DATES OF TEST(S)

EKG (heart test)

EEG (brain wave test)

Treadmill (exercise test)
Cardiac Catheterization

HIV Test
Blood Test (not HIV)

Biopsy (list body part)

X-Ray (list body part)

Hearing Test
Speech/Language Test
Vision Test

MRI/CT Scan (list body part)

Other

Breathing test
If you do not have any more doctors or hospitals to describe, go to
Section 5 - Medicines on page 9.
4.D. Tell us who may have medical records covering the last 12 months about any of your physical
or mental condition(s) (including emotional or learning problems). This includes doctors'
offices, hospitals (including emergency room visits), clinics, and other health care
facilities. Tell us about your next appointment, if you have one scheduled.
NAME OF FACILITY OR OFFICE

NAME OF HEALTHCARE PROFESSIONAL THAT TREATED YOU

ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE
PROFESSIONAL ABOVE
PHONE NUMBER

PATIENT ID# (if known)

MAILING ADDRESS
CITY

STATE/Province

ZIP/Postal Code

COUNTRY (if not USA)

Dates of Treatment (within the last 12 months)
1. Office, Clinic or
2. Emergency Room Visits 3. Overnight Hospitals Stays
Outpatient visits
List the most recent date first
First visit

A.

Last visit
Next Scheduled Appointment B.
(if any)

C.
Form SSA-454-BK (04-2014) ef (04-2014)

Page 4

A. Date in

Date out

B. Date in

Date out

C. Date in

Date out

SECTION 4 - MEDICAL TREATMENT (continued)
What medical conditions were treated or evaluated?

What treatment did you receive for the above conditions? (Do not describe medicines or tests in
this box.)

Check the boxes below for any tests this provider performed or sent you to within the last 12
months, or has scheduled you to take. Please give the dates for past and future tests. If you need
to list more tests, use Section 11 - Remarks.
Check this box if no tests by this provider or at this facility.
KIND OF TEST

DATES OF TEST(S)

KIND OF TEST

DATES OF TEST(S)

EKG (heart test)
Treadmill (exercise test)
Cardiac Catheterization
Biopsy (list body part)

EEG (brain wave test)
HIV Test
Blood Test (not HIV)
X-Ray (list body part)

Hearing Test
Speech/Language Test
Vision Test
Breathing test

MRI/CT Scan (list body part)

Other

If you do not have any more doctors or hospitals to describe, go to
Section 5 - Medicines on page 9.
4.E. Tell us who may have medical records covering the last 12 months about any of your physical
or mental condition(s) (including emotional or learning problems). This includes doctors'
offices, hospitals (including emergency room visits), clinics, and other health care
facilities. Tell us about your next appointment, if you have one scheduled.
NAME OF FACILITY OR OFFICE

NAME OF HEALTHCARE PROFESSIONAL THAT TREATED YOU

ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE
PROFESSIONAL ABOVE
PHONE NUMBER

PATIENT ID# (if known)

MAILING ADDRESS
CITY

STATE/Province

Form SSA-454-BK (04-2014) ef (04-2014)

Page 5

ZIP/Postal Code

COUNTRY (if not USA)

SECTION 4 - MEDICAL TREATMENT (continued)
Dates of Treatment (within the last 12 months)
1. Office, Clinic or
2. Emergency Room Visits 3. Overnight Hospitals Stays
Outpatient visits
List the most recent date first
First visit

A.

Last visit
Next Scheduled Appointment B.
(if any)

C.

A. Date in

Date out

B. Date in

Date out

C. Date in

Date out

What medical conditions were treated or evaluated?

What treatment did you receive for the above conditions? (Do not describe medicines or tests in
this box.)

Check the boxes below for any tests this provider performed or sent you to within the last 12
months, or has scheduled you to take. Please give the dates for past and future tests. If you need
to list more tests, use Section 11 - Remarks.
Check this box if no tests by this provider or at this facility.
KIND OF TEST

DATES OF TEST(S)

KIND OF TEST

EKG (heart test)
Treadmill (exercise test)
Cardiac Catheterization

EEG (brain wave test)
HIV Test
Blood Test (not HIV)

Biopsy (list body part)

X-Ray (list body part)

Hearing Test
Speech/Language Test
Vision Test
Breathing test

MRI/CT Scan (list body part)

DATES OF TEST(S)

Other

If you do not have any more doctors or hospitals to describe, go to
Section 5 - Medicines on page 9.
4.F. Tell us who may have medical records covering the last 12 months about any of your physical
or mental condition(s) (including emotional or learning problems). This includes doctors'
offices, hospitals (including emergency room visits), clinics, and other health care
facilities. Tell us about your next appointment, if you have one scheduled.
NAME OF FACILITY OR OFFICE
Form SSA-454-BK (04-2014) ef (04-2014)

NAME OF HEALTHCARE PROFESSIONAL THAT TREATED YOU

Page 6

SECTION 4 - MEDICAL TREATMENT (continued)
ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE
PROFESSIONAL ABOVE
PHONE NUMBER

PATIENT ID# (if known)

MAILING ADDRESS
STATE/Province

CITY

ZIP/Postal Code

COUNTRY (if not USA)

Dates of Treatment (within the last 12 months)
1. Office, Clinic or
2. Emergency Room Visits 3. Overnight Hospitals Stays
Outpatient visits
List the most recent date first
First visit

A.

