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Child Disability Report
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Questions?
How to Contact Us?
Welcome!
To complete a Child Disability Report on behalf of a child
applying for Supplemental Security Income (SSI) disability
benefits, you need to:
give us information about the child's medical conditions,
medical records, education, and work history and
contact Social Security to complete an application for SSI
benefits.
You can complete the Child Disability Report online but you
must contact us to complete the SSI application. The SSI
application can't be completed online. You can apply in person or
over the phone, or get more information about SSI and this
application process.
Using the online Child Disability Report gives you:
security and privacy for the child's information
step by step instructions and examples to help you
complete the report
a process to collect information that applies to the child,
similar to the interview process in a Social Securiiy office
the ability to work at your own pace, stopping when you
want and coming back to finish later
Applying in Person or Over the Phone
If you preter no: to -10:INS repoc on the Internet, you can use any
of the following ways to complete a Disability Report.
Call our toll-free number, 1-800-772-1213. Explain that you
want to file an SSI application on behalf of a child. If you
are deaf 01' hsrd of heal-illy, call our toli-free "TT'f' number,
1-800-325-0778. Representatives are available Monday
http:lleis.ba.ssa.gov/appages/i3820 November06lee00 1. html
Page 2 o f 2
Welcome
.
.
.
through Friday from 7 a.m. to 7 p.m.
Go to your local Social Security Office and ask to file an SSI application on
of the child.
If you have a working printer, print a paper Disability Report-Child from the
Internet. This form is in Portable Document Format (PDF) and requires Adc
Acrobat Reader to open and print it. If you don't have Adobe Acrobat Read1
your computer you can download it at
http://www.adobe.comlaccessibility/index.html.
If you live outside the United States, see Service Around the World.
More Information About SSI and this Process
How the Supplemental Security Income Application Process Works
The Definition of Disability for Children Applying for SSI
Internet Security Policy
The Privacy Act Statement
Social Securiys Accessibility Policy
-
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Privacy Policy I Website Policies & Olher Important Informalion I Site Map
4XD
@enefits,gov
Page 1 of 2
About this Internet Form
Stzicial . Q C L U ~ ~
Child Disability Report
About This Internet Form
Using Social Security Online Services
Using the online Child Disability Report gives you:
Security and privacy for your information.
Step by step instructions and examples to help you
complete the disability report.
.
A process to collect information that applies to you, similar
to the interview process in a Social Security office.
The ability to work at your own pace, stopping when you
want and coming back to finish later.
To complete this report you will need:
lnternet access
A personal computer with a Web browser that supports
128-bit encryption
Adobe Acrobat Reader - to download a free copy, go to
http://www.adobe.com/accessibilitylindex.html.
Privacy Information
The Social Security Administration has access to the information
you provide on this report and is authorized to keep even partially
completed reports. This is for the purpose of helping you
complete the application process or update your information. If
you have decided you want to continue, you can start the report
now, or, if you are undecided, you may do so at a later time. For
more information about completing this report online or other
services provided by the Social Security Administration, please
call our toll-free number shown below.
Paperwork Reduction Act
This information collection meets the clearance requirements of
44 U.S.C. s3507, as amended by section 2 of the Papework
Reduction Act of 1995. You are not required to answer these
questions unless we display a valid Office of Management and
Page 2 o f 2
About this Internet Form
Budget control number. We estimate that it will take you an average of 120 minutc
respond, but total time required will depend upon the number of questions you ne
answer.
You may send comments on our estimate of the time needed to complete the Chi
Disability Report to: SSA, 1338 Annex Building. Baltimore, MD 21235-0001. Sent
comments relating to our time estimate to this address, not the completed r
The OMB approval number for the Internet Child Disability Report is 0960-0577;
expiration date 0713112007.
Contacting Social Security by Phone
Call our toll-free number, 1-800-772-1213. If you are deaf or hard of hearing, call
free "l-rY"number, 1-600-325-0778. Representatives are available Monday throu
Friday from 7 a.m. to 7 p.m.
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8 Other Important lnformat~onI S ~ t eMap
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Page 1 o f 2
What You Will Need
sxial
Sec'11rity
Child Disability Report
What You Will Need
The online Child Disability Report will ask for information about
the child, the child's medical history, and the child's education
and work history. The list below shows details about what you
will need:
About the Child
The child's full name, Social Security Number, and date of
birth.
Your (the applicant's) name, address, telephone number,
and e-mail address if you have one.
The name, address, and telephone number of someone
else who knows about the child's illnesses, injuries, or
conditions (referred to from here on as "condition" or
"conditions").
A description of the child's conditions, including when they
began and how they limit the child's daily activities.
Education and Work History (if applicable)
The names, addresses, and telephone numbers for all
schools or educational facilities that the child has attended
in the last 12 months.
The type of behavioral or learning test(s) that the child had,
and when the test(s) was done.
A description of the child's last job, if he or she has
worked.
Medical History
The names, addresses and telephone numbers for all
doctors, hospitals, and clinics that the child has seen for
his or her conditions, the dates of and reasons for the
visits.
Name@)of any medical test(s) that the child had, when
and where the test(s) was done, and who ordered it.
Name(;; of each pisscripti~nini.dicine(s) that tile cl~ild
takes and the doctor(s) who prescribed it.
What You Will Need
.
Name@)of any non-prescription medicine(s) that the child takes
For us to decide if the child is disabled under Social Security Law, you must give I
enough information so that we can contact the child's doctors and hospitals to get
child's medical records. It is important that you give us the names, addresses, an(
of treatment for all the child's doctors and hospitals. You do not have to get the m8
records.
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Privacy Policy I Website Policies 8 Other Important Information / Site Map
@!tefitsngov
How The Online Child Disability Report Works
Social ~ e c ~ ~ r i t v
Child Disability Report
How the Online Child Disability Report
Works
The Online Child Disability Report has four main
parts:
.
About the Child, Part 1 .
Education and Work. Part 2,
Medical History, Part 3, and
Review and Send, Part 4
We will give you instructions and examples to guide you on
completing each part. At the end of each part, you will have a
chance to review your answers and add or change information.
The Online Child Disability Report does not have to be
done all at once. After you fill in your contact
information (on an upcoming screen), you will get a
Reentry Number. You will be able to stop working on the
report whenever you want, and then use this Reentry
Number to come back to the section where you left off.
When you have completed the Report, you will see a full
summary of the information you entered. You can make any
necessary changes and then print a copy of this summary for
your records.lf you do not have enough room to enter all the
information you want to give us on the Report, including the
Remarks block in the Review and Send Section, please write the
information on a separate sheet of paper and send it to us at the
address we will give you afIer you've completed this online
Report.
General description of how to move around in the
Disability Report.
Your session will time out after 30 minutes on a page and you
will lose whatever you entered on that page. Please choose a
navigation button every 25 minutes to avoid losing your work on
that page.
TO move backward page by pane in order in the report, use the
Previous Page button at the bottom of the page. Do NOT use the
How The Online Child Disability Report Works
Page 2 o f 2
"Back button on your browser to move backward
If you are navigating using only the keyboard or using an assistive device and net
visit our instructional page for alternative views and navigation. Warning: If you sf
this link, you will leave this secure site and go to a new browser window. You will
automatically return to this page when you close the new browser window.
Under the Paperwork Reduction Act, we are required to tell you how long we thin1
take you to do this Report. We estimate that it will take you an average of 120 mir
Special Instructions for Blind Users
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Prlvacy Pollcy I Webslte Pollcles 8 Other Important lnformatlon I Slte Map
Gefits.gov
Should You Complete This Report
Social Seauity
Child Disability Report
Should You Complete This Report
Not everyone will be able to complete a Disability Report online.
You must answer all of the following questions to help determine
if you should use this lnternet Report
The OMB approval number for the lnternet Child Disability
Report is 0960-0577; expiration date 0713112007.
Have y o u spoken
0Yes 0NO
to a Social
Security
representative?
Are y o u a child
filing for
yourself?
O Y e s ONO
General Information About the C h i l d
What is the child's
name?
Suffix (if any)
Please enter the
child's first name,
middle initial, and
last name
What i s the child's
Social Securitv
number?
Please enter the
child's Social
Security Number
without dashes.
'f the child does not
,lave one, you need
to get one before
you can fill out this
form online.
What is the child's
date of birth'?
U C h i l d does not have one yet
Page 1 o f 2
Should You Complete This Report
(Month, Day, Year)
Do you and the
child both live in
the United States
or the Northern
Mariana Islands?
C'Yes
ONO
Information About The Child's Illnesses, Injuries or Conditions
You will be asked to provide more details about this later.
Does the child's
illness, injury, or
condition seriously
limit hislher daily
activities?
OYes O N o
Is the child's
illness, injury, or
condition expected
to last for more
than 12 months or
end in death?
C'Yes-
Has the child
previously
been
denied SSI
disability benefits?
OYes, more than 60 days ago
OYes, less than 60 days ago
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-
0 No
0 I am not sure
Prlvacy Pol~cyI Webslte Pollcles 8 Other Important lnfomatlon 1 Site Map
social ~ e c . ' ~ u i ~
Name: Frank Doe
SSN: 743-99-4143
Child Disability Report
Go Ahead
Since you have chosen to continue with this report, please read
the important information below. The first section of the report
asks for information, including:
Your name, address, and phone number.
Someone else we can contact
A description of the child's condition.
Because we need some basic information first, you cannot skip
ahead to other parts of the report until you complete Part 1,
"About the Child." When you finish Part 1, you will have a chance
to review your answers and add or change information.
Time Limit
We need a signed formal application for disability benefits before
we can process the child's claim. This Disability Report is NOT a
formal application, but it is a required part of the claims process.
When you complete this report, we will give you instructions on
filing the formal application.
The child may lose benefits if w e d o n o t receive a signed
formal application w i t h i n 60 days o f when you f i r s t
started t o complete a n online disability report for
Supplemental Security I n c o m e (SSI).
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Prlvacy Pollcy I Webslte Pol~c~es
&Other Important lnformatlon I Site Map
4am
6enefits.gov
Sign Off
Social S
~ L T U ~ ~
Child Disability Report
Online
www.socialsecurity.gov
Name:
SSN:
Sign Off
If you want, you can stop for now. You can come back later to
where you left off and continue working on this report. You can
also review the parts you already completed and add or change
information.
To Come Back to This Report Later
1. Go to this web site:
hftp://www.socialsecurity.gov/childdisabilityreport.
2. Choose "Go Back to the Report I Already Started."
3. Type in the child's Social Security Number and Reentry
Number shown below.
4. You can choose to go back to the page of the report where
you were when you left or to another section.
DO NOT Forget Your Reentry Number
Your Reentry Number is:
.
Do not give this number t o anyone else. If you lose or forget
your Reentry Number, you will have to begin this report over
again and you will lose all the information you already entered.
To ensure the child's privacy, no one else can have access to
your Reentry Number. Social Security can help you start the
process over again, but we cannot access your Reentry Number.
To have a record of your Reentry Number, print or save this
page, or write down the number, and keep it in a safe place.
Time Limit
We need a signed formal application for disability benefits before
we can pro-2-s t k c'.ilc.;''s c!aim. This Disability Report is NOT a
! s i~it I:; a I ~ Q I ,-ed
.
part of the claims process.
formal appi;~.~fioer,
After you cornplots this report, we will give you instructions on
completing the formal application, if you have not already done
SO.
The child may lose benefits if w e do n o t receive a signed
formal application w i t h i n 60 days of when you f i r s t
started t o complete a n online disability report for Supplemental Securit
Income (SSI).
Unable to Come Back?
If, for some reason, you are unable to come back to this report later, you can use
the following ways to complete a Child Disability Report:
.
Call our toll-free number, 1-800-772-1213. Explain that you are unable to u:
online Child Disability Report process and ask the representative to mail yo
paper Disability Report. If you are deaf or hard of hearing, call our toll-free "
number, 1-800-325-0778. Representatives are available Monday through F
from 7 a.m. to 7 p.m.
.
.
.
Go to your local Social Security office and pick up a paper form (SSA-3820:
If you have a working printer, you may print a paper Child Disability Report
the Internet. (You will need to have Adobe Acrobat installed on your compu
If you live outside the United States, see Service Around the World
If you know now that you will not be able to return to this report, we urge you to sc
electronically whatever you have already finished. We will contact you later for an
missing information. To send us what you have finished:
1. Choose Return to Report below.
2. Go to the Review & Send tab at the top of that page.
3. Follow the instructions there to send us the Child Disability Report.
To print or save this page, please use your brower's Print function or Save As fun,
-%RSTGOV
Pr~vacyPollcy I Webs~tePollc~es8 Other Important Informahon I Slte Map
@%efits,gov
Welcome Back
Stdal Secnritv
Child Disability Report
-
Welcome Back
If you want, you can review the information about how this report
works and how to move around in the report.
Please enter the
child's Social
Security Number.
(without dashes or
hyphens)
Please enter your
Reentry Number.
If you have lost your Reentry Number, you will not be able to continue with the Child
Disability Report you already began. You can start a new online Child Disability Report
up to three times. You can either begin the report again or contact your local Social
Security office and they will help you. However, Social Security cannot access your
Reentry Number.
If you had errors on a page that were not corrected when you signed off, you will need to
correct them now before you can continue to new pages.
If you have not finished "Aboutthe Child", you will be taken back to where you left off in
that section. You must finish "About the Child" before you can start any other section.
Where Do You
Want to Go?
-'F~RSTGOV
0Back t o where I left off
C T o the "About the Child" section
G T o the "Education and Work" section
0To the "Medical History" section
C)To the "Review and Send" section
Privacy Policy 1 Website Policies 8 Other Important Information I Site Map
=efits,cjov
Information About You
Social secluity
Child Disability Report
Online
www.socialsecurity.gov
Name: Frank Doe
SSN: 743-99-4143
Information About You
Please tell us about yourself, as the person providing information
for Frank Doe. You must complete this page before continuing.
Your Name:
Suffix (if any)
7-4
(First, Middle Initial.
Last)
Agency Name (if
applicable):
If you work for an
agency that is
assisting the child,
please provide the
agency's name.
Your
Relationship to
Frank Doe:
0Mother
0Father
0Sister
0Brother
0Grandparent
0Aunt
0Uncle
OCousin
0Stepmother
0Stepfather
0Neighbor
0Friend
0Husband or Wife
C)Significant Other
(>I; the s~ktiorsttp is "Other" (such as Social Worker, Attorney, Legal
Reptecentative), %.teasespecify: :
Your Mailing Address:
Information About You
Please provide your complete mailing address, including apartment number if
applicable. Please do NOT use punctuation; for example, no periods or commas.
Example: 528 Dawn St Apt 101
(Street Address
Line I )
(Street Address
Line 2)
(Street Address
Line 3)
(City, State, ZIP)
Your Daytime
Phone Number:
(
-
)
E
~
~
~
~
~
~
~
OThis i s my phone number
OI don't have a phone, but you can leave a message at this number
Email
Address
Your
(Optional):
Y o u r Language Information
Can You speak and
understand
English?
O Y e s ONo, my preferred language i s
If you cannot speak
and understand
English, we will
provide an
interpreter, free of
charge.
Can you read and
understand
English?
Oyes
Contact SSA
NO
I How to Move Around This Report
~
:
Print Your Reentry Number
Social ~
~
~
Child
r
iDisability
~
Report
-
.
About the Child
Name: Frank Doe
SSN: 743-99-4143
m
i
i
l
,
.
ist to^..::
. -..
Review
-
ii...T..u,...,,..
.
and
Print Your Reentry Number
Keep Your Reentry Number
Before going any further, we are giving you a Reentry Number. If
you get disconnected, or if you decide to work on the Report
again later, you will need this number. It will allow you to come
back to the Report and continue where you left off without losing
any information you already entered.
Your Reentry Number is:
45967428
Print or save this page, or write down
the number, so you will have a copy of
your Reentry Number.
If you lose or forget your Reentry Number, you will have to begin
this Disability Report over again, and you will lose all the
information you already entered. You can start a new Disability
Report only 3 times. To protect your privacy, no one else can
have access to your Reentry Number. Social Security can help
you start the process over again, but we cannot look up your
Reentry Number for you.
To Come Back to This Report Later:
1. Go to this web site:
http://www.socialsecurity.gov/childdisabilityreport
2. Choose "Go Back to the Report I Already Started."
3. Enter your Social Security Number and Reentry Number
shown above.
