Form SSA-3441 Disability Report-Appeal

DISABILITY REPORT - APPEAL
SSA-3441-BK
PLEASE READ THIS INFORMATION BEFORE COMPLETING THIS REPORT
This report is used to update your information for your disability appeal. Completing this report accurately
helps us process your claim. Please complete as much of this report as you can.
IF YOU NEED HELP
Please do not ask your health care provider to complete this report. You can get help from other people,
such as a friend or family member. If you cannot complete this report, a Social Security representative
can assist you. If you make an appointment with us, please complete as much of this report as you can
and have it with you for your appointment.
HOW TO COMPLETE THIS REPORT
If you have Internet access, you may be able to complete this report online at
www.ssa.gov/disability/appeal
If you complete this report on paper:

•
•

Print or write clearly.

•

Provide complete phone numbers, including area code. If a phone number is outside the
United States, also 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 this report indicates otherwise. You can write "don't
know," or "none," or "does not apply" if you need to.

•

If you need more space to answer any question, please use the REMARKS section on the last
page, SECTION 10. Include the number of the question you are answering.

Include a ZIP or postal code with each address.

YOUR MEDICAL RECORDS
If you have any medical records that you have not given to us, send or bring them to our office with this
completed report. Please tell us if you want us to return them to you. If you are having an interview in our
office, bring your medical records, your prescription medicine containers (if available), and this 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.
HOW TO SUBMIT THIS REPORT
Send or bring this completed report to your local Social Security office. If you have Internet access, you
can locate your nearest Social Security office by zip code at www.socialsecurity.gov/locator. Our offices
are also listed under U.S. Government agencies in your telephone directory or you may call Social
Security at 1-800-772-1213 (TTY 1-800-325-0778).

Privacy Act Statement
Disability Report - Appeal
Collection and Use of Personal Information

See Revised Privacy Act and
PRA Statements Attached

Sections 205(a), 223 (d), and 1631(e) 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 us from reconsidering and reviewing your initial or continuing disability
determination or evaluating any request for a hearing.
We will use the information you provide to update your disability appeal information. The information we
collect also assists the State DDSs and administrative law judges in preparing for the appeals and
hearings, and issuing a determination or decision on an individual’s entitlement (initial or continuing) to
disability benefits.
We may also share your information for the following purposes, called routine uses:
1. To State audit agencies for auditing State supplementation payments and Medicaid
eligibility considerations;
2. To third party contacts where necessary to establish or verify information provided by
representative payees or payee applicants; and
3. To Federal, State or local agencies for administrating cash or non-cash income maintenance or
health maintenance programs.
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 (SORNs)
60-0089), entitled Claims Folder Systems; 60-0090, entitled Master Beneficiary Record; 60-0320, entitled
to Electronic Disability; and 60-0103, entitled Supplemental Security Income Record and Special
Veterans Benefits. Additional information and a full listing of all our SORNs are available on our website
at www.socialsecurity.gov/foia/bluebook.

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 45 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 form.

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

Form Approved
OMB No. 0960-0144

SOCIAL SECURITY ADMINISTRATION

DISABILITY REPORT – APPEAL

For SSA use only. Please do not write in this box.
Related SSN

Number Holder

If you are filling out this report for someone else, please provide information about him or her. When a question
refers to “you” or “your,” it refers to the person who is applying for disability benefits.
SECTION 1 – INFORMATION ABOUT THE DISABLED PERSON
1. A. Name (First, Middle, Last, Suffix)

1. B. Social Security Number

1. C. Daytime Phone Number, including area code (include IDD and country codes if outside the U.S. or Canada)
Check this box if you do not have a phone number where we can leave a message.
1. D. Alternate Phone Number – another number where we may reach you, if any
1. E. Email Address (Optional)

SECTION 2 – CONTACTS

Give the name of someone (other than your doctors) we can contact who knows about your medical conditions,
and can help you with your claim. (e.g., friend or relative)
2. A. Name (First, Middle, Last)
2. B. Relationship to Disabled Person
2. C. Mailing Address (Street or PO Box), include apartment number or unit if applicable.
City

State/Province

ZIP/Postal Code

Country (if not U.S.)

2. D. Daytime Phone Number, including area code (include IDD and country codes if outside the U.S. or Canada)
2. E. Can this person speak and understand English?
Yes

No

If no, what language does the contact person prefer?
2. F. Who is completing this form?
The person who is applying for disability (Go to SECTION 3 - MEDICAL CONDITIONS).
The person listed in 2.A. (Go to SECTION 3 - MEDICAL CONDITIONS).
Someone else (Please complete the information below).
2. G. Name (First Middle Last)

2. H. Relationship to Disabled Person

2. I. Mailing Address (Street or PO Box) Include apartment number or unit if applicable.
City

State/Province

ZIP/Postal Code

Country (if not U.S.)