Last visit
Next Scheduled Appointment B.
(if any)

C.

A. Date in

Date out

B. Date in

Date out

C. Date in

Date out

What medical conditions were treated or evaluated?

What treatment did you receive for the above conditions? (Do not describe medicines or tests in
this box.)

Check the boxes below for any tests this provider performed or sent you to within the last 12
months, or has scheduled you to take. Please give the dates for past and future tests. If you need
to list more tests, use Section 11 - Remarks.
Check this box if no tests by this provider or at this facility.
KIND OF TEST

DATES OF TEST(S)

KIND OF TEST

EKG (heart test)
Treadmill (exercise test)

EEG (brain wave test)
HIV Test

Cardiac Catheterization
Biopsy (list body part)

Blood Test (not HIV)
X-Ray (list body part)

Hearing Test
Speech/Language Test

MRI/CT Scan (list body part)

DATES OF TEST(S)

Vision Test
Other
Breathing test
If you do not have any more doctors or hospitals to describe, go to
Section 5 - Medicines on page 9.
Form SSA-454-BK (04-2014) ef (04-2014)

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SECTION 4 - MEDICAL TREATMENT (continued)
4.G. Tell us who may have medical records covering the last 12 months about any of your physical
or mental condition(s) (including emotional or learning problems). This includes doctors'
offices, hospitals (including emergency room visits), clinics, and other health care
facilities. Tell us about your next appointment, if you have one scheduled.
NAME OF FACILITY OR OFFICE

NAME OF HEALTHCARE PROFESSIONAL THAT TREATED YOU

ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE
PROFESSIONAL ABOVE
PHONE NUMBER

PATIENT ID# (if known)

MAILING ADDRESS
STATE/Province

CITY

ZIP/Postal Code

COUNTRY (if not USA)

Dates of Treatment (within the last 12 months)
1. Office, Clinic or
2. Emergency Room Visits 3. Overnight Hospitals Stays
Outpatient visits
List the most recent date first
First visit

A.

Last visit
Next Scheduled Appointment B.
(if any)

C.

A. Date in

Date out

B. Date in

Date out

C. Date in

Date out

What medical conditions were treated or evaluated?

What treatment did you receive for the above conditions? (Do not describe medicines or tests in
this box.)

Check the boxes below for any tests this provider performed or sent you to within the last 12
months, or has scheduled you to take. Please give the dates for past and future tests. If you need
to list more tests, use Section 11 - Remarks.
Check this box if no tests by this provider or at this facility.

Form SSA-454-BK (04-2014) ef (04-2014)

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SECTION 4 - MEDICAL TREATMENT (continued)
KIND OF TEST

DATES OF TEST(S)

KIND OF TEST

EKG (heart test)
Treadmill (exercise test)

EEG (brain wave test)
HIV Test

Cardiac Catheterization
Biopsy (list body part)

Blood Test (not HIV)
X-Ray (list body part)

Hearing Test

MRI/CT Scan (list body part)

DATES OF TEST(S)

Speech/Language Test
Vision Test
Breathing test

Other

If you need to list more doctors or hospitals use Section 11 - Remarks and give the same
detailed information as above for each one you list.
SECTION 5 - MEDICINES
5. Are you now taking, or have you taken in the last 12 months, any prescription or non-prescription
medicines?
Yes (Complete the following information. Look at your medicine containers, if necessary.)
No (Go to section 6 - Other Medical Information on page 10.)
IF PRESCRIBED, GIVE
NAME OF MEDICINE
REASON FOR MEDICINE
NAME OF DOCTOR

If you need to list other medicines use Section 11 - Remarks.
If you are under age 18, Skip to Section 11 - Remarks.

Form SSA-454-BK (04-2014) ef (04-2014)

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SECTION 6 - OTHER MEDICAL INFORMATION
Complete only if you are age 18 years or older
6. Does anyone else have medical information about your physical or mental condition(s) (including
emotional and learning problems) covering the last 12 months, or are you scheduled to see
anyone else? (This may include places such as workers' compensation, vocational rehabilitation,
insurance companies who have paid you disability benefits, prisons, attorneys, social service
agencies and welfare agencies.)
Yes (Complete the following information.)
No (Go to SECTION 7 - Education and Training.)
NAME OR ORGANIZATION
PHONE NUMBER
MAILING ADDRESS
CITY

STATE/Province

NAME OF CONTACT PERSON

ZIP/Postal Code

COUNTRY (if not USA)

CLAIM NUMBER (if any)

Date First Contact (in last 12 months) Date Last Contact (in last 12 months) Date Next Contact (if any)

Reason(s) for Contacts

If you need to list other people or organizations use Section 11 - Remarks and give the same
detailed information as above for each one you list.
SECTION 7 - EDUCATION AND TRAINING
Complete only if you are age 18 years or older
7.A. Have you received any education since your last disability decision? (See date at top of Page1.)
YES

NO

Deleted: (Complete the information below.)
Deleted: , go to question 7.B below

If YES, describe the education you received:
________________________________________________________________________________

Deleted: what year did you last attend any school?