4. You can choose to go back to the page of the report where
you were when you left or to another section.
Print Your Reentry Number
60 Day Time Limit
We need a signed formal application for disability benefits before we can process
child's claim. This Disability Report is NOT a formal application, but it is a requirec
the claims process. The child may lose benefits if we do not receive a signed forn
application within 60 days from when you first started completing an online disabil
report for Supplemental Security Income (SSI) for the child.
To print or save this page, please use your browser's print function or the File me1
commands.
Contact SSA I How to Move Around This Report
Someone We Can Contact Who Speaks and Understands English
Sock1S ~ C ' I U ~ ~
Online
Name: Frank Doe
SSN: 743-99-4143
Child Disability Report
Someone We Can Contact Who Speaks and
Understands English
You told us that you do not speak and understand English.
Please give us the name of someone in the United States who
speaks and understands English and will give you messages. If
there is no one who will do that, please check the box below and
do not enter any other information.
f l C h e c k i f there is no English-speaking person we can contact
Contact Person's
Name:
Suffix (if any)
(First, Middle Initial.
Last)
Your
Relationship to
Frank Doe:
C)Mother
0 Father
0Sister
0 Brother
0Grandparent
C)Aunt
'2 Uncle
C)Cousin
0Stepmother
0Stepfather
0Neighbor
0Friend
Husband or Wife
0Significant Other
GOther (such as Social Worker, Attorney, Legal Representative) :
Mailing Address:
Please provide this person's complete address, including apartment number if
applicable. Please do NOT use punctuation; for example, no periods or commas.
-4
Someone We Can Contact Who Speaks and Understands English
Page 2 of 2
UCheck if same as Eric Doe's address
(Street Address
Line 1)
(Street Address
Line 2)
(Street Address
Line 3)
a
(city, state, ZIP)
Daytime Phone
Number:
UCheck ifthe contact's phone number is the same as Eric Doe's phone
number
We need to be able
to contact this
person during the
day.
1
I
-
ONOphone or unknown
Contact SSA 1 How to Move Around This Report
About the Child: Information about
Child Disability Report
Social S ~ L ‘ L ~ ~ V
Name: Frank Doe
SSN: 743-99-4143
About the Child: Information About Frank
Doe
Please give us some basic information about Frank Doe. You
must complete this page before continuing.
Does Frank Doe
live with you (or
an institution
you represent)?
O Yes 0NO
Does Frank Doe
have a
custodian or
legal guardian
other than you?
0Yes 0NO
Is there another
adult who helps
care for Frank
Doe and can
help us get
information
about the child if
necessary?
OYes
Can Frank Doe
speak and
understand
English?
0Yes c) No, Frank Doe speaks these languages
If the child cannot
speak yet, select No
and enter None
If Frank Doe
understands any
other languages,
enter them here.
0No
About the Child: Information about
Contact SSA 1 How to Move Around This Report
Page 1 o f 2
About the Child: Adult Who Lives With
Social S
Child Disability Report
~ C I ~ ~ V
,
-
- -"-
S W W ~
Name: Frank Doe
SSN: 743-99-4143
F"..
Wd
.
.
> O
- ....
Medical History.
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~
.
< - -,-. ..-. ..
; . .,Rev~ew
. -,,. .. and
.. .
,
2
About the Child: Adult Who Lives With Frank
Doe
You told us earlier that Frank Doe doesn't live with you. Please
tell us about the person with whom Frank Doe lives.
Name:
Suffix (if any)
(First, Middle Initial,
Last)
Your
Relationship to
Frank Doe:
C)Mother
G Father
DSister
0Brother
0Grandparent
Aunt
C)Uncle
O Cousin
0Stepmother
C)Stepfather
0 Neighbor
0Friend
,3Husband or Wife
CSignificant Other
G Other (such as Social Worker, Attorney, Legal Representative)
Mailing Address:
Please provide this person's complete at',.!;e. s, ;nr'urlmg aaartrrr?nt number if
ods or commas
applicable. Please do NOT use punctuatt.;!?; . ? - p i
(Street Address
Line I)
(Street Address
Line 2)
:%
About the Child: Adult Who Lives With
(Street Address
Line 3)
(City, State, ZIP)
Daytime Phone
Number:
We need to be
to contact this
person during the
day.
(
-
)
Extension:
No phone or unknown
Language
Can this person
speak and
understand
English?
e y e s ONO, shelhe prefers this language:
Can this person
read and
understand
English?
Dyes
ONO
Contact SSA I How lo Move Around This Report
About the Child: Custodian or Legal Guardian
social secluity
Page 1 of 2
Child Disability Report
Name: Frank Doe
SSN: 743-99-4143
About the Child: Custodian or Legal
Guardian
You told us earlier that Frank Doe has a custodian or legal
guardian. Please tell us about this legal guardian or custodian
Custodian or
Legal Guardian's
Name:
Suffix (if any)
(First, Middle Initial,
Last)
Your
Relationship to
Frank Doe:
0 Mother
o~
~
t
h
~
~
0 Sister
0 Brother
Grandparent
0Aunt
0Uncle
0Cousin
0 Stepmother
0Stepfather
0 Neighbor
9 Friend
Husband or Wife
OSignificant Other
0Other (such as Social Worker, Attorney, Legal Representative)
Mailing Address:
Please provide the custodian or legal guardian's complete address, including apartment
number if applicable. Please do NOT use punctuation; for example, no periods or
commas.
nCheck if the same as Eric Doe's address
@:
About the Child: Custodian or Legal Guardian
(Street Address
Line I)
(Street Address
Line 2)
(Street Address
Line 3)
(City, State, ZIP)
Daytime Phone
Number:
We need to be able
to contact this
person during the
day.
UCheck if the same as Eric Doe's phone number
(
1
Extension:
-
3 No phone or unknown
Language Information:
Can this person
speak and
understand
English?
OYes
Can this person
read and
understand
English?
@Yes O N o
0 No, shelhe prefers this language
Contact SSA I How to Move Around This Report
About the Child: Adult Who Helps Care For
Child Disability Report
Social Secnritv
Online
wwW.socialsecurihl.aov
...
.- ,
2 -
I
Name: Frank Doe
SSN: 743-99-4143
Educat~onand Work
1
About the Child: Adult Who Helps Care for
Frank Doe
You told us earlier that there is another adult who helps care for
Frank Doe and can help us get information about the child if
necessary. Please tell us about this person.
Contact Person's
Name:
Suffix (if any)
(First. Middle Initial,
Last)
Relationship of
0Mother
this Adult to
Frank Doe:
0 Father
0 Sister
0Brother
0 Grandparent
0Aunt
C Uncle
G Cousin
0Stepmother
0Stepfather
0 Neighbor
0 Friend
0 Husband or Wife
OSignificant Other
OOther (such as Social Worker, Attorney, Legal Representative)
Mailing Address:
Please provide this person's complete address, including apartment number if
applicable. Please do NOT use punctuation; for example, no periods or commas,
(Street Address
Line 1)
.i
*;.#
About the Child: Adult Who Helps Care For
(Street Address
Line 2)
(Street Address
Line 3)
(City, State, ZIP)
Daytime Phone
Number:
We need to be able
to contact this
person during the
day.
(
)
Extension:
No phone or unknown
Language
Can this person
speak and
understand
English?
O ~ e 0
s No, Shelhe speaks these languages
Can this person
read and
understand
English?
OYes O N o
Contact SSA I How to Move Around This Report
Page 2 of 2
Child Disability Report
Social Skm~rity
,
.
d
Name: Frank Doe
SSN: 743-99-4143
------
.*.
rkducatgon and ~ o r k J f'%=l
Send
-- j
Fitoyu
.
a
About the Child: About Frank Doe's
Illnesses, Injuries, or Conditions
Please tell us about all of Frank Doe's illnesses, injuries, and
conditions (referred to from here on as conditions):
If Frank Doe has more than one condition, list and
describe each of them.
Use your own words if you do not know the medical
names.
Include all physical, mental, and emotional conditions.
including learning disabilities and behavioral problems.
We will consider these conditions whether or not Frank
Doe has been receiving treatment.
You must answer all of the questions on this page before you
can continue. We will ask you for more information about these
conditions later.
List and describe
ALL of Frank
Doe's disabling
conditions.
Your answer can be
no more than 1000
characters, which is
about 20 lines of
typing. If you need
more space,
continue in the
Remarks section at
the end of this
report.
have entered 0
characters
When did Frank
,i?c-y;ew and
1
Examples of Condition Descriptions
1
9
a
About the Child: About Illnesses, Injuries, or Conditions
Doe become
disabled?
Enter the closest
date you can
remember.
Do any of the
above ever cause
pain or other
symptoms?
e y e s ONo
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Page 2 of 2
About the Child: Frank Doe's Treatments
Social sec~uitv
Child Disability Report
Name: Frank Doe
SSN: 743-99-4143
About the Child: Frank Doe's Treatments
Answer these questions about treatments from medical
professionals and doctors, including physicians, psychologists.
optometrists, nurse practitioners, therapists, chiropractors,
acupuncturists, etc. We will ask you for more information about
all of these later.
You gave us the following list and descriptions of Frank
Doe's disabling illnesses, injuries or conditions:
Injury insult
Has Frank Doe
gone t o a doctor,
hospital, clinic,
or anyone else,
or are any future
visits scheduled,
OYes O N o
for the
conditions listed
above?
Has Frank Doe
had any medical
tests, or are any
tests scheduled
for the
conditions listed
above?
OYes O N o
Does Frank Doe
currently take
any prescription
Oyes
or nonprescription
medicines,
(including over
the counter
medicines, or
0NO
About the Child: Frank Doe's Treatments
herbal remedies)
for the
conditions listed
above?
Has Frank Doe
gone to a doctor,
hospital, clinic,
or anyone else,
or are any future
visits scheduled,
for mental or
emotional
problems that
limit his or her
daily activities?
OYes O N o
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Summary of Information About the Child
~ o c iL~c l; e t ~ ~ t y
Online
Child Disability Report
Name: Frank Doe
SSN: 743-99-4143
About Frank Doe: Summary
Please review the information you gave us and make sure it is
correct. To go back to any item in the list, select Edit.
Note: To save space, this summary shows only the first 100
characters of the descriptions you gave us on the prior pages.
However, everything you told us will be included in this report
when you transmit it to Social Security.
Contact lnformation
lnformation About You
Ell
Eric Doe
Father
100 Main Street
Baltimore, MD 21201
Someone We Can Contact Who Speaks and Understands English
Jane Smits
100 Main Street
Baltimore, MD 21202
Frank Doe's Custodian or Legal Guardian
a
Legal Guardian
100 Main Street
Baltimore, MD 21201
Adult Who Lives with Frank Doe
Lives With
100 Main Street
Baltimore, MD 21202
Adult Who Knows about Frank Doe's Condition
&
J
j Other Adult
About Frank Doe's Disabling Condition
List of Disabling Conditions
Injury insult
The conditions first bothered Frank Doe on
0110112000
Frank Doe's conditions have caused pain or
other symptoms.
100 Main Street
Baltimore, MD 21202
Summary of Information About the Child
Frank Doe's Treatments
&
Frank Doe has gone to a doctor, hospital or
clin~c.
Frank Doe has had medical tests
a
Frank Doe has taken prescription andlor
nonprescription medicines.
Frank Doe has received treatment for mental
or emotional problems.
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Page 2 of 2
About the Child: End of Part 1
social
~ec'~~riitv
w
Online
Child Disability Report
~ . ~ o ~ i a l ~ e ~ ~ r i t ~ . a o ~
Name: Frank Doe
SSN: 743-99-4143
About the Child: End of Part 1
You have now completed Part 1 of this report
If you want to add to or change this information later, you can
select the "About the Child" tab at the top to come back to it.
If You Continue
The next part of the report will ask about the child's education
and work history, including all schools the child has attended in
the last 12 months and any work or vocational rehabilitation he or
she may have done.
If You Want To Stop
If you want to stop and come back to this later, you can do so at
any time by selecting "Sign Off" at the top left corner of the page.
Signing off makes sure that the information you have entered has
been saved, and protects the child's confidentiality by requiring
that you sign on again with your reentry number when you are
ready to continue.
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Education and Work: Education and Work History Introduction
social
Lsect~tv
-
Child Disability Report
.Educat~onand Work
Name: Frank Doe
SSN: 743-99-4143
1
Education and Work: Education and Work
History Introduction
In this part of the report we will ask for information about Frank
Doe's education and work history:
.
The child's current schools
All schools the child attended in the last 12 months
Any testing that was done at the schools
Any vocational rehabilitation the child may have had
Any work experience the child may have had
It is important that you give us as much information as you can
about all of Frank Doe's schools. We need enough information to
contact his or her schools for school records and other
information. You do not have to contact the schools for this
information.
Note: You can leave some questions blank for now and come
back to them later, if necessary.
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Education and Work: About Education and Work History
~ c~ecurity
~ ~
Online
Child
l
Disability Report
Name: Frank Doe
SSN: 743-99-4143
Education and Work: About Frank Doe's
Education and Work History
We may contact all the schools that Frank Doe attended over the
last 12 months. Schools are excellent sources of important
information.
Schools
Has Frank Doe
ever attended
school (including
daycare,
preschool,
Headstart, home
school, Public,
Private or other
educational
programs)?
CYes ONO
Vocational Rehabilitation
Has Frank Doe
received
Vocational
Rehabilitation or
other employment
support services to
help him or her go
to work?
GYes C ~ N O
Work History
Has Frank Doe
ever worked
(including
sheltered work)?
CYes O N o
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Education and Work: Why Has Never Attended School
~ o ~~ i ud i t y
Online
Child Disability Report
www.socialsecurity.gov
Name:
SSN:
Education and Work: Why Has Never
Attended School
You told us
earlier that has
never attended
school.
@TOO
young
Please explain
why he or she
has never
attended school.
Your answer can be
no more than 1000
characters, which is
about 20 lines of
typing. Example: too
disabled to go to
school. If you need
more space.
continue in the
Remarks section at
the end of this
report.
You
have entered 0
characters
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Education and Work: About Schools
Social ~ e c ' ~ u i t ~
Child Disability Report
Name: Frank Doe
SSN: 743-99-4143
Education and Work: About Frank Doe's
Schools
List the names of the schools that the child has attended over the
last 12 months. If Frank Doe is not currently attending school,
please list the last school attended. We will ask you for more
information about these schools later.
After you leave this page, the information you entered will be
locked. If you need to correct the information you gave us, you
will be able to make changes on following pages where we ask
you for more details. Or, you can make changes from the
summary page at the end of each section, or at the end of this
report.
Is Frank Doe
currently
enrolled in
school?
OYes
ONO
School Names and Types
List the names of
the schools that
Frank Doe has
attended over the
last 12 months.
Include preschool.
after school
1. School Name:
School Type:
2. School Name:
School Type:
programs and
special education
classes.
Example: George
Washington
Elementary
3. School Name:
School Type:
4. School Name:
School Type:
5. School Name:
Education and Work: About Schools
School Type:
6. School Name:
School Type:
a
UCheck here if you want to add more schools that Frank Doe has attended
months.
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Education and Work: More About Schools
Social Sec~~rity
Name: Frank Doe
SSN: 743-99-4143
Child Disability Report
Education and Work: More About Frank
Doe's Schools
List the names of the schools that the child has attended over the
last 12 months. We will ask you for more information about these
schools later.
After you leave this page, the information you entered will be
locked. If you need to correct the information you gave us, you
will be able to make changes on following pages where we ask
you for more details. Or, you can make changes from the
summary page at the end of each section, or at the end of this
report.
List the names of
the schools that
Frank Doe has
attended over the
last 12 months.
Include preschool,
after school
programs and
special education
classes.
Example: George
Washington
Elementary
7. School Name:
School Type:
8. School Name:
School Type:
9. School Name:
School Type:
10. School Name:
School Type:
11. School Name:
School Type:
3
12. School Name:
School Type:
-%
Education and Work: More About Schools
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Education and Work: About PreschoolDaycare
Child Disability Report
Social ~ ~ ' ~ u i t v
Online
Name: Frank Doe
SSN: 743-99-4113
Education and Work: About
PreschoollDaycare
Please give us as much information as possible
School Name:
N e w t o w n Preschool
Examples: American
Preschool; Sanders
Daycare.
Teacher's Name:
Give the name of the
teacher or person
who spent the most
time with the child, if
known. Provide as
much information as
you know.