2. J. Daytime Phone Number, including area code (include IDD and country codes if outside the U.S. or Canada)
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SECTION 3 – MEDICAL CONDITIONS
3. A. Since you last told us about your medical conditions, has there been any CHANGE (for better or worse)
in your physical or mental conditions?
Yes, approximate date change occurred:

No

If yes, please describe in detail

3. B. Since you last told us about your medical conditions, do you have any NEW physical or mental
conditions?
Yes, approximate date of new conditions:

No

If yes, please describe in detail:
If you need more space, use SECTION 10 – REMARKS on the last page.

SECTION 4 – MEDICAL TREATMENT
4. A. Have you used any other names on your medical or educational records? Examples are maiden name,
other married name, or nickname.
No
Yes
If yes, please list the other names used:
4. B. Since you last told us about your medical treatment, have you seen a doctor or other health care
provider, received treatment at a hospital or clinic, or do you have a future appointment scheduled?
Yes

No (Go to SECTION 6 – MEDICINES)

4. C. What type(s) of condition(s) were you treated for, or will you be seen for?
Physical

Mental (including emotional or learning problems)

If you answered “Yes” to 4.B., please tell us who may have NEW medical records about any of your physical or
mental conditions (including emotional or learning problems).
Use the following pages to provide information for up to three (3) providers. Complete one page for each
provider. If you have more than three providers, list them in SECTION 10 - REMARKS on the last page.
Please include:
•
•
•
•
•

doctors' offices
hospitals (including emergency room visits)
clinics
mental health center
other health care facilities.
Only list the providers you have seen since you last told us about your medical treatment.

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SECTION 4 – MEDICAL TREATMENT (continued)
Provider 1

4. D. Name of facility or office

Name of health care provider who you

ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROVIDER ABOVE.
Phone Number

Patient ID# (if known)

Address
City

State/Province

ZIP/Postal Code

Country (if not U.S.)

Dates of Treatment (approximate date, if exact date is unknown)
Office, Clinic or Outpatient visits at
this facility

Emergency Room visits at
this facility

Overnight hospital stays at
this facility

First Visit

Date

Date in

Date out

Last Visit

Date

Date in

Date out

Next scheduled appointment

Date

Date in

Date out

(if any)

None

None

What medical conditions were treated or evaluated?
What treatment did you receive for the above conditions? (Do not list medicines or tests in this box.)
Has this provider performed or sent you to any tests? Please include tests you are scheduled to have in the
future.
Yes (Please complete the information below.)
No (Go to the next page.)
KIND OF TEST

DATES OF
TESTS

KIND OF TEST

Biopsy (list body part)

MRI/CT Scan (list body part)

Blood Test (not HIV)

Speech/Language Test

Breathing Test

Treadmill (exercise test)

Cardiac Catheterization

Vision Test

EEG (brain wave test)

X-ray (list body part)

EKG (heart test)
Hearing Test

Other (please describe)

HIV Test
IQ Testing

If you need to list more tests, use SECTION 10 - REMARKS on the last page.

If you do not have any more providers to describe,
go to SECTION 5 – OTHER MEDICAL INFORMATION on page 6.
(will be replaced with appropriate page number by the design branch)
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DATES OF
TESTS

SECTION 4 – MEDICAL TREATMENT (continued)
Provider 2

4. D. Name of facility or office

Name of health care provider who treated you

ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROVIDER ABOVE.
Phone Number

Patient ID# (if known)

Address
City

State/Province

ZIP/Postal Code

Country (if not U.S.)

Dates of Treatment (approximate date, if exact date is unknown)
Office, Clinic or Outpatient visits at
this facility

Emergency Room visits at
this facility

Overnight hospital stays at
this facility

First Visit

Date

Date in

Date out

Last Visit

Date

Date in

Date out

Next scheduled appointment

Date

Date in

Date out

(if any)

None

None

What medical conditions were treated or evaluated?
What treatment did you receive for the above conditions? (Do not list medicines or tests in this box.)
Has this provider performed or sent you to any tests? Please include tests you are scheduled to have in the
future.
Yes (Please complete the information below.)
No (Go to the next page.)
KIND OF TEST

DATES OF
TESTS

KIND OF TEST

Biopsy (list body part)

MRI/CT Scan (list body part)

Blood Test (not HIV)

Speech/Language Test

Breathing Test

Treadmill (exercise test)

Cardiac Catheterization

Vision Test

EEG (brain wave test)

X-ray (list body part)

EKG (heart test)
Hearing Test

Other (please describe)

HIV Test
IQ Testing

If you need to list more tests, use SECTION 10 - REMARKS on the last page.

If you do not have any more providers to describe,
go to SECTION 5 – OTHER MEDICAL INFORMATION on page 6.
(will be replaced with appropriate page number by the design branch)
Form SSA-3441-BK (03-2015) ef (03-2015)

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DATES OF
TESTS

SECTION 4 – MEDICAL TREATMENT (continued)
Provider 3

4. D. Name of facility or office

Name of health care provider who treated you

ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROVIDER ABOVE.
Phone Number
Patient ID# (if known)
Address
City

State/Province

ZIP/Postal Code

Country (if not U.S.)