Name of School: ______________________
Telephone:________________ Fax:__________
Mailing Address: ______________________
City:____, State/Province:_______________
Zip/Postal Code:______________________
Country (if not U.S.):__________________
Type of program:_____________________
Date(s) of attendance:____________________
Date completed (or scheduled to be completed):_________________________________________
Degree attained, if any: _____________________________________________

Commented [Mockup3]: Add options

Please describe the education you received.
7.B. Have you received any type of specialized job, trade, or vocational training since your last
disability decision? (See date at top of Page 1.)
YES
NO
Form SSA-454-BK (04-2014) ef (04-2014)

Page

Deleted: (Complete the information below.)

If Yes, describe the training you received: ____________________________
Name of Training Facility: ______________
Telephone:________ Fax:__________
Mailing Address: ______________________
City:__________, State/Province: _________
Zip/Postal Code:_______________________
Country (if not U.S.):___________________
Type of program: ______________________
Date(s) of attendance: _________________
Date completed (or scheduled to be completed) __________________
Certificate/License attained, it any: _____________________________
PHONE

NAME OF TRAINING FACILITY
MAILING ADDRESS
CITY

STATE/Province

TYPE OF PROGRAM

ZIP/Postal Code

COUNTRY (if not USA)

Date Completed (or scheduled to be completed)

If you need to list other education information or training facilities use Section 11 - Remarks
and give the same detailed information as above

Form SSA-454-BK (04-2014) ef (04-2014)

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SECTION 8 - VOCATIONAL REHABILITATION, EMPLOYMENT, OR
OTHER SUPPORT SERVICES
Complete only if you are age 18 years or older
8.A. Since the date of your last medical disability decision (see date on top of Page 1), have
you participated, or are you participating, in:
• an individualized 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 (PASS);
• an Individualized Education Program (IEP) through a school (if a student age 18-21); or
• any program providing vocational rehabilitation, employment services, or other support
services to help you go to work?
YES (Complete the information below.)

NO (Go to Section 9 - Daily Activities)

If YES, what year did you last attend any school?
NAME OF ORGANIZATION OR SCHOOL
NAME OF COUNSELOR, INSTRUCTOR OR JOB COACH

PHONE NUMBER

MAILING ADDRESS
CITY

STATE/Province

ZIP/Postal Code

COUNTRY (if not USA)

8.B. When did you start participating in the plan or program?
8.C. Are you still participating in the plan or program?
YES, I am scheduled to complete the plan or program
on:

NO, I completed the plan or program on:

(date to be completed)

(date completed)

NO, I stopped participating in the plan before completing it because:

8.D. What types of services, tests, or evaluations were provided (for example: intelligence or
psychological testing, vision or hearing tests, physical exam, work evaluations, or classes?)

If you need to list another plan or program use Section 11 - Remarks and give the same
detailed information as above
Form SSA-454-BK (04-2014) ef (04-2014)

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SECTION 9 - DAILY ACTIVITIES
Complete only if you are at age 18 years old or older
9.A. Describe what you do in a typical day (for example: I get up around 7 A.M., take a shower,
eat breakfast, etc.).

If you need more space, go to Section 11 - Remarks
9.B. Do you have hobbies or
interests? YES NO
If YES, please describe what they are and how much time you spend doing them.

9.C. Do you ever have difficulty doing any of the following? (Please explain any "Yes" answers.)
Dressing
Bathing
Caring for hair

YES
YES
YES

NO
NO
NO

Taking medicines
Preparing meals
Feeding self
Doing chores (inside/outside house)

YES
YES
YES
YES

NO
NO
NO
NO

Driving or using public transportation
Shopping
Managing money
Walking
Standing

YES
YES
YES
YES
YES

NO
NO
NO
NO
NO

Lifting objects
Using arms

YES
YES

NO
NO

Using hands or fingers
Sitting

YES
YES

NO
NO

Seeing, hearing, or speaking

YES

NO

Concentrating
Remembering
Understanding or following directions

YES
YES
YES

NO
NO
NO

Completing tasks

YES

NO

Getting along with people

YES

NO

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SECTION 10 - WORK
Complete only if you are age 14 years old or older
10. Since the date of your last medical disability decision have you worked? (see date at top of
Page1)
YES (If yes, we may contact you for additional information)
NO
SECTION 11 - 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 tell us the additional requested in those sections. Be sure to show the section to which
you are referring.

Date Report Completed (month, day, year)
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