Examples: Mr.
Smith, Miss Donna
Address:
Please provide the complete address. Please do NOT use punctuation; for example, no
periods or commas.
(Street Address
1)
(Street Address
2)
(Street Address
3)
(City, State, ZIP)
Phone Number:
(
)
Extensior;:
Education and Work: About Preschool/Daycare
Dates Attended:
If you cannot remember the exact dates, be as specific as possible. If the child is
currently attending this preschool or daycare, type "present" in the "To:" space.
Examples:
06/02/2002; 06/02;
June 2002; Summer
2002
From:
To:
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Education and Work: About School Detail
~ o c i set~uitv
a~
Online
Name: Frank Doe
SSN: 743-99-4143
Child Disability Report
Education and Work: About Golden Special
Education
Please give us as much information as possible,
School Name:
Golden Special Education
Examples: George
Washington
Elementary;
Clarksville Middle
School; Centennial
High School
Teacher's Name:
Give the name of the
homeroom teacher,
counselor, or person
who spent the most
time with the child, if
known. Provide as
much information as
you know (i.e., Mr.
Smith, Ms. Donna)
Address:
Please provide the complete address. Please do NOT use punctuation; for example, no
periods or commas.
(Street Address
1)
(Street Address
2)
(Street Address
3)
(City, State, ZIP)
a
Education and Work: About School Detail
Phone Number:
(
)
Extension:
.
Dates Attended:
If you cannot remember the exact dates, be as specific as possible. Or, you may give
the child's grade in school. If the child is currently attending this school, type "present" in
the "To" space.
Examples:
06/02/2002;
06/02;
June 2002:Summer
2002;3rd grade
From:
-
10:
Tests a n d Programs
Has Frank Doe
been in special
education classes
or resource rooms,
or getting
counseling, or any
other services for
special needs at
Golden Special
Education?
OYes 0No 0 I don't know
If yes, name of teacher or counselor:
Has Frank Doe
received WeechOr
language therapy
at Golden Special
Education?
OYes 0No 0I don't know
If yes, name of therapist:
Has Frank Doe
been tested for
learning or
behavioral
problems at
Golden Special
Education?
Examples:
.
.
.
.
achievement
testing
intelligence
testing
psychological
testing
s~eechllanguage
testing
OYes O N o
Education and Work: About School Detail
.
team
evaluations
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Education and Work: Learning and Behavioral Tests at
Social
Name:
SSN:
~~~~~
Child Disability Report
Education and Work: Learning and
Behavioral Tests at
You can list up to 4 learning and behavioral tests for this school.
If you cannot remember the exact dates, be as specific as
possible. Or, you may give the child's grade in school. Examples:
06/02/2002;
06/02;Summer 2002;3rd grade.
Page 1 of 2
Education and Work: Learning and Behavioral Tests at
List names and
the dates of the
testing that has
taken at :
Examples:
.
Achievement
testing
.
Intelligence
testing
Psychological
testing
.
Speechllanguage
testing
.
Team
evaluations
I. Name of Test:
Date of Testing:
2. Name of Test:
Date of Testing:
3. Name of Test:
Date of Testing:
4. Name of Test:
Date of Testing:
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Education and Work: More About Education History
Child Disability Report
~~~ls e ~ ~ u i ~
Online
Name: Frank Doe
SSN:743-99-4143
Education and Work: More About Frank
Doe's Education History
You told us earlier that Frank Doe is currently enrolled. If this is not
correct, please
What is Frank
Doe's current
grade in school?
Please check all
schools that
Frank Doe is
currently
attending:
@
Newtown Preschool
0Midvale Headstart
Westmore Elementary
UAlgonquin Summer School
OAfter Five Tutoring
Golden Special Education
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Education and Work: More About Education History 2?
Social S~LZI~~Q
Child Disability Report
Name:
SSN:
Education and Work: More About's
Education History
.
You told us earlier that is not currentlv enrolled. If this is not correct.
please
@
What is the
highest grade
that completed?
Please explain
why is not
enrolled in
school now:
Your answer can be
no more than 1000
characters, which is
about 20 lines of
typing. If you need
more space,
continue in the
Remarks section at
the end of this form.
Examples:
.
quit school
expelled from
school
too disabled to
$ 3 tn schooi.
You
have entered 0
characters
Education and Work: More About Education History 2?
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Page 2 of 2
Education and Work: About Vocational Rehabilitation
Social ~ e ~ 1 u i t \ ~
Online
Child Disability Report
Name: Frank Doe
SSN: 743-99-4143
Education and Work: About Frank Doe's
Vocational Rehabilitation Experience
Please complete as much information as possible.
Agency Name:
Contact Name:
(First. Last)
Address:
Please provide the complete address. Please do NOT use punctuation; for example, no
periods or commas.
(Street Address
1)
(Street Address
2)
(Street Address
3)
Phone Number:
(
)
-
Extension:
File or Record
Number:
List the names
and dates of the
tests that Frank
Doe has had at
this agency.
I . Name of Test:
Date of Test:
2. E!ame cf Tes::
Examples:
Education and Work: About Vocational Rehabilitation
Achievement
testing
Date of Test:
Intelligence
testing
3. Name of Test:
Psychological
testing
Speechllanguage
testing
Team
evaluations
Date of Test:
4. Name of Test:
Date of Test:
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Page 2 o f 2
Education and Work: About Work Experience
~~~
Social
Online
Child Disability Report
~~~.socialsecurity.g~v
Name: Frank Doe
SSN: 743-99-4143
Education and Work: About Frank Doe's Job
1
You told us earlier that Frank Doe has worked (including
sheltered work). Please give us information about Frank Doe's
job to help us make a decision on this claim.
Employer's
Name:
~u~ervisor's
Name:
Address:
Please provide the complete address. Please do NOT use punctuation; for example, no
periods or commas.
(Street Address
1)
(Street Address
2)
(Street Address
3)
Phone Number:
(
Extension:
Job Title:
Be as specific as
possible.
Examples:
.
.
Paper boy
Cashier
Education and Work: About Work Experience
Dates Worked:
If you cannot remember the exact dates, be as specific as possible. If Frank Doe is
currently working in this job, enter "present" in the To: space.
Examples:
From:
06/02/2002;
06/02;
June 2002;Summer
2002
To:
Describe Frank
Doe's job duties.
Your answer can be
no more than 1000
characters, which is
about 20 lines of
typing. If you need
more space,
continue in the
Remarks section at
the end of this
report.
You
Examples of job dut~es
have entered 0
characters
Describe any
problems Frank
Doe had doing
this job.
Include:
How the child
worked with
and related to
other people
The level of
supervision or
instruction the
child required
Whether or
not the child
completed
work chores
satisfactorily
Any other
work
Examples of problems on the job
Page 2 of 3
Education and Work: About Work Experience
information
that could
pertain to the
child's
condition
Your answer can be
no more than 1000
characters, which is
about 20 lines of
typing. If you need
more space,
continue in the
Remarks section at
the end of this
report.
You
have entered 0
characters
UCheck here ifyou want to add another job that Frank Doe has done in
the last 12 months.
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Summary of Education and Work
-
Child Disability Report
Sccial ~ e ~ ~ i t v
,
Educat~onand Work
Name: Frank Doe
SSN: 743-99-4143
1
Summary of Frank Doe's Education and
Work History
Please review this information you gave us and make sure it is
complete. To go back to any item in the list, select Edit.
Note: To save space, this summary shows only the first 100
characters of the descriptions you gave us on the prior pages.
However, everything you told us will be included in this report
when you transmit it to Social Security.
About Frank Doe's Education Status
Education History
Has attended school
Current Education Status
&&# Is currently enrolled in school.
a
You did not select the current grade
#@j
You did not select any schools.
Schools
About PreschoollDaycare at Newtown Preschool
Newtown Preschool
Teacher Name: Mrs Landis
123 Main St
Baltimore, MD 21202
About Midvale Headstart
&@J
Midvale Headstart
Teacher Name: Mrs Landis
123 Main St
Baltimore, MD 21202
Testing at Midvale Headstart
Has been tested for learning and behavioral problems at Midvaie Headstarb.
Name: IQ testing
About Westmore Elementary
Summary of Education and Work
a
Westmore Elementary
Teacher Name: Mrs Landis
123 Main St
Baltimore, MD 21202
Testing at Westmore Elementary
Has been tested for learning and behavioral problems at Westmore Elementary.
k%~# Name: IQ testlng
Date: January 2003
About Algonquin Summer School
Algonquln Summer School
Teacher Name. Mrs Land~s
123 Main St
Baltimore, MD 21202
Testing at Algonquin Summer School
Has been tested for learn~ngand behavioral problems at Algonquln Summer School
&
Name: IQ testing
Date: January 2003
About After Five Tutoring
After Five Tutoring
Teacher Name: Mrs Landis
123 Main St
Baltimore, MD 21202
Testing at After Five Tutoring
Has been tested for learning and behavioral problems at After Flve Tutoring
Name: IQ testlng
Date: January 2003
About Golden Special Education
Golden Spec~alEducation
Teacher Name: Mrs Land~s
123 Main St
Baltimore. MD 21202
Testing at Golden Special Education
Has been tested for learning and behavioral problems at Golden Special Education,
Name: IQ testing
Date: January 2003
About Frank Doe's Vocational Rehabilitation Experience
Has had vocational rehabilitation or other employment support services to help him
or her go to work.
Vocational Rehabilitation History
Voc Rehab Organization
You did not enter the citylstatehip for
Summary of Education and Work
Tests and Services Received:
Reading Comprehension, January 2003
Page 3 of 3
this agency.
Baltimore, MD
About Frank Doe's Jobs
Has had work experience.
Job 1
Employer Name
You did not enter the supervisor's name
From: "No Date Entered" to: "No Date
Entered"
You did not enter Frank Doe's job duties.
You did not enter Frank Doe's problems in
performing hislher job.
You did not enter the address for this
job.
Baltimore,
Contan SSA I How to Move Around This Report
Education and Work: End o f Part 2
Social ~ecwitv
Online
Name: Frank Doe
SSN: 743-99-4143
Page 1 o f 1
Child Disability Report
Education and Work: End of Part 2
You have now completed Part 2 of the report.
If you want to add to or change this information later, you can
select the "Education and Work tab at the top to come back to it.
If You Continue
The next part of the report will ask about the child's medical
history, including the child's doctors, hospitals, medicines, and
medical tests.
If You Want to Stop
If you want to stop and come back to this later, you can do so at
any time by sdecting "Sign Off' at the top left corner of the page.
Signing off makes sure that the information you have entered has
been saved, and protects the child's confidentiality by requiring
that you sign on again with your reentry number when you are
ready to continue.
If You've Done All That You Can
When you feel you've done all you can in all sections of the
report, you can go to the Review and Send section of this report
using the button at the upper right corner.
-
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Medical History: Medical History Introduction
Child Disability Report
Social ~ e c . ' ~ ~ r i ~
Online
WWW.SoCialsecurit~.gov
Name: Frank Doe
SSN: 743-99-4143
Medical History: Medical History Introduction
In this part of the report, we will ask for information about Frank
Doe's medical history for the past 12 months.
Doctors and other medical professionals Frank Doe has
seen for his or her conditions or is scheduled to see
Hospitals or clinics where Frank Doe has received
treatment
.
Medicines that Frank Doe is currently taking
Tests that Frank Doe had or will have
Other people or places that may have medical records
We need enough information so that we can get all of Frank
Doe's medical records. It is important that you give us the names.
addresses, and dates of treatment for all of the doctors and
hospitals. You do not have to contact the doctors to get this
information; just give us as much information as you have.
Note: You can leave some information blank for now and come
back to it later, if necessary.
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Medical History: About Doctors and Other Medical Professionals 1
Social security
Online
Child Disability Report
Name: Frank Doe
SSN: 743-99-4143
Medical History: About Frank Doe's Doctors
and Other Medical Professionals
List all the doctors and other medical professionals Frank Doe
has seen for his or her condition for at least the last year. Start
with the doctor who is most familiar with Frank Doe's condition
Include: physicians, psychologists, optometrists, nurse
practitioners, therapists, chiropractors, speech and language
pathologists, acupuncturists, etc.
If Frank Doe has seen several medical professionals, list
each of them on a separate line.
If Frank Doe has been an inpatient or outpatient at a
hospital or clinic, do not list staff doctors. We will ask about
them later.
We will ask you for more information about each of these people
later. If necessary, you can leave some things blank for now and
come back to them later.
After you leave this page, the information you entered will be
locked. If you need to correct the information you gave us, you
will be able to make changes on following pages where we ask
you for more details. Or, you can make changes from the
summary page at the end of each section, or at the end of this
report.
What medical professionals have seen Frank Doe for his or her
condition? If none, select the continue button.
(First Name, Last
Name)
Include physicians,
psychologists,
optometrists, nurse
practitioners.
therapists,
chiropractors,
acupuncturists, etc.
You can check
current med~cine
1. Or.
&
2. Dr. @
3.
"1.
5. Dr.
a
$a
Medical History: About Doctors and Other Medical Professionals 1
bottles for doctors'
names.
Examples: Dr.
Melissa Scott; Mr.
Don Camp
6. Or.
a
7. D r .
a
8. Dr.
m~heck
here if you want to add more doctors or medical professionals for Frank
Doe.
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Medical History: More Doctors and Other Medical Professionals 2
Social 5ieauity
Child Disability Report
Name: Frank Doe
SSN: 743-99-4143
Medical History: More Doctors and Other
Medical Professionals
Please list more of the doctors and other medical professionals
who have treated Frank Doe.
You can list up to 30 medical professionals in this section. We
will ask you for more information about each of these people
later.
After you leave this page, the information you entered will be
locked. If you need to correct the information you gave us, you
will be able to make changes on following pages where we ask
you for more details. Or, you can make changes from the
summary page at the end of each section, or at the end of this
report.
List additional doctors or medical professionals Frank Doe has seen for
his or her conditions:
(First Name, Last
Name)
Page 1 of 2
11. Dr.
a
12. Dr.
a
17. Dr.
&#
Medical History: More Doctors and Other Medical Professionals 2
Page 2 of 2
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Medical History: More Doctors and Other Medical Professionals 3
kciial ~ecluitv
Child Disability Report
Name: Frank Doe
SSN: 743-99-4143
Medical History: More Doctors and Other
Medical Professionals
Please list more of the doctors and other medical professionals
who have treated Frank Doe.
You can list up to 30 medical professionals in this section. We
will ask you for more information about each of these people
later.
After you leave this page, the information you entered will be
locked. If you need to correct the information you gave us, you
will be able to make changes on following pages where we ask
you for more details. Or, you can make changes from the
summary page at the end of each section, or at the end of this
report.
List additional doctors or medical professionals Frank Doe has seen for
his or her conditions:
(First Name, Last
Name)
Page 1 o f 2
21, Dr.
4
*,
22.
@
Dr.
Medical History: More Doctors and Other Medical Professionals 3
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Page 2 of 2
More about Doctor
Child Disability Report
Stdal , ~ e ~ ' ~ u i ~
Name: Frank Doe
SSN: 743-99-4143
Medical History: More About Dr Marcus
Wellby
Please give us enough information to contact Dr Marcus Wellby
If you do not have all the information, give us as much as you
can. Missing or incomplete information can delay or prevent us
from getting Frank Doe's records.
Doctor's Name:
Dr.
&
c ~ s
Wellby
HMO, Clinic, or
Office Name:
(If applicable)
Address:
Check the phone book, the child's appointment card, or billing statement for the
address. Please include the ZIP Code, since it helps us contact the child's doctor more
quickly. Please do NOT use any punctuation; for example, no periods or commas.
(Street Address
1)
(Street Address
2)
(Street Address
3)
(City, State, ZIP)
Phone Number:
(
)
Extension:
W h a t has Frank
D o e been seeing
Dr M a r c u s Wellby
for?
Include as much
-
Page 2 o f 3
More about Doctor
detail as possible.
We will ask for more
details about
medicines and tests
later.
Examples:
.
.
The child goes
regularly to
get hislher
blood
monitored.
In April 2002,
the child had a
seizure and
was referred
to a specialist.
Last month,
the child
developed an
infection.
Your answer can be
no more than 1000
characters, which is
about 20 lines of
typing.
You
have entered 0
characters
What treatments
did Frank Doe
receive from Dr
Marcus Wellby?
Examples:
The child had
physical
therapy
weekly for
'hre, K:OT.l:13
d i e ~.ik;s .; v,~.
The child
attends
counseling
sessions three
times a iveek.
More about Doctor
.
The child had
heat
treatments
and massage
for muscle
spasms.
Your answer can be
no more than 1000
characters, which is
about 20 lines of
typing.
have entered 0
characters
Dates of Visits to Dr Marcus Wellby:
If you can't remember the exact dates, try to give us approximate dates.
Examples: 12-20-01, Dec. 2002. last winter
When did Frank
Doe first go7
When did Frank
Doe last go?
When is Frank
Doe's next
appointment?
If not scheduled,
enter None.
Chart, HMO, or
Patient Number:
(If known)
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Medical History: About Hospitals or Clinics
Social S~CLU~QJ
Online
Child Disability Report
Name: Frank Doe
SSN: 743-99-4143
Medical History: About Frank Doe's
Hospitals or Clinics
Please list each hospital or clinic where Frank Doe has been
treated for any physical, mental, or emotional conditions related
to his or her disability. If there are several, list each of them on a
separate line. We will ask you for more information about each of
them later.
After you leave this page, the information you entered will be
locked. If you need to correct the information you gave us, you
will be able to make changes on following pages where we ask
you for more details. Or, you can make changes from the
summary page at the end of each section, or at the end of this
report.
List all hospitals, clinics, or other places where Frank Doe has been
treated.
Include places other
than doctors' offices
where the child went
for treatments, tests,
surgery, or
emergency room
visits.
Examples: University
Hospital, Mayo
Clinic, Radiology
Associates Inc.
1,
2.
3.
4.
5.
Medical History: About Hospitals or Clinics
Page 2 of 2
n ~ h e c here
k
if you want to add more hospitals or clinics where Frank Doe has bee
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Medical History: More Hospitals or Clinics
Child Disability Report
%cia1 s e ~ ~ u i ~
Online
www.socialsecurity.gov
Name: Frank Doe
SSN: 743-99-4143
Medical History: More Hospitals or Clinics
Please list more of the hospitals, clinics or other places where
Frank Doe has been treated for any physical, mental, or
emotional conditions related to his or her disability.
After you leave this page, the information you entered will be
locked. If you need to correct the information you gave us, you
will be able to make changes on following pages where we ask
you for more details. Or, you can make changes from the
summary page at the end of each section, or at the end of this
report.
At what hospitals, clinics, or other places has Frank Doe been treated?
Medical History: More Hospitals or Clinics
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Medical History: About Hospital
sCxial~ ' ~ u i t v
Child Disability Report
Name: Frank Doe
SSN: 743-99-4143
Medical History: About Bayview
Please fill in all the information you can about Frank Doe's visits
to Bayview. We need full information so we can request the
child's medical records. If necessary, you can leave some things
blank for now and come back to them later.
Note: If you want to delete this hospital after you have given us
dates on the following pages, you must first delete the page@)
where you have entered dates.
Hospital or Clinic
Name:
Bayview
Address:
Check the phone book, your appointment card, or your billing statement for the address.
Please include the Zip code, since this helps us to contact the hospital more quickly.
Please do NOT use punctuation; for example, no periods or commas.
(Street Address
1)
(Street Address
2)
(Street Address
3)
(City, State, ZIP)
Phone Number:
numpc:r I 1 casd ije
need to call this
hospital or clinic.
(
)
-
Medical History: About Hospital
Page 2 o f 3
(if known)
This is your patient
number, not your
billing number.
What doctors did
Frank Doe see on
a regular basis in
this hospital or
clinic?
List the first and last
name of each
doctor, if possible.
Provide as much
information as you
can.
Example: Dr. Jas
Linder, Dr. Brenda
Battle. Dr. Taylor,
and Dr. Degler
Your answer can be
no more than 1000
characters, which is
about 20 lines of
typing. If you need
more space.
continue in the
Remarks section at
the end of this
report.
have entered 0
characters
What type of visits did Frank Doe have at this hospital or clinic?
Inpatient Stay:
OYes O N o
Stayed over at least
one night.
Outpatient Stay or
Appointment:
0Yes
NO
Went home the
same day.
Emergency Room
(ER):
0Yes C)NO
Medical History: About Hospital
Went to ER and then
went home.
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Page 3 of 3
Medical History: Inpatient Dates o f Visits to Hospital
,Social secluity
Page 1 o f 1
Child Disability Report
Name: Frank Doe
SSN: 743-99-4143
Medical History: Dates of Inpatient Visits to
Bayview
Please tell us when Frank Doe went to Bayview for treatment or
to see a doctor.
When did Frank Doe go to Bayview for inpatient (overnight) stays?
If you can't remember the exact dates, try to give us approximate dates, including year.
Most recent
overnight stay at
Bayview
From:
To:
Next most recent
overnight stay at
Bayview
F
To:
~
~
~
:
Third most recent
overnight stay at
Bayview
F
To:
~
~
~
:
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Medical History: Outpatient Dates of Visits to Hospital
social ~ e c ' ~ u i t ~
Online
Page 1 of 1
Child Disability Report
www.socialsecurity.gov
Name: Frank Doe
SSN: 743-99-4143
Medical History: Dates of Outpatient Visits to
Bayview
Please tell us when Frank Doe went to Bayview for treatment or
to see a doctor.
When did Frank D o e go to Bayview for outpatient visits?
If you can't remember the exact dates, try to give us approximate dates, including year
Date of most recent
outpatient visit at
Bayview
Date of first
outpatient visit at
Bayview
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Medical History: Dates o f Emergency Room Visits to Hospital
Social S ~ L ' L U ~ ~
Child Disability Report
Name. Frank Doe
SSN: 743-99-4143
Medical History: Dates of Emergency Room
Visits to Bayview
Please tell us when Frank Doe went to the Emergency Room
(and home the same day) at Bayview.
When did Frank Doe go to the Emergency Room (and home the same
day) at Bayview?
Please list all dates
as closely as you ,
can remember,
including year,
starting with the
most recent.
Examples (separate
each date with
commas): 11117103,
1 113103. 1017103
Your answer can be
no more than 60
characters.
You
have entered 0
characters
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Medical History: About Visits to Hospital
Social set~~ritv
Online
Child Disability Report
Name: Frank Doe
SSN: 743-99-4143
Medical History: About Frank Doe's Visits at
Bayview
Please explain why Frank Doe went and what treatment(s) Frank
Doe received during each visit to Bayview. We will ask about
tests and medicines later. Be sure to answer these questions for
the following visits:
.
.
..
Inpatient stays:
o From January 3,2003 to January 7,2003
0
From to
0
From to
Outpatient visits between and February 13, 2003
Emergency room visits on March 20, 2003
Any additional visits not listed here.
Note: If you want to delete this hospital after you have given us
dates on the prior pages, you must first delete the page@)where
you have entered dates.
Your answer can be no more than 1000 characters, which is
about 20 lines of typing. If you need more space, continue in the
Remarks section at the end of this report.
Tell us t h e
reason f o r each
visit to Bayview.
Examples:
.
Had 30
outpatient
visits between
March 2004
and the
present for his
cancer.
Page 1 of 3
Medical History: About Visits to Hospital
monthly blood
transfusions
as outpatient
every month
for the past
year.
.
.
Had surgery
on June 20.
2002 and
stayed in the
hospital for a
week because
he developed
an infection.
.
Went to ER on
October 13,
2002 because
she was
nauseated,
dizzy, and
running a high
fever.
Spent the
summer of
2002 in the
hospital for
third degree
burns.
have entered 0
characters
Tell us what
treatments Frank
Doe received for
each visit to
Bayview.
Include the location
within the hospital if
possible.
Examples:
.
.
Physical
therapy at the
Rehab Clinic
from Jan.March 2003.
Knee surgery
Page 2 o f 3
Page 3 of 3
Medical History: About Visits to Hospital
on March 29,
2003.
Chemotherapy
at the
Oncology
Clinic weekly
since Jan.
2003.
Needed 30
stitches on
Sept. 14,
2002.
You
have entered 0
characters
When is the
child's next
appointment at
Bayview?
If not scheduled.
enter None. Please
give us the exact
date if known.
Examples: 1-19-04,
1/19/2004, Jan.
2004
Deleting the data on this page is not allowed
because you gave us more information about this
on another page.
Prevlous Page
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Continue
Medical History: About Medicines
Stdal Seallit)
Child Disability Report
Name: Frank Doe
SSN: 743-99-4143
Medical History: About Frank Doe's
Medicines
Please list all prescription and non-prescription (over-thecounter) medicines that Frank Doe now takes for his or her
conditions, including herbal remedies. We will ask for more
information about each of them later.
What
prescription a n d
1.
over-the-counter
medicines does
Frank Doe
2.
currently take?
4.
Copy the name
directly from the
medicine container,
if you have it.
Examples:
5.
Ritalin
8.
Albuterol
9.
.
.
.
3.
6.
7.
Insulin
10.
Aspirin
11.
Tylenol
Melatonin
12.
13.
14.
15.
aCheck here toadd more medicines for Frank Doe
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Page 1 of 1
Medical History: More Medicines
Social Sec~~ritv
Child Disability Report
Name: Frank Doe
SSN: 743-99-4143
Medical History: More of Frank Doe's
Medicines
Please list all prescriptionand non-prescription (over-thecounter) medicines that Frank Doe now takes for his or her
conditions, including herbal remedies. We will ask for more
information about each of them later.
What
prescription and
over-the-counter
medicines does
Frank Doe
currently take?
Copy the name
directly from the
medicine container,
if you have it.
16.
17.
18.
19.
20.
21.
22.
If Frank Doe has more medications than this, please include them in the
remarks section at the end of this report.
Pi-e~Urow)~~__iContinue 1
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Medical History: About Medicine
Social S~LYU~Q
Child Disability Report
Name: Frank Doe
SSN: 743-99-4143
Medical History: About Medicine Fifteen
Please tell us about this medicine. Try to give us enough
information to understand your condition and how the medicine
affects it. If you do not have all the information, give us as much
as you can.
Each answer can be no more than 1000 characters, which is
about 20 lines of typing. If you need more space, continue in the
Remarks section at the end of this report.
Medicine Name:
Midicine F i f t e e n
What doctor, if
any, told YOU to
take this
medicine?
Other: (Title, First Name, Last Name)
(If a doctor did not
tell you to take this
medicine, leave this
question blank.) If
the doctor's name is
not in the list, type it
in the space marked
"Other" below the
list. If you are not
sure which doctor
told you to take it or
do not remember the
doctor's name, leave
the space blank.
Why does Frank
Doe take this
medicine?
Examples:
.
To calm him
down so that
Page I of 2
Dr.
-,
Medical Histoly: About Medicine
.
.
he can
behave in
school.
To regulate
her blood
sugar.
To stop the
pain.
You
have entered 0
characters
What side effects
does Frank Doe
have, if any?
Do not include side
effects on the
medicine label if the
child has not
experienced them.
Include physical or
mental effects and
allergic reactions.
Examples:
.
.
.
Makes her so
tired she can't
do anything.
Makes her
sick to her
stomach.
Causes
diarrhea.
You
have entered 0
characters
Prev'O_usP*
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1
Continue :
Medical History: About Medical Tests
stxialSec.uri&
Child Disability Report
Name: Frank Doe
SSN:743-99-4143
Medical History: About Frank Doe's Medical
Tests
This is a list of common medical tests. Please select all of the
tests Frank Doe has had or expects to have. Include tests Frank
Doe has had once and those he or she has had many times. If
Frank Doe had a test that is not in the list, please fill in the name
of the test in the space provided. We will ask for more
information about each test later.
Select the tests
Frank Doe had or
expects to have:
If you're not sure.
select the test name
to get a description
of the test.
fl SpeechlLanguage Test
0Hearing Test
nvision Test
1Q Test
EKG (heart test)
UTreadmill (exercise test)
UCardiac Catheterization
Biopsy
fl EEG (brain wave test)
HIV test
Blood test (not HIV)
Breathing test
X-Ray
UMRIICT Scan
a
Are there any
other tests Frank
Doe had or will
have?
Page 1 of 2
1.
2,
3.
4.
Medical History: About Medical Tests
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Medical History: More About Test
Page 1 of 2
Child Disability Report
Social , ~ ~ ~ r i t ~
Online
Name: Frank Doe
SSN: 743-99-4143
Medical History: More About Other Test
Please tell us about the most recent time Frank Doe had or
expects to have this medical test. Try to give us enough
information to request the test results. If you do not have all the
information, give us as much as you can.
Name of Test:
Other Test (2 of 2)
'
!
-
Twm
J
When was or will
this test be
done?
If you cannot give us
the exact date, be as
specific as possible.
Examples:
1013012002, October
2002, fall 2002
Where was or
where will it be
done?
0Unknown
(Choose one)
If the place is not in
the list, please
include it in the
remarks section at
the end of the report
Who sent Frank
for this test?
:@
Other: (Title, First Name, Last Name)
r.li
Dr.
If the doctor's name
IS not In the k t ,
enter it in the space
provided below the
list.
Unknown
U C h e c k here to add another Other Test for Frank Doe.
Medical History: More About Test
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Page 2 of 2
Medical History: Additional Testing or Examination
Social ~ e ~ ~ u - i t v
Online
Child Disability Report
Name: Frank Doe
SSN: 743-99-4143
Medical History: Additional Sources of
Testing or ~xa-mination
Has Frank Doe been tested or examined by a n y of t h e following?
Headstart (Title V)
C)yes 0NO c>1 don't know
Public or
Community Health
Department
(2Yes i? No 0l don't know
Child Welfare or
Social Service
Agency
(3Yes 0No 01 don't know
Women, Infants
and Children (WIC)
Program
C;!Yes Ci NO
l don't know
Program for
Children with
Special Health
Care Needs
OYes
0No
c)l don't know
Mental
HealthlMental
Retardation Center
0Yes (2No C)I don't know
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Page 1 of 1
Medical History: About Testing at Headstart
Child Disability Report
Social ~ e c ~ u i ~
Online
www.socialsecurity,gov
Name: Frank Doe
SSN: 743-99-4143
Medical History: About Frank Doe's Medical
Testing at Headstart
Please fill in as much information as you can so that we may
obtain Frank Doe's complete records. Headstart may have
important information to help Frank Doe's case, and they may
also help us find other medical records. Do not include any
learning and behavioral tests that you already listed in the
schools section for this place.
Name of
Headstart
Program:
If you don't know the
exact name, tell us
as closely as you
remember.
Example: Headstart
at East Baltimore
Elementary
Address:
If you don't have the full street address, give us as much as you can, and be sure to
include the city and state. Please do NOT use punctuation; for example, no periods Or
commas.
Example: "On Main St next to the Courthouse"
(Street Address
1)
(Street Address
2)
(Street Address
3)
(City, State, ZIP)
Phone Number:
(
)
Extension:
.
.
Medical History: About Testing at Headstart
File or Record
Number:
Tests at this Headstart School:
Please list all types of tests Frank Doe had at this Headstart school. If you cannot
remember the speclfic dates, be as specific as possible.
Examples: 06/02/2002; 06/02; June 2002; Summer 2002.
Test 1:
Examples: vision
test, hearing test,
motor skills test
Test type:
Date:
Test 2:
Test type:
Date:
Test 3:
Test type:
Date:
Test 4:
Test type:
Date:
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Page 2 of 2
Medical History: About Testing at PublicICommunity Health Dept.
Social S e ~ ~ u i p
OlIIine
Page 1 o f 2
Child Disability Report
www.soc~alsecuritygov
Name: Frank Doe
SSN: 743-99-4143
Medical History: About Frank Doe's Testing
at a Public or Community Health Department
Please fill in as much information as you can so that we may
obtain Frank Doe's complete records. The Health Department
may have important information to help Frank Doe's case, and
they may also help us And other medical records.
Name of Health
Department:
If you don't know the
exact name, tell us
as closely as you
remember.
Example: Howard
County Health
Department
Address:
If you don't have the full street address, give us as much as you can, and be sure to
include the city and state. Please do NOT use punctuation; for example, no periods or
commas.
Example: "On Main St next to the Courthouse"
(Street Address
1)
(Street Address
2)
(Street Address
3)
(City, State, ZIP)
Phone Number:
(
1
Extension:
File or Record
-
Medical History: About Testing at PubliciCommunity Health Dept.
Page 2 of 2
Number:
Tests at this Health Department:
Please list all types of tests Frank Doe had at this Public or Community Health
Department. If you cannot remember the specific dates, be as specific as possible.
Grades are OK if you cannot remember exact dates.
Examples: 06/02/2002; 06/02; June 2002; Summer 2002; 3rd grade.
Test 1:
Examples: vision
test, hearing test,
motor skills test
Test type:
Date:
Test 2:
Test type:
Date:
Test 3:
Test type:
Date:
Test 4:
Test type:
Date:
U C h e c k here if you want to add another public or community health
department where Frank Doe was tested.
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Medical History: About Testing at Child WelfarelSocial Service Agency
Social ~ec'~uitv
Child Disability Report
Name: Frank Doe
SSN: 743-99-4143
Medical History: About Frank Doe's Testing
at a Child Welfare or Social Service Agency
Please fill in as much information as you can so that we may
obtain Frank Doe's complete records. The Child Welfare or
Social Service Agency may have important information to help
Frank Doe's case, and they may also help us find other medical
records.
Name of Agency:
If you don't know the
exact name, tell us
as closely as you
remember.
Example: Howard
County Social
Services
Address:
If you don't have the full street address, give us as much as you can, and be sure to
include the city and state. Please do NOT use punctuation; for example, no periods or
commas.
Example: "On Main St next to the Courthouse"
(Street Address
1)
(Street Address
2)
(Street Address
3)
(City, State, ZIP)
Phone Number:
(
1
Extension:
File or Record
Number:
Page I of 2
Medical History: About Testing at Child WelfareiSocial Service Agency
Tests at this Child Welfare or Social Service Agency:
Please list all types of tests Frank Doe had at this Child Welfare or Social Service
Agency. If you cannot remember the exact dates, be as specific as possible. Grades are
OK if you cannot remember exact dates.
Examples: 06/02/2002; 06/02; June 2002; Summer 2002; 3rd grade.
Test 1:
Examples: vision
test, hearing test,
motor skills test
Test type:
Date:
Test 2:
Test type:
Date:
Test 3:
Test type:
Date:
Test 4:
Test type:
Date:
n ~ h e c here
k
if you want to add another Child Welfare or Social Service
Agency where Frank Doe was tested.
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Medical History: About Frank Doe's Testing at a Women, Infant, Children Program
%cia1 S K ' I ~ N
Online
Name: Frank Doe
SSN: 743-99-4143
Child Disability Report
Medical History: About Frank Doe's Testing
at a Women, Infants and Children (WIC)
Program
Please fill in as much information as you can so that we may
obtain Frank Doe's complete records. The WIC Program may
have important information to help Frank Doe's case, and they
may also help us find other medical records.
Name o f WIC
Program:
If you don't know the
exact name, tell us
as closely as you
remember.
Example: WIC of
Montgomery County
Maryland
Address:
If you don't have the full street address, give us as much as you can, and be sure to
include the city and state. Please do NOT use punctuation; for example, no periods or
commas.
Example: "On Main St next to the Courthouse"
(Street Address
1)
(Street Address
2)
(Street Address
3)
(City, State, ZIP)
Phone Number:
(
)
Extension:
Medical History: About Frank Doe's Testing at a Women, Infant. Children Program
Page 2 of 2
File or Record
Number:
Tests at this WIC Program:
Please list all types of tests Frank Doe had at this WIC Program. If you cannot
remember the exact dates, be as specific as possible. Grades are OK if you cannot
remember exact dates.
Examples: 06/02/2002; 06/02; June 2002; Summer 2002; 3rd grade.
Test 1:
Examples: vision
test, hearing test,
motor skills test
Test type:
Date:
Test 2:
Test type:
Date:
Test 3:
Test type:
Date:
Test 4:
Test type:
Date:
Check here if you want t o add another WIC Program where Frank Doe
was tested.
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Medical History: About Testing at Special Health Care Needs
socialS~L'IU~~V
Name: Frank Doe
SSN: 743-99-4143
Child Disability Report
Medical History: About Frank Doe's Testing
at a Program for Children with Special Health
Care Needs
Please fill in as much information as you can so that we may
obtain Frank Doe's complete records. The Program may have
important information to help Frank Doe's case, and they may
also h e l us
~ find other medical records.
Name o f
Program:
If you don't know the
exact name, tell us
as closely as you
remember.
Example: Cerebral
Palsy Association of
Kings County
Address:
If you don't have the full street address, give us as much as you can, and be sure to
include the city and state. Please do NOT use punctuation; for example, no periods or
commas.
Example: "On Main St next to the Courthouse"
(Street Address
1)
(Street Address
2)
(Street Address
3)
(City, State, ZIP)
Phone Number:
(
)
Extension:
-
Medical History: About Testing at Special Health Care Needs
File or R e c o r d
Number:
Tests a t this Program:
Please list all types of tests Frank Doe had at this Program. If you cannot remember the
exact dates, be as specific as possible. Grades are OK if you cannot remember exact
dates.
Examples: 06/02/2002; 06/02; June 2002; Summer 2002; 3rd grade.
Test 1:
Examples: vision
test, hearing test,
motor skills test
Test type:
Date:
Test 2:
Test type:
Date:
Test 3:
Test type:
Date:
Test 4:
Test type:
Date:
OCheck here if you want t o add another Program for Children with
Special Health Care Needs where Frank Doe was tested.
Contact SSA I How to Move Around This Report
Medical History: About Frank Doe's Testing at a Mental Health or Mental Retardation Ce ... Page I of 2
Social Sec~~ritv
Name: Frank Doe
SSN: 743-99-4143
Child Disability Report
Medical History: About Frank Doe's Testing
at a Mental Health or Mental Retardation
Center
Please fill in as much information as you can so that we may
obtain Frank Doe's complete records. The Mental Health or
Mental Retardation Center may have important information to
help Frank Doe's case, and they may also help us fn
i d other
medical records.
Name of Mental
Health or Mental
Retardation
Center:
If you don't know the
exact name, tell us
as closely as you
remember.
Example: Bay
County Association
for Retarded
Citizens
Address:
If you don't have the full street address, give us as much as you can, and be sure to
include the city and state. Please do NOT use ~unctuation:for exam~le.no Deriods or
commas.
Example: "On Main St next to the Courthouse"
(Street Address
1)
(Street Address
2)
(Street Address
3)
(City, State, ZIP)
Medical History: About Frank Doe's Testing at a Mental Health or Mental Retardation Ce ... Page 2 of 2
Phone Number:
(
)
Extension:
File or Record
Number:
Tests a t this Mental Health or Mental Retardation Center:
Please list all types of tests Frank Doe had at this Mental Health or Mental Retardation
Center. If you cannot remember the exact dates, be as specific as possible. Grades are
OK if you cannot remember exact dates.
Examples: 06/02/2002; 06/02; June 2002; Summer 2002; 3rd grade.
Test 1:
Examples: vision
test, hearing test8
motor skills test
Test type:
Date:
Test 2:
Test type:
Date:
Test 3:
Test type:
Date:
Test 4:
Test type:
Date:
U C h e c k here if you want to add another Mental Health or Mental
Retardation Center where Frank Doe was tested.
Contact SSA 1 How to Move Around Thls Report
Medical History: Other Medical Records
social ~
Online
~
Child
u
i Disability
~
Report
Name: Frank Doe
SSN: 743-99-4143
Medical History: Other Medical Records
Although this does not apply to everyone, some people may
have relevant medical records in other places. These other
records may contain important information that we need to
consider in evaluating Frank Doe's disability application. If you
check any of the items below, we will ask for more information
Remember, this refers only to those contacts and services
received since you last gave us medical information.
Note: Do not repeat any places you already told us about in this
form (i.e., doctors' offices or hospitals).
Have you
received services
from other
organizations
that would have
your medical
records?
O ~ e sO N o
(If "yes", please select any of the following that might have medical records or
information about Frank Doe's condition:)
Tutor
nWorkers' Compensation
Counselor
Detention Center
nInsurance Company
UAttorney or Lawyer
UAnother Place
Medical History: Other Medical Records
Conlacl SSA ( How to Move Around This Report
Page 2 of 2
About Tutor Records
Social ~ e c ~ u i t v
Page 1 of 3
Child Disability Report
Name: Frank Doe
SSN: 743-99-4143
Medical History: About Frank Doe's Tutor
Records
Please fill in as much information as you can so that we may
obtain the child's complete records. The child's tutor may have
important information to help Frank Doe's case and may also be
able to help us find other medical records.
Tutor's Name:
(First, Last)
Tutoring Center
Name, if any:
If you don't know the
exact name, tell us
as closely as you
remember.
Example: ABC
Learning Center
Address:
If you don't have the full street address, give us as much information as you can, and be
sure to include the city and state. Please do NOT use punctuation; for example, no
periods or commas.
Example: "On Main St next to the Courthouse"
(Street Address
1)
(Street Address
2)
(Street Address
3)
(City, State, ZIP)
Phone Number:
(
)
-
Page 2 o f 3
About Tutor Records
Extension:
When did the
child first go?
If you cannot
remember the exact
dates, be as specific
as possible.
Examples: 12-1-02,
Feb. 2003, Winter
2002
When did the
child last go?
When is the
child's next
appointment?
If not scheduled
enter None.
Student Number:
(if any)
Reasons for
Visits or
Services:
Include as much
information as
possible about the
reasons for the
child's visits.
Your answer can be
no more than 1000
characters, which is
about 20 lines of
typing.
You
characters
OCheck here if you want to add another Tutor who has records for Frank
Doe
Page 3 of 3
About Tutor Records
Contact SSA I How to Move Around This Repon
About Medical Records at Workers Compensation
social ~ u i t v
Online
Child Disability Report
Name: Frank Doe
SSN: 743-99-4143
Medical History: About Frank Doe's Medical
Records at Workers' Compensation
Please fill in as much information as you can so that we may
obtain Frank Doe's complete records. Workers' Compensation
may have important information to help Frank Doe's case, and
may also be able to help us find other medical records.
Workers'
Compensation
Office:
If you don't know the
exact name, tell us
as closely as you
remember.
Example: Allied
Workers' Comp
Contact Name:
(First, Last)
Address:
If you don't have the full street address, give us as much as you can, and be sure to
include the city and state. Please do NOT use punctuation: for example, no periods or
commas.
Example: "On Main St next to the Courthouse"
(Street Address
1)
(Street Address
2)
(Street Address
3)
&
(City, State, ZIP)
Phone Number:
(
)
About Medical Records at Workers Compensation
Extension:
Date of First
Contact:
Tell us when you
first applied for
Workers'
Compensation. If
you cannot
remember the exact
dates, be as specific
as possible.
Examples: 12-1-02,
Feb. 2003, Winter
2002
Date of Most
Recent Contact:
Next
Appointment:
If not scheduled,
enter None.
Claim Number:
Reason for
Contact with
Workers'
Compensation:
Your answer can be
no more than 1000
characters, which is
about 20 lines of
typing. If you need
more space.
continue in the
Remarks section at
the end of this
report.
You
have entered 0
characters
OCheck here if you want to add another Workers' Compensation office
that has records for Frank Doe
About Medical Records at Workers Compensation
Contact SSA I How to Move Around This Report
Page 3 of 3
About Counselor Records
Social S e ~ ~ ~ r i k j
Name: Frank Doe
SSN: 743-99-4143
Child Disability Report
Medical History: About Frank Doe's
Counselor Records
Please fill in as much information as you can so that we may
obtain the Frank Doe's complete records. This counselor may
have important information to help Frank Doe's case and may
also be able to help us find other medical records.
Name of
Counselor:
(First, Last)
Name of
Counseling
Center, if any:
If you don't know the
exact name, tell us
as closely as you
remember.
Example: ABC
Counseling Center
Address:
If you don't have the full street address, give us as much information as you can, and be
sure to include the city and state. Please do NOT use punctuation; for example, no
periods or commas.
Example: "On Main St next to the Courthouse"
(Street Address
1)
(Street Address
2)
(Street Address
3)
(City, State, ZIP)
a$
About Counselor Records
Phone Number:
(
1
Extension:
When did the
child first go?
If you cannot
remember the exact
dates, be as specific
as possible.
Examples:
12/1/2002, February
2003, Winter 2003
When did the
child last go?
When is the
child's next
appointment?
If not scheduled,
enter None.
Case Number:
(if any)
Reasons for
Visits or
Services:
Include as much
information as
possible about the
reasons for the
child's visits.
Your answer can be
no more than 1000
characters, which is
about 20 lines of
typing. If you need
more space.
continue in the
Remarks section at
the end of this
report.
You
have entered 0
characters
About Counselor Records
Page 3 of 3
OCheck here if you want to add another Counselor who has records for
Frank Doe
Py$y&us Rage
Contact SSA I How lo Move Around This Report
1
Continue
I
About Medical Records at a Detention Center
socialsfXXuitJ'
Child Disability Report
Name: Frank Doe
SSN: 743-99-4143
Medical History: About Frank Doe's Medical
Records at a Detention Center
If Frank Doe saw a doctor or clinic while helshe was in a
detention center, please fill in as much information as you can so
that we may get Frank Doe's complete records. This organization
may have important information to help Frank Doe's case, and
may also be able to help us find other medical records.
Detention Center
Name:
If you don't know the
exact name, tell us
as closely as you
remember.
Example: Strickland
Youth Center
N a m e of Doctor:
(First, Last)
Address:
If you don't have the full street address, give us as much information as you can, and be
sure to include the city and state. Please do NOT use punctuation; for example, no
periods or commas.
Example: "On Main St next to the Courthouse"
(Street Address
1)
(Street Address
2)
(Street Address
3)
(City, State, ZIP)
P h o n e Number:
Page I of 2
(
)
About Medical Records at a Detention Center
Page 2 of 2
Extension:
First Visit to
Detention Center
Doctor:
If you cannot
remember the exact
dates, be as specific
as possible.
Examples:
121112002, February
2003, Winter 2003
Last Visit to
Detention Center
Doctor:
Inmate Number:
Reasons for
Visits or
Sewices:
Include as much
information as
possible about the
reasons for the
child's visits. Your
answer can be no
more than 1000
characters, which is
about 20 lines of
typing. If you need
more space,
continue in the
Remarks section at
the end of this
report.
YOU
have entered 0
characters
U C h e c k here if you want to add another Detention Center that has
medical records for Frank Doe
Contact SSA I How to Move Around This Report
h~p:/leis.ba.ssa.gov/appages/i3820~November06/mh023.html
Page 1 of 2
About Medical Records at an Insurance Company
Social Sec~uitv
Child Disability Report
www soclalsecurlty gov
p E G G q
Name: Frank Doe
SSN: 743-99-4143
Medical History: About Frank Doe's Medical
Records at an Insurance Company
Please fill in as much information as you can so that we may get
Frank Doe's complete records. This company may have
important information to help Frank Doe's case, and they may
also help us find other medical records.
lnsurance
Company Name:
If you don't know the
exact name, tell us
as closely as you
remember.
Example: Blue
Cross of Maryland
Contact Name:
(First, Last)
Address:
If you don't have the full street address, give us as much information as you can, and be
sure to include the city and state. Please do NOT use punctuation; for example, no
periods or commas.
Example: "On Main St next to the Courthouse"
(Street Address
1)
(Street Address
2)
(Street Address
3)
*
(City, State, ZIP)
Phone Number:
(
)
About Medical Records at an Insurance Company
Page 2 of 2
Extension:
F i r s t Contact:
If you cannot
remember the exact
dates, be as specific
as possible.
Examples:
12/1/2002, February
2003, Wtnter 2003
Most Recent
Contact:
IdentificationlClaim
Number:
(if any)
Reasons for
Visits or
Services:
Include as much
information as
possible about the
reasons for the
child's visits.
Your answer can be
no more than 1000
characters, which is
about 20 lines of
typing. If you need
more space,
continue in the
Remarks section at
the end of this
report.
have entered 0
characters
1 You
Check here if you want to add another insurance company that has
records for Frank Doe
Contact SSA I How to Move Around This Report
http:lleis.ba.ssa.gov/appagesli3820 November061mh024.htm1
211512007
About AttorneyiLawyer Records
,Social ~ e a u i t y
Online
Child Disability Report
Name: Frank Doe
SSN: 743-99-4143
Medical History: About Frank Doe's
AttorneylLawyer Records
Please fill in as much information as you can so that we may
obtain the child's complete records. The child's lawyer may have
important information to help hislher case and may also be able
to help us find other medical records.
AttorneylLawyer
Name:
(First, Last)
L a w F i r m Name,
if any:
If you don't know the
exact name, tell us
as closely as you
remember.
Example:
ABC Legal Center
Address:
If you don't have the full street address, give us as much as you can, and be sure to
include the city and state. Please do NOT use punctuation; for example, no periods or
commas.
Example: "On Main St next to the Courthouse"
(Street Address
1)
(Street Address
2)
(Street Address
3)
(City, State, ZIP)
Phone Number:
(
)
Page 1 of 3
About AttorneyILawyer Records
Extension:
When did the
child first go?
If you cannot
remember the exact
dates, be as specific
as possible.
Examples:
12/1/2002, February
2003, Winter 2003
When did the
child last go?
When is the
child's next
appointment?
If not scheduled.
enter None.
Case Number:
(if any)
Reasons for
Visits or
Services:
Include as much
information as
possible about the
reasons for Frank
Doe's visits.
Your answer can be
no more than 1000
characters, which is
about 20 lines of
typing. If you need
more space,
continue in the
Remarks section at
the end of this
report.
You
have entered 0
characters
Page 2 o f 3
About AttorneyiLawyer Records
Page 3 of 3
Check here if you want to add another attorney or law firm that has
records for Frank Doe
Contact SSA I How to Move Around This Report
About Medical Records at Another Place
Page 1 of 2
stxtal~ e ~ ' ~ u i t y Child Disability Report
Name: Frank Doe
SSN: 743-99-4143
Medical History: About Frank Doe's Medical
Records at Another Place
You told us that another place has some of the child's medical
records. Those records may have important information about
the child's condition and could help us find other medical records
Please fill in as much information as you can so that we may
obtain the child's complete records.
Name of Place:
Contact Name:
(First, Last)
Address:
If youdon't have the full street address, give us as much as you can, and be sure to
include the city and state. Please do NOT use punctuation; for example, no periods or
commas.
Example: "On Main St next to the Courthouse"
(Street Address
1)
(Street Address
(Street Address
3)
(City, State, ZIP)
Phone Number:
(
)
Extension:
W h e n did t h e
c h i l d f i r s t go?
If you cannot
remember the exact
About Medical Records at Another Place
Page 2 of 2
dates, be as specific
as possible.
Examples:
12/1/2002,
February
2003.Winter 2003
When did t h e
c h i l d l a s t go?
When is the
child's n e x t
appointment?
If not scheduled.
enter None.
Case Number:
(if any)
Reasons for
Visits o r
Services:
Include as much
information as
possible about the
reasons for Frank
Doe's visits.
Your answer can be
no more than 1000
characters, which is
about 20 lines of
typing. If you need
more space,
continue in the
Remarks section at
the end of this
report.
You
have entered 0
characters
U C h e c k here if you want to add another place that has records for Frank
Doe
Contact SSA I How to Move Around Thls Report
Other Information
S ~ KSec~~ritv
~ ~ I
Child Disability Report
Name: Frank Doe
SSN: 743-99-4143
Medical History: Other Information
Please answer a few last questions about Frank Doe's medical
and school history.
Are there other
name(s) that
might be on
Frank Doe's
medical or
school records?
OYes
(TINO
Examples: birth
name, adopted
name. nickname
Does Frank Doe
have a medical
assistance or
Medicaid card
issued by the
state?
C)yes
(3No
This number can
help us get all Frank
Doe's medical
records promptly. If
yes, please provide
the number if you
can.
Height and Weight:
Frank Doe's height and weight are important to evaluate his or her condition. Please
give us this information even though you believe it may be in the child's medical
records.
What is Frank
Doe's height
without shoes?
Feet
@ Inches
id#
Other Information
What is Frank
Doe's weight
without shoes?
Page 2 of 2
Pounds
ounces
2i#
Previoits Page
Contact SSA 1 How to Move Around This Report
.. 1
~ontblue i
Other Names
Stdal .Sec~.trit\'
Online
Page 1 of 1
Child Disability Report
WWW.~ocialSeCurity.gov
Name: Frank Doe
SSN: 743-99-4143
Medical History: Other Names
You indicated that Frank Doe's medical or school records may be
listed under another name (birth name, adopted name,
nickname, etc.). Please list this name(s) below.
(First, Middle
Initial, Last)
If we cannot request
Frank Doe's records
by the correct name,
we may not receive
all of the information
we need.
Example: Mary L
Smith
Contact SSA I How to Move Around Th~sReport
Summary of Medical History
Social ~ec'~uitv
Online
Page 1 of I I
Child Disability Report
Name: Frank Doe
SSN: 743-99-4143
Summary of Frank Doe's Medical History
Please review the information you gave us and make sure it is
correct and as complete as possible. To go back to any item in
the list, select Edit.
If you have not been able to find all of the requested information
about the child's medical history, you can still send in the report.
When we receive it, we will try to help you find any missing
information.
Note: To save space, this summary shows only the first 100
characters of the descriptions you gave us on the prior pages,
However, evemhing you told us will be included in this report
when you transmit iito Social Security
About Frank Doe's Doctors and Other Medical Professionals
About Dr. Jose Morra
M a ~ nStreet Doctors Association
You d ~ dnot provide any reasons for Frank
Doe's vis~t.
Treatments included: Complete physical
You did not enter the address of this
doctor
Balt~more,MD 21202
About Dr. Linda Robins
Main Street Doctors Association
You dld not provide any reasons for Frank
Doe's vis~t
Treatments ~ncludedComplete physical
You did not enter the address of this
doctor.
Baltimore, MD 21202
About Dr. Wayne Dwyer
Main Street Doctors Association
You did not provide any reasons for Frank
Doe's vis~t.
Treatments included: Complete physical
You did not enter the address of this
doctor.
Baltimore, MD 21202
About Dr. Sue Watson
9 Main Street Doctors Association
You did not provide any reasons for Frank
Doe's visit.
Treatments included: Complete physical
You did not enter the address of this
doctor.
Balt~more,MD 21202
Summary of Medical History
About Dr. Fifth Doctor
&
Main Street Doctors Association
You did not provide any reasons for Frank
Doe's visit.
Treatments included: Complete physical
You did not enter the address of this
doctor.
Baltimore, MD 21202
About Dr. Sixth Doctor
Main Street Doctors Association
You did not provide any reasons for Frank
Doe's visit.
Treatments included: Complete physical
You did not enter the address of this
doctor.
Baltimore. MD 21202
About Dr. Seventh Doctor
a
Main Street Doctors Association
You did not provide any reasons for Frank
Doe's visit.
Treatments included: Complete physical
You did not enter the address of this
doctor.
Baltimore, MD 21202
About Dr. Eighth Doctor
%
Main Street Doctors Association
You did not provide any reasons for Frank
Doe's visit.
Treatments included: Complete physical
You did not enter the address of this
doctor.
Baltimore, MD 21202
About Dr. Nineth Doctor
a
Main Street Doctors Association
You did not provide any reasons for Frank
Doe's visit.
Treatments included: Complete physical
You did not enter the address of this
doctor.
Baltimore. MD 21202
About Dr. Tenth Doctor
9 Main Street Doctors Association
You did not provide any reasons for Frank
Doe's visit.
Treatments included: Complete physical
You did not enter the address of this
doctor.
Baltimore, MD 21202
About Dr. Samuel Lang
Main Street Doctors Association
You did not provide any reasons for Frank
Doe's visit.
Treatments included: Complete physical
You did not enter the address of this
doctor.
Baltimore, MD 21202
About Dr. Jeffrey Ross
Main Street Doctors Association
You did not provide any reasons for Frank
Doe's visit.
Treatments included: Complete physical
You did not enter the address of this
doctor.
Baltimore, MD 21202
About Dr. Martha Riley
E d Main Street Doctors Association
-"
You did not enter the address of this
Summary of Medical History
You did not provide any reasons for Frank
Doe's visit.
Treatments included: Complete physical
doctor.
Baltimore, MD 21202
About Dr. Fourteenth Doctor
Main Street Doctors Association
You did not provide any reasons for Frank
Doe's visit.
Treatments included: Complete physical
You did not enter the address of this
doctor.
Baltimore, MD 21202
About Dr. Fifteenth Doctor
Edit]
Main Street Doctors Association
You did not provide any reasons for Frank
Doe's visit.
Treatments included: Complete physical
You did not enter the address of this
doctor.
Baltimore, MD 21202
About Dr. Sixteenth Doctor
Main Street Doctors Association
You did not provide any reasons for Frank
Doe's visit.
Treatments included: Complete physical
You did not enter the address of this
doctor.
Baltimore, MD 21202
About Dr. Seventeenth Doctor
Main Street Doctors Association
You did not provide any reasons for Frank
Doe's visit.
Treatments included: Complete physical
You did not enter the address of this
doctor.
Baltimore, MD 21202
About Dr. Eighteenth Doctor
Etl)tl
Main Street Doctors Association
You did not provide any reasons for Frank
Doe's visit.
Treatments included: Complete physical
You did not enter the address of this
doctor.
Baltimore. MD 21202
About Dr. Nineteenth Doctor
Main Street Doctors Association
You did not provide any reasons for Frank
Doe's visit.
Treatments included: Complete physical
You did not enter the address of this
doctor.
Baltimore, MD 21202
About Dr. Marcus Wellby
Main Street Doctors Association
You did not provide any reasons for Frank
Doe's visit.
Treatments included: Complete physical
About Frank Doe's Hospitals and Clinics
About City General
You did not enter the address of this
doctor.
Baltimore, MD 21202
Summary of Medical History
&
HospitallClinic record #: 12345678
Doctors: Linda Robins
Visits Included: lnpatient visit, Outpatient
visit, Emergency Room visit
Page 4 of l l
123 Main ST
Baltimore, MD 21202
lnpatient Stays:
From: January 3,2003 to: January 7,2003
Outpatient visits between February 13, 2003 and "No Date Entered"
&
Emergency Room visits on March 20, 2003
Edtc:j
Reasons for Visits: Complete Physical
Treatments received: Complete Physical
You did not enter date for next appointment.
About County General
ospitallClinic record #: 12345678
Doctors: Linda Robins
Visits Included: lnpatient visit. Outpatient
visit, Emergency Room visit
E(sitj
a
a
123 Main ST
Baltimore, MD 21202
lnpatient Stays:
From: January 3,2003 to: January 7,2003
Outpatient visits between February 13, 2003 and "No Date Entered"
Emergency Room visits on March 20, 2003
Reasons for Visits: Complete Physical
Treatments received: Complete Physical
You did not enter date for next appointment.
About University Hospital
9
HospitallClinic record #: 12345678
Doctors: Linda Robins
Visits Included: lnpatient visit, Outpatient
visit, Emergency Room visit
123 Main ST
Baltimore, MD 21202
lnpatient Stays:
From: January 3.2003 to: January 7,2003
&
&
Outpatient visits between February 13, 2003 and "No Date Entered"
Emergency Room visits on March 20, 2003
Reasons for Visits: Complete Physical
Treatments received: Complete Physical
You did not enter date for next appointment.
About Hospital Four
HospitalIClinic record #: 12345678
Doctors: Linda Robins
Visits Included: lnpatient visit, Outpatient
visit, Emergency Room visit
123 Main ST
Baltimore, MD 21202
Summary of Medical History
Page 5 of 11
lnpatient Stays:
From: January 3,2003 to: January 7, 2003
Outpatient visits between February 13, 2003 and "No Date Entered"
@
Emergency Room visits on March 20, 2003
Reasons for Visits: Complete Physical
Treatments received: Complete Physical
You did not enter date for next appointment.
About Hospital Five
a
HospitallClinic record #: 12345678
Doctors: Linda Robins
Visits Included: lnpatient visit, Outpatient
visit, Emergency Room visit
123 Main ST
Baltimore, MD 21202
lnpatient Stays:
From: January 3,2003 to: January 7,2003
Outpatient visits between February 13, 2003 and "No Date Entered"
Emergency Room visits on March 20, 2003
Et#HI
Reasons for Visits: Complete Physical
Treatments received: Complete Physical
You did not enter date for next appointment.
About Hospital Six
HospitallClinic record #: 12345678
Doctors: Linda Robins
Visits Included: lnpatient visit, Outpatient
visit, Emergency Room visit
&
a
123 Main ST
Baltimore, MD 21202
lnpatient Stays:
From: January 3,2003 to: January 7, 2003
Outpatient visits between February 13, 2003 and "No Date Entered"
Emergency Room visits on March 20, 2003
Reasons for Visits: Complete Physical
Treatments received: Complete Physical
You did not enter date for next appointment.
About Hospital Seven
&
HospitallClinic record #: 12345678
Doctors: Linda Robins
Visits Included: lnpatient visit, Outpatient
visit, Emergency Room visit
123 Main ST
Baltimore, MD 21202
lnpatient Stays:
From: January 3,2003 to: January 7,2003
ecRilj
Outpatient visits between February 13, 2003 and "No Date Entered"
9
Emergency Room visits on March 20,2003
Summary of Medical History
&
Reasons for Vislts. Complete Physical
Treatments received: Complete Physical
not enter date for next appointment
You d ~ d
About Hospital Eight
HospitallClinic record #: 12345678
Doctors: Linda Robins
Visits Included: lnpatient visit, Outpatient
visit, Emergency Room visit
123 Main ST
Baltimore, MD 21202
lnpatient Stays:
From: January 3,2003 to: January 7,2003
Outpatient visits between February 13, 2003 and "No Date Entered"
Emergency Room visits on March 20.2003
Reasons for Visits: Complete Physical
Treatments received: Complete Physical
You did not enter date for next appointment
About Hospital Nine
HospitallCl~n~c
record #: 12345678
Doctors: Llnda Robins
Visits Included: lnpatient visit, Outpatient
vis~t,Emergency Room visit
Edit]
123 Main ST
Baltimore, MD 21202
Inpatlent Stays:
From: January 3, 2003 to: January 7, 2003
Outpatient visits between February 13, 2003 and "No Date Entered"
Emergency Room visits on March 20, 2003
@ Reasons for Visits: Complete Physical
Treatments received: Complete Physical
You did not enter date for next appointment
About Bayview
&&j
a
HospitallClinic iecord #: 12345678
Doctors: Linda Robins
Visits Included: lnpatient visit, Outpatient
visit. Emergency Room visit
123 Main ST
Baltimore, MD 21202
lnpatient Stays:
From: January 3,2003 to: January 7, 2003
Outpatient vls~tsbetween February 13, 2003 and "No Date Entered
9 Emergency Room visits on March 20,2003
Reasons for Visits: Complete Physical
Treatments received: Complete Physical
You did not enter date for next appointment.
Summary of Medical History
About Frank Doe's Medicines
About Aspirin
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this
medication.
About Tylenol
%
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this
medication.
About lbuprofin
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this
medication.
About Alleve
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this
medication.
About Medicine Five
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this
medication.
About Medicine Six
&
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this
medication.
About Medicine Seven
a
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this
medication.
About Medicine Eight
9
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this
medication.
About Medicine Nine
Summary of Medical History
E(W1
Page 8 of 11
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this
medication.
About Medicine Ten
&
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this
medication.
About Medicine Eleven
&
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this
medication.
About Medicine Twelve
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this
medication.
About Medicine Thirteen
ENReason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this
medication.
About Medicine Fourteen
eason for medicine: Headaches
!ids effects: None
You did not indicate which doctor or medical professional prescribed this
medication.
About Medicine Fifteen
a
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this
medication.
About Frank Doe's Medical Tests
You indicated that Frank Doe has had or is scheduled to have medical tests. Select
the "Add Another Type of Test" button if you would like to add another type of
medical test that you have not told us about.
About Biopsy
i
j
$
i
t
J You did not enter a date for this test.
You did not indicate what part of Frank Doe's body was or will be covered by this
Summary of Medical History
test.
You did not indicate where this test was done or will be done.
You did not indicate who sent Frank Doe or will send Frank Doe for this test.
About Other Test 1 of 2
&
You did not enter a date for this test.
You did not indicate where this test was done or will be done.
You did not indicate who sent Frank Doe or will send Frank Doe for this test.
About Other Test 2 of 2
You did not enter a date for this test.
You did not indicate where this test was done or will be done.
You did not indicate who sent Frank Doe or will send Frank Doe for this test.
About Frank Doe's Additional Tests and Examinations
About Testing at Headstart
Newtown Headstart
You did not enter the address of this
headstart school.
Baltimore.
About Testing at Health Department
.. -
Baltimore County Health Dept
You did not enter the address of this
public or community health
department.
Baltimore.
About Testing at Child Welfare or Social Service Agency
&
E
Baltimore County Social Services
You did not enter the address of this
child welfare or social service agency.
Baltimore,
About Testing at WIC Program
Ed#
Balt~moreCounty WIC
About Testing at Special Health Care Program
You did not enter the address of this
Women, Infants and Children (WIC)
program.
Baltimore.
Summary of Medical History
a
No Child Left Behind
Page 10 of I I
You did not enter the address of this
program for children with special care
needs.
Baltimore,
About Testing at Mental Health or Mental Retardation Center
Baltimore County Assert
You did not enter the address of this
mental health or mental retardation
center.
Baltimore,
About Frank Doe's Other Medical Records
About Tutor
&
You did not enter the name of this tutoring
center
Lauren Greene
You did not enter the address of this
tutoring center.
Baltimore,
About Workers' Compensation
Mr. Smith
You did not enter the contact name for this
workers' compensation office.
You did not enter the address of this
workers' compensation ofice.
Baltimore,
About Counselor
a
You did not enter the name of this counseling
center
Ralph Doe
You did not enter the address of this
counseling center.
Baltimore,
About Detention Center
ELlitj
Baltimore County Detention Center
You did not enter the contact name for this
detention center.
You did not enter the address of this
detention center.
Baltimore,
About Insurance Company
9 State Farm
You did not enter the contact name for t h ~ s
insurance company.
You did not enter the address of this
insurance company
Baltimore,
About AttorneylLawyer
You did not enter the name of this law firm
You did not enter the address of this
Summary of Medical History
Stephen L Miles
law firm.
Baltimore,
About Medical Records at Another Place
1 Name
You did not enter the contact name for
another place.
You did not enter the address of
another place.
Baltimore.
Other Information
Other Names
Other Information
ErBfj
YOUd ~ d
not enter your he~ght.
You d ~ dnot enter your weight
You did not enter a medical assistance or Medicaid card issued by the state
Contact SSA I How to Move Around This Report
Page 1 of 1
End of Part 3
social ~ec~uity
Name: Frank Doe
SSN: 743-99-4143
Child Disability Report
Medical History: End of Part 3
You have now completed the third section of the report.
If you want to add to or change this information later, you can
select the "Medical History" tab at the top to come back to it.
If You Continue
The next section will ask you to review your answers and send
the report to Social Security.
If You Want to Stop
If you want to stop and come back to this later, you can do so at
any time by clicking "Sign Off' at the top left corner of the page.
Signing off makes sure that the information you have entered has
been saved, and protects the child's confidentiality by requiring
that you sign on again with your Reentry Number when you are
ready to continue.
If You've Done All That You Can
When you feel that you have done all you can in all parts of this
report, you should go to the Review and Send section by
selecting the review and send tab at the upper right corner.
Contact SSA I How to Move Around This Report
Review and Send: Summary
So~ial
~ec.~uit~
Online
Page I of 14
Child Disability Report
Name: Frank Doe
SSN: 743-99-4143
Review and Send: Summary for Frank Doe
If you've filled out the report to this point, you are almost done!
This is a summary of your answers. Please review and use the
Edit button to go back to pages where you want to add, correct or
change information. If any sections are not complete, please see
if you now have the information to finish them. If not, go ahead
and send us this report. We will help you complete it later. To go
back to any item in the summary, select Edit.
If you have a working printer, you may want to print a copy of this
summary for your records. You will not be able to print the entire
Child Disability Report. If you want a copy of each page, you will
need to go back through the Report and print each page using
your browser's Print function.
Note: to save space, this summary shows only the first 100
characters of the descriptions you gave us on the prior pages.
However, everything you told us will be included in this report
when you transmit it to Social Security.
Contact Information
lnformation About You
Eric Doe
Father
100 M a ~ n
Street
Balt~more,MD 21201
Someone We Can Contact Who Speaks and Understands English
&
Jane Srn~ts
100 M a ~ n
Street
Balt~more,MD 21202
Frank Doe's Custodian or Legal Guardian
8.
.
Lega.1Guardian
100 Main Street
Baltimore, MD 21201
Adult Who Lives with Frank Doe
$
k
J
Lives With
100 Main Street
Baltimore, MD 21202
Adult Who Knows about Frank Doe's Condition
w
-f J
t
Other Adult
100 M a ~ Street
n
Review and Send: Summary
Baltimore, MD 21202
About Frank Doe's Disabling Condition
List of Disabling Conditions
Injury insult
The conditions first bothered Frank Doe on
0110112000
Frank Doe's conditions have caused pain or
other symptoms.
Frank Doe's Treatments
Frank Doe has gone to a doctor, hospital or
clinic.
Frank Doe has had medical tests.
e d Frank Doe has taken prescription andlor
nonprescription medicines.
Frank Doe has received treatment for mental
or emotional problems.
About Frank Doe's Education Status
Education History
Has attended school
Current Education Status
&
a
IScurrently enrolled in school.
You did not select the current grade.
You did not select any schools.
Schools
About PreschoollDaycare at Newtown Preschool
123 Main St
Newtown Preschool
Baltimore. MD 21202
Teacher Name: Mrs Landis
&
About Midvale Headstart
EJij
Midvale Headstart
Teacher Name: Mrs Landis
123 Main St
Baltimore, MD 21202
Testing at Midvale Headstart
Has been tested for learning and behavioral problems at Midvale Headstart.
edrtj
Name: IQ testing
Date: January 2003
aji&&@#j@y#E;,>:-.g
Page 3 of 14
Review and Send: Summary
About Westmore Elementary
Westmore Elementary
Teacher Name: Mrs Landis
123 Main St
Baltimore, MD 21202
Testing at Westmore Elementary
Has been tested for learning and behavioral problems at Westmore Elementary
f&t&
Name: IQ testing
Date: January 2003
About Algonquin Summer School
J@&t
Algonquin Summer School
Teacher Name: Mrs Landis
123 Main St
Baltimore, MD 21202
Testing at Algonquin Summer School
a
Has been tested for learning and behavioral problems at Algonquin Summer School
Name IQ testing
Date January 2003
About After Five Tutoring
After Five Tutoring
Teacher Name: Mrs Land~s
123 Main St
Baltimore, MD 21202
Testing at After Five Tutoring
Has been tested for learnlng and behaworal problems at After Flve Tutorlng
Name: IQ testing
Date. January 2003
About Golden Special Education
$&
Golden Special Education
Teacher Name: Mrs Land~s
123 Main St
Baltimore, MD 21202
Testing at Golden Special Education
Has been tested for learning and behavioral problems at Golden Special Education.
&
Name: IQ testing
Date: January 2003
About Frank Doe's Vocational Rehabilitation Experience
Has had vocational rehabilitation or other employment support services to help him
or her go to work.
Vocational Rehabilitation History
Page 4 of 14
Review and Send: Summary
VOCRehab Organization
Tests and Services Received:
Reading Comprehension, January 2003
You did not enter the citylstatelzip for
this agency.
Baltimore, MD
About Frank Doe's Jobs
Has had work experience.
Job 1
E
J
S
P .,,.,
Employer Name
You did not enter the supervisor's name
From: "No Date Entered" to: "No Date
Entered"
You did not enter Frank Doe's job duties.
You did not enter Frank Doe's problems in
performing hislher job.
You did not enter the address for this
job.
Baltimore,
About Frank Doe's Doctors and Other Medical Professionals
About Dr. Jose Morra
&
Main Street Doctors Association
You dld not prov~deany reasons for Frank
Doe's vis~t.
Treatments included: Complete physical
You did not enter the address of this
doctor
Baltimore, MD 21202
About Dr. Linda Robins
( Main Street Doctors Association
You did not provide any reasons for Frank
Doe's visit.
Treatments included: Complete physical
You did not enter the address of this
doctor.
Baltimore, MD 21202
About Dr. Wayne Dwyer
lJj@
Main Street Doctors Association
You did not provide any reasons for Frank
Doe's visit.
Treatments included: Complete physical
You did not enter the address of this
doctor.
Baltimore, MD 21202
About Dr. Sue Watson
&
Ma~nStreet Doctors Assoc~ation
You did not prov~deany reasons for Frank
Doe's v~sit
Treatments included Complete phys~cal
You did not enter the address of this
doctor.
Baltimore, MD 21202
About Dr. Fifth Doctor
@
$J
Maln
. Street Doctors Association
You did not provide any reasons for Frank
Doe's v~sit
Treatments included Complete physlcal
About Dr. Sixth Doctor
You dld not enter the address of this
doctor
Balt~more,MD 21202
Review and Send: Summary
%
Main Street Doctors Association
You did not provide any reasons for Frank
Doe's visit.
Treatments included: Complete physical
About Dr. Seventh Doctor
Maln
. Street Doctors Association
You did not provide any reasons for Frank
Doe's visit.
Treatments included: Complete physical
a
Page 5 of 14
You did not enter the address of this
doctor.
Baltimore, MD 21202
You did not enter the address of this
doctor.
Baltimore. MD 21202
About Dr. Eighth Doctor
Main Street Doctors Association
You did not provide any reasons for Frank
Doe's visit.
Treatments included: Complete physical
You did not enter the address of this
doctor.
Baltimore, MD 21202
About Dr. Nineth Doctor
edll;j
Main Street Doctors Association
You did not provide any reasons for Frank
Doe's visit.
Treatments included: Complete physical
You did not enter the address of this
doctor.
Baltimore, MD 21202
About Dr. Tenth Doctor
., .
Main Street Doctors Association
You did not provide any reasons for Frank
Doe's visit.
Treatments included: Complete physical
You did not enter the address of this
doctor.
Baltimore, MD 21202
About Dr. Samuel Lang
Main Street Doctors Association
You did not provide any reasons for Frank
Doe's visit.
Treatments included: Complete physical
You did not enter the address of this
doctor.
Baltimore. MD 21202
About Dr. Jeffrey Ross
J#@ Main Street Doctors Association
You did not provide any reasons for Frank
Doe's visit.
Treatments included: Complete physical
You did not enter the address of this
doctor.
Baltimore. MD 21202
About Dr. Martha Riley
Main Street Doctors Association
You did not provide any reasons for Frank
Doe's visit.
Treatments included: Complete physical
a
About Dr. Fourteenth Doctor
M .
aln Street Doctors Association
You did not provide any reasons for Frank
Doe's visit.
You did not enter the address of this
doctor.
Baltimore, MD 21202
You did not enter the address of this
doctor.
Baltimore, MD 21202
Page 6 of 14
Review and Send: Summary
Treatments included: Complete physical
About Dr. Fifteenth Doctor
Main Street Doctors Association
You did not provide any reasons for Frank
Doe's visit.
Treatments included: Complete physical
You did not enter the address of this
doctor.
Baltimore, MD 21202
About Dr. Sixteenth Doctor
Main Street Doctors Association
You did not provide any reasons for Frank
Doe's visit.
Treatments included: Complete physical
You did not enter the address of this
doctor.
Baltimore. MD 21202
About Dr. Seventeenth Doctor
Main Street Doctors Association
You did not provide any reasons for Frank
Doe's visit.
Treatments included: Complete physical
You did not enter the address of this
doctor.
Baltimore, MD 21202
About Dr. Eighteenth Doctor
a
Main Street Doctors Association
You did not provide any reasons for Frank
Doe's visit.
Treatments included: Complete physical
You did not enter the address of this
doctor.
Baltimore, MD 21202
About Dr. Nineteenth Doctor
a
Main Street Doctors Association
You did not provide any reasons for Frank
Doe's visit.
Treatments included: Complete physical
You did not enter the address of this
doctor.
Baltimore, MD 21202
About Dr. Marcus Wellby
&
Main Street Doctors Association
You did not provide any reasons for Frank
Doe's visit.
Treatments included: Complete physical
You did not enter the address of this
doctor.
Baltimore, MD 21202
About Frank Doe's Hospitals and Clinics
About City General
9 Hosp~talIClinicrecord #. 12345678
Doctors L~ndaRob~ns
V ~ s ~Included:
ts
lnpatient vls~t,Outpatient
v ~ s ~Emergency
t,
Room visit
123 Ma~nST
Baltimore, MD 21202
fJj@ lnpatient Stays:
From: January 3,2003 to: January 7, 2003
Outpatient visits between February 13. 2003 and "No Date Entered"
Page 7 of 13
Review and Send: Summary
&
4
Emergency Room visits on March 20, 2003
Reasons for Visits: Complete Physical
Treatments received: Complete Physical
You did not enter date for next appointment.
About County General
&&j
HospitalIClinic record #: 12345678
Doctors: Linda Robins
Visits Included: lnpatient visit, Outpatient
visit, Emergency Room visit
123 Main ST
Baltimore. MD 21202
lnpatient Stays:
From: Januaty 3,2003 to: Januaty 7.2003
&
a
a
Outpatient visits between Februaty 13, 2003 and "No Date Entered"
Emergency Room visits on March 20, 2003
Reasons for Visits: Complete Physical
Treatments received: Complete Physical
You did not enter date for next appointment.
About University Hospital
4
a
&
a
HospitalIClinic record #: 12345678
Doctors: Linda Robins
Visits Included: lnpatient visit, Outpatient
visit, Emergency Room visit
123 Main ST
Baltimore, MD 21202
lnpatient Stays:
From: Januaty 3, 2003 to: Januaty 7,2003
Outpatient visits between Februaty 13, 2003 and "No Date Entered"
Emergency Room visits on March 20, 2003
Reasons for Visits: Complete Physical
Treatments received: Complete Physical
You did not enter date for next appointment.
About Hospital Four
a
&
4
HospitalIClinic record #: 12345678
Doctors: Linda Robins
Visits Included: lnpatient visit, Outpatient
visit, Emergency Room visit
lnpatient Stays:
From: Januaty 3, 2003 to: January 7,2003
Outpatient visits between February 13, 2003 and "No Date Entered"
Emergency Room visits on March 20, 2003
&
123 Main ST
Baltimore, MD 21202
Reasons for Visits: Complete Physical
Treatments received: Complete Physical
You did not enter date for next appointment.
Review and Send: Summary
Page 8 of 14
About Hospital Five
Ellit]
HospitallClinic record #: 12345678
Doctors: Linda Robins
Visits Included: lnpatient visit, Outpatient
visit, Emergency Room visit
123 Main ST
Baltimore, MD 21202
lnpatient Stays:
From: January 3,2003 to: January 7, 2003
Outpatient visits between February 13, 2003 and "No Date Entered"
&
A
Emergency Room visits on March 20, 2003
Reasons for Visits: Complete Physical
Treatments received: Complete Physical
You did not enter date for next appointment.
About Hospital Six
a
HospitallClinic record #: 12345678
Doctors: Linda Robins
Visits Included: lnpatient visit, Outpatient
visit, Emergency Room visit
123 Main ST
Baltimore, MD 21202
lnpatient Stays:
From: January 3,2003 to: January 7,2003
&
&
Outpatient visits between February 13, 2003 and "No Date Entered"
Emergency Room visits on March 20, 2003
Reasons for Visits: Complete Physical
Treatments received: Complete Physical
You did not enter date for next appointment.
About Hospital Seven
&
**
HospitallClinic record #: 12345678
Doctors: Linda Robins
Visits Included: lnpatient visit, Outpatient
visit, Emergency Room visit
123 Main ST
Baltimore, MD 21202
lnpatient Stays:
From: January 3,2003 to: January 7,2003
Outpatient visits between February 13, 2003 and "No Date Entered"
Emergency Room visits on March 20, 2003
Reasons for Visits: Complete Physical
Treatments received: Complete Physical
You did not enter date for next appointment.
About Hospital Eight
HospitalIClinic record #: 12345678
Doctors: Linda Robins
Visits Included: lnpatient visit, Outpatient
123 Main ST
Baltimore, MD 21202
Page 9 of 14
Review and Send: Summary
visit, Emergency Room visit
lnpatient Stays:
From: January 3,2003 to: January 7,2003
3 Outpatient visits between February 13, 2003 and "No Date Entered"
Emergency Room visits on March 20, 2003
Reasons for Visits: Complete Physical
Treatments received: Complete Physical
You did not enter date for next appointment.
About Hospital Nine
a
HospitallClinic record #: 12345678
Doctors: Linda Robins
Visits Included: lnpatient visit, Outpatient
visit, Emergency Room visit
123 Main ST
Baltimore, MD 21202
lnpatient Stays:
From: January 3,2003 to: January 7, 2003
9 Outpatient visits between February 13, 2003 and "No Date Entered"
Emergency Room visits on March 20, 2003
&i&j Reasons for Visits: Complete Physical
Treatments received: Complete Physical
You did not enter date for next appointment.
About Bayview
&
a
a
&
HospitallClinic record #: 12345678
Doctors: Linda Robins
Visits Included: lnpatient visit, Outpatient
visit, Emergency Room visit
123 Main ST
Baltimore, MD 21202
lnpatient Stays:
From: January 3,2003 to: January 7,2003
Outpatient visits between February 13, 2003 and "No Date Entered"
Emergency Room visits on March 20, 2003
Reasons for Visits: Complete Physical
Treatments received: Complete Physical
You did not enter date for next appointment.
About Frank Doe's Medicines
About Aspirin
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this
medicat~on
Review and Send: Summary
About Tylenol
&
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this
medication.
About lbuprofin
&
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this
medication.
About Alleve
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this
medication.
About Medicine Five
&
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this
medication.
About Medicine Six
a
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this
medication.
About Medicine Seven
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this
medication.
About Medicine Eight
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this
medication.
About Medicine Nine
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this
medication.
About Medicine Ten
Reason for medicine: Headaches
Page 10 of 14
Review and Send: Summary
Page 1 1 of 14
Side effects: None
You did not indicate which doctor or medical professional prescribed this
medication.
About Medicine Eleven
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this
medication.
About Medicine Twelve
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this
medication.
About Medicine Thirteen
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this
medication.
About Medicine Fourteen
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this
medication.
About Medicine Fifteen
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this
medication.
About Frank Doe's Medical Tests
You indicated that Frank Doe has had or is scheduled to have medical tests. Select
the "Add Another Type of Test" button if you would like to add another type of
medical test that you have not told us about.
About Biopsy
#
k
J
!
You did not enter a date for this test.
You did not indicate what part of Frank Doe's body was or will be covered by this
test.
You did not indicate where this test was done or will be done.
You did not indicate who sent Frank Doe or will send Frank Doe for this test.
About Other Test 1 of 2
Page 12 of 14
Review and Send: Summary
You did not enter a date for this test.
You did not indicate where this test was done or will be done.
You did not indicate who sent Frank Doe or will send Frank Doe for this test.
About Other Test 2 of 2
You did not enter a date for this test.
You d ~ dnot Indicate where this test was done or will be done.
You d ~ dnot indicate who sent Frank Doe or w~llsend Frank Doe for this test
About Frank Doe's Additional Tests and Examinations
About Testing at Headstart
Newtown Headstart
You did not enter the address of this
headstart school.
Baltimore,
About Testing at Health Department
Edfl
Baltimore County Health Dept
You did not enter the address of this
public or community health
department.
Baltimore.
About Testing at Child Welfare or Social Service Agency
Baltimore County Soc~alServices
You did not enter the address of thls
child welfare or social servlce agency
Baltimore,
About Testing at WIC Program
Baltimore County WlC
You did not enter the address of this
Women, Infants and Children (WIC)
program.
Baltimore,
Care Program
No Child Left Behind
e
You did not enter the address of this
program for children with special care
needs.
Baltimore,
- Review and Send: Summary
Page 13 of 14
About Testing at Mental Health or Mental Retardation Center
Editj
Baltimore County Assert
You did not enter the address of this
mental health or mental retardation
center.
Baltimore.
About Frank Doe's Other Medical Records
About Tutor
You did not enter the name of this tutoring
center
Lauren Greene
You did not enter the address of this
tutoring center.
Baltimore,
About Workers' Compensation
4
Mr. Smith
You did not enter the contact name for this
You did not enter the address of this
workers' compensation office.
Baltimore,
About Counselor
You did not enter the name of this counseling You did not enter the address of this
center
counseling center.
Ralph Doe
Baltimore,
About Detention Center
Baltimore County Detention Center
You did not enter the contact name for this
detention center.
You did not enter the address of this
detention center.
Baltimore,
About Insurance Company
#&j
State Farm
You did not enter the contact name for this
insurance company.
You did not enter the address of this
insurance company.
Baltimore,
About AttorneylLawyer
YOUdid not enter the name of this law firm
Stephen L Miles
About Medical Records at Another Place
You did not enter the address of this
law firm.
Baltimore,
Page 14 of 14
Review and Send: Summary
Jt@f
Name
You did not enter the address of
You did not enter the contact name for
another place.
another place.
Baltimore,
Other Information
Other Names
Other lnformation
a
You did not enter your height.
You did not enter your weight
You did not enter a medical assistance or Medicaid card issued by the state.
Contact SSA I How to Move Around This Report
Review and Send: Additional Remarks
Social sec~uitv
Child Disability Report
www soclalsecur~tygov
-
L
Name: Frank Doe
SSN: 743-99-4143
'
Z
Review and Send: Additional Remarks
Before you send this report, do you have any additional
comments or information about Frank Doe's illnesses, injuries or
condition(s) that you think we should know when reviewing the
case? If so, please describe them here.
Please include any doctors, hospitals, medicines, tests, schools,
etc. that you did not already tell us about. If you do not have
enough room to enter all the information you want to give us,
please write the information on a separate sheet of paper and
send it to us at the address we will give you.
Please enter any
additional
remarks:
Your answer can be
no more than 2000
characters. This is
about 40 lines or
320 words.
You
have entered 0
characters
Review and Send: Additional Remarks
Contact SSA I How to Move Around This Report
Page 2 of 2
Review and Send: Instructions for Printing the Cover Sheet
Social Sec~uity
Child Disability Report
Name: Frank Doe
SSN: 743-99-4143
Review and Send: Printer
If you have a working printer, or if you can complete this report at
a location where you can use a printer, we will tell you how to
print and send your medical release forms and a cover sheet for
them. Sending these items will allow us to start processing your
medical records sooner than if we have to mail the release forms
to you to sign.
If you do not have a working printer, continue on and submit the
report electronically. A representative from Social Security will
contact you.
Do you have a
working printer
for your
computer?
OYes
ONo
Pie*P$ge
Contact SSA I How to Move Around This Report
,
j
,
Continue
1
Review and Send: Print Coversheet
Child Disability Report
social ~ e ~ ~ u i t v
Name: Frank Doe
SSN: 743-99-4143
Review and Send: Print Coversheet
Please print and mail or bring this page to the following Social
Security office to submit medical release forms for Frank Doe
If you have problems printing this page, please try again.
If you are still unable to print this page, please write the
informat~onbelow on a separate piece of paper and then
continue. Important: Please include the name and the
Social Security number of the child.
My Name is:
Eric Doe
My address and phone number are:
100 Main Street
Baltimore, MD 21201
(410) 555-1212
I have attached the following items:
-Medical Releases - 827 (Please attach 45 copies)
-Medical Evidence
-School Records
-Other (please list below):
Mail or bring to:
SOCIAL SECURITY ADMINISTRATION
1010 Park Ave
Suite 200
Baltimore, MD 21201
(410) 962-7675
Review and Send: Print Coversheet
Contact SSA I How to Move Around Thls Report
Review and Send: Print the Medical Release Forms
Stdal .Se~~uity
Online
Child Disability Report
www.socialsecurity.gov
and Send
Name: Frank Doe
SSN: 743-99-4143
I
Review and Send: Print the Medical Release
Forms
You also need to print and sign some medical release forms. The
law requires us to have a signed authorization form to get Frank
Doe's medical records from the child's doctors or hospitals, and
from other sources that you gave us.
What you need to do next:
1. Use the link below to access the medical release forms.
The medical release form is in Portable Document Format
(PDF) and requires Adobe's Acrobat Reader to open it and
print it. If you don't have Adobe's Acrobat Reader on your
computer you can download it at
http://www.adobe.com/accessibility/index.html.
2. Print the medical release forms. You must print BOTH
sides, front and back.
3
Sign and date all of the medical release forms.
Note: These medical releases are to be signed by the
child's parent, legal guardian, or other person
authorized by State law to act for the child.
4. Mail or bring them along with the cover sheet for the Child
Disability Report to Social Security at the address we will
give you. DO NOT take these forms to the child's doctor or
school.
Here are instructions for completing the medical release
forms.
Please print 45 copies
Medical Release Forms
If you are not able to print:
Please try again. If you are not able to print the medical release
forms, continue. Contact Social Security at the address and
phone number shown on the next page.
Review and Send: Print the Medical Release Forms
Contact SSA I How lo Move Around This Report
Page 2 of 2
Review and Send: Send the Report
Social ~ u i t v
Name: Frank Doe
SSN: 743-99-4143
Child Disability Report
Review and Send: Send 'This Report
Important: After you send this report, you will not be
able to come back to it online.
You are ready to send this report electronically to Social Security
If you were not able to complete all parts of the report, don't
worry. We will contact you if we need any more information.
If you want to make changes after sending the online Child
Disability Report, you will have to contact your Social
Security office.
If you want a copy of the summary page and you have not
yet printed it, choose the "Previous Page" button to go
back to the summary before using "Send. You can then
return to this page and send the report to us.
If you are ready to submit this report, use the "Send"
button.
Contact SSA ( How to Move Around This Report
Review and Send: Confirmation
Child Disability Report
Social s e ~ ~ ~ t y
Onlil~e
www.socialsecurity.gov
Name: Frank Doe
SSN: 743-99-4143
Review and Send: Confirmation
Thank you.
We have received Frank Doe's Child Disability Report on
November 8, 2006 at 2:08PM Eastern Time.
We recommend you read this entire page then print or save it
for your records.
IMPORTANT NEXT STEPS
Frank Doe's claim for disability benefits is very important to us
We want to process Frank Doe's claim quickly and accurately.
Please help us start work on the claim as soon as possible by
taking all the following steps:
.
File a formal application for benefits. The disability
report you just completed is NOT a formal application for
benefits, but it is part of the claims process. We need a
signed, formal application for disability benefits before we
can start work on your claim.
If you have not already done so, contact us immediately.
Contact your local Social Security ofice at the address
below, or call our toll-free number 1-800-772-1213 to make
an appointment to apply for disability benefits. If you are
deaf or hard of hearing, call our toll-free "TTY" number 1800-325-0778. Representatives are available Monday
through Friday from 7 a.m. to 7 p.m.
In addition to an application you also need to:
.
Sign and date the medical releases you printed. We
need evidence from the medical sources you listed on
Frank Doe's disability report. We cannot get the evidence
we need without the medical releases.
Complete and date the cover sheet you printed for the
disability report.
.
Mail or take the cover sheet and the medical releases
to your local Social Security office. Include any medical
records you have about your condition. The address for
your local ofice is below. If you do not see an address
h~p://eis.ba.ssa.gov/appages/i3820~November06/rs007.
html
Review and Send: Confirmation
Page 2 of 2
below, use the Office Locator to find where you should send or take them.
SOClAL SECURlTY ADMlNISTRATlON
1010 Park Ave
Suite 200
Baltimore, MD 21201
(410) 962-7675
You can mail or bring these documents to a different Social Security office. You c.
the Office Locator to find another Social Security office.
Time Limit:
We cannot begin to process Frank Doe's claim until we receive the signed formal
application, and the signed medical releases. Frank Doe may lose benefits if we c
receive these papers within 60 days from when you first started completing an on1
disability report.
What to expect:
It takes about 120 days to process an application for disability payments, bi
case is different. Frank Doe's claim may take more or less time to process.
While we are processing Frank Doe's application, we may contact you for n
information or to set up an interview. We may need you to fill out additional
If we need more medical evidence, we may ask Frank Doe to see a doctor
special exam. We will pay for this exam.
If you have copies of any of Frank Doe's medical records, mail or bring ther
your local field office at the above address.
Please contact Social Security immediately if Frank Doe:
Goes to a new doctor
Has a new medical test done
Has a change in his or her condition
Changes his or her address or phone number, or if you change your addres
phone number.
For more information on the disability process, go to How the Disability Applicatio~
Process Works.
Review and Send: Survey
Srxial secluitv
Online
www.socialsecurily.gov
Child Disability Report
Home
Questions?
How to Contact Us?
Search
Name: Frank Doe
SSN: 743-99-4143
Review and Send: Survey
Thank you for using our Internet Child Disability Report. We
would like to know what you think of this service. Please take a
minute to fill out our survey below. If you do not want to fill out
the survey, you may leave this site by selecting the Finished
button below. If you would like to provide additional feedback
about this report or any of our other services, you may do so by
going to the Social Security home page and selecting the links
for compliments, suggestions and complaints.
1. H o w easy or hard w a s it for you to fill out t h e C h i l d Disability Report?
E v e r y Easy
0 Somewhat Easy
0Somewhat Hard
OVery Hard
2. If you felt the Child Disability Report was hard to fill out, please tell us why.
Select all the reasons from the list below that apply to you:
q Did not understand what information I needed to give.
OTOO
many questions to answer.
OProblems of my own (Could not find Information needed; was
interrupted).
Computer too slow.
Problems typing andlor changing information.
Problems moving from one place t o another on the report or from one
place t o another on a page.
3. Which section of the Child Disability Report was the hardest to fill o u t ?
O A b o u t the Child (Identifying information, description of the child's
medical condition)
0EducationMlork History (Education and jobs the child had)
Medical History (Doctors, hospitals, tests, medications, etc.)
4. Did you fill out the Child Disability R e p o r t because you are applying for disability
benefits for y o u r own child or someone else's child?
C3Applying for benefits for my child
( Y ) ~ p ~ lfor
~ i anchild
~
in my care, that is not my child or stepchild
Q Helping someone else
Review and Send: Survey
Page 2 of 2
5. Overall, how would you rate the Child Disability Report as an Internet Service?
h
:./Excellent
(2Very Good
G GOO^
9 Fair
0Poor
0Very Poor
A Child Filing for Yourself
Social Sec~uitv
Child Disability Report
A Child Filing for Yourself
This Internet Child Disability Report is designed for use by an
adult who is filing on behalf of a child. Please contact Social
Security to get more information about your specific situation:
Call our toll-free number, 1-800-772-1213, If you are deaf
or hard of hearing, call our toll-free "TTY number, 1-800325-0778. Representatives are available Monday through
Friday from 7 a.m. to 7 p.m.
Visit your local Social Security Office.
Change Your Answer
Child Disability Report
Social ~ e ~ ~ u i t ~
Changing the Name of This Test
You have 2 Other Test. You indicated that you would like to
change the name of these tests. Remember that this will change
all tests with this name.
This test will change from Other Test to:
O t h e r Test
If you choose No. Don't Change Answer, you will return to the
page you came from.
Does not match records
Child Disability Report
Social , ~ ~ u i t ~
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Check the Information You Entered
The information you entered does not match our records
If you typed the wrong information, you will need to correct
it before continuing.
If the information is correct, please confirm it by reentering
the same information.
To do either of the above, select the Previous Page button
below.
If you prefer, you may contact Social Security to make other
arrangements to complete a Disability Report. Be sure to tell the
representative that you tried the Internet Disability Report and
received this message.
To contact Social Security:
Call our toll-free number, 1-800-772-1213. If you are deaf
or hard of hearing, call our toll-free "TTY" number. 1-800325-0778. Representatives are available Monday through
Friday from 7 a.m. to 7 p.m.
Visit your local Social Security Office.
Check the Social Security Number You Entered
Social secl1rity
Child Disability Report
Check the Social Security Number You
Entered
Our system cannot accept an lnternet Child Disability Report on
the Social Security Number you entered: .
Please check this number:
If you typed the wrong number, you will need to correct it
before continuing.
If this is your correct Social Security number, contact
Social Security to make other arrangements to complete a
Disability Report. Be sure to tell the representative that you
tried the lnternet Disability Report and received this
message.
To contact Social Security, you can:
Call our toll-free number. 1-800-772-1213. If you are deaf
or hard of hearing, call our toll-free "TTY number, 1-800325-0778. Representatives are available Monday through
Friday from 7 a.m. to 7 p.m.
Visit your local Social Security Office.
Child Disability Report Already Received
Social .%curit\;
Online
Child Disability Report
www.socialsecurity.gov
Child Disability Report Already Received
We have already received a Child Disability Report on the Social
Security Number you entered.
If you have new information, you must contact us. We cannot
accept additional information over the Internet.
Please contact your local Social Security oftice to:
tell us about any changes in the child's condition(s) or
treatments.