Dates of Treatment (approximate date, if exact date is unknown)
Office, Clinic or Outpatient visits at
this facility

Emergency Room visits at
this facility

First Visit

Date

Date in

Date out

Last Visit

Date

Date in

Date out

Next scheduled appointment

Date

Date in

Date out

(if any)

Overnight hospital stays at
this facility

None

None

What medical conditions were treated or evaluated?
What treatment did you receive for the above conditions? (Do not list medicines or tests in this box.)
Has this provider performed or sent you to any tests? Please include tests you are scheduled to have in the
future.
Yes (Please complete the information below.)
No (Go to the next page.)
KIND OF TEST

DATES OF
TESTS

KIND OF TEST

Biopsy (list body part)

MRI/CT Scan (list body part)

Blood Test (not HIV)

Speech/Language Test

Breathing Test

Treadmill (exercise test)

Cardiac Catheterization

Vision Test

EEG (brain wave test)

X-ray (list body part)

DATES OF
TESTS

EKG (heart test)
Hearing Test

Other (please describe)

HIV Test
IQ Testing

If you need to list more tests, use SECTION 10 - REMARKS on the last page.
If you have been treated by more providers, use section 10 - REMARKS on the last page.
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SECTION 5 – OTHER MEDICAL INFORMATION
5. Since you last told us about your other medical information, does anyone else have medical information
about any of your physical or mental conditions (including emotional and learning problems) or are you
scheduled to see anyone else?
This may include:
• workers’ compensation
• vocational rehabilitation services
• insurance companies who have paid you disability benefits
• prisons and correctional facilities
• attorneys
• social service agencies
• welfare agencies
• school/education records
Yes (Please complete the information below.)
No (Go to SECTION 6 – MEDICINES)
Name of Organization
Claim or ID Number (if any)
Address
City

State/Province ZIP/Postal Code

Name of Contact Person

Country (if not U.S.)

Phone Number

Date of First Contact

Date of Last Contact

Date of Next Contact (if any)

Reasons for Contacts

If you need to list more people or organizations, use SECTION 10 – REMARKS on the last page.

SECTION 6 – MEDICINES
6. Are you currently taking any medicines (prescription or non-prescription)?
Yes (Please complete the information below. You may need to look at your medicine containers.)
No (Go to SECTION 7 – ACTIVITIES)
NAME OF MEDICINE

IF PRESCRIBED,
NAME OF DOCTOR

REASON FOR MEDICINE

SIDE EFFECTS
YOU HAVE

If you need to list more medicines, use SECTION 10 – REMARKS on the last page.

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SECTION 7 - ACTIVITIES
7. Since you last told us about your activities, has there been any change (for better or worse) in your daily
activities due to your physical or mental conditions? (Examples of daily activities are household tasks,
personal care, getting around, hobbies and interests, social activities, etc.)
Yes

No

If yes, please describe in detail:

If you need more space, use SECTION 10 – REMARKS on the last page.
SECTION 8 – WORK AND EDUCATION
8. A. Since you last told us about your work, have you worked or has your work changed?
Yes
No
If yes, you will be asked to provide additional information.
8. B. Since you last told us about your education, have you completed or are you enrolled in any type of GED
classes, specialized job training, trade school, or vocational school, or college classes?
Yes

No

If yes, what type?
Date(s) attended:
Degree(s) attained, if any: ________________________

Date of attainment: _____/ _____
MM YYYY

If you need more space, use SECTION 10 – REMARKS on the last page.
SECTION 9 – VOCATIONAL REHABILITATION, EMPLOYMENT, OR OTHER SUPPORT SERVICES
9. Since you last told us about your vocational rehabilitation, 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 (PASS)?
an individualized education program (IEP) through an educational institution (if a student age 18-21)?
any program providing vocational rehabilitation, employment services, or other support services to help
you go to work?
Yes (Please complete the information below.)
No (Go to SECTION 10 – REMARKS)

Name of Organization or School
Name of Counselor, Instructor, or Job Coach

Phone Number

Address
City

State/Province

ZIP/Postal Code

Country (if not U.S.)

Date when you started participating in the plan or program:

If you need more space, use SECTION 10 – REMARKS on the last page.
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SECTION 10 – REMARKS
Use this space to provide any information you could not show in earlier sections of this form or any additional
information you feel we should know about. Please be sure to include the number of the question you are answering
(For example, 3A, 4D, etc.).

Date Report Completed MM/DD/YYYY:
Form SSA-3441-BK (03-2015) ef (03-2015)

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SSA will insert the following revised Privacy Act Statement into the form as soon
as possible:
Privacy Act Statement
Collection and Use of Personal Information

Sections 205(a), 223(d), 1614(a), and 1631 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 reconsider and review an initial disability determination; review a
continuing disability; and evaluate a request for a hearing. 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 the
Social Security Administration 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 Federal, State, or local agencies (or agents on their behalf) for administering cash or
non-cash income maintenance or health maintenance programs (including programs
under 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 of our SORNs, is available on our website at www.ssa.gov/privacy.

SSA will insert the following revised PRA Statement into the form as soon
as possible:
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
50 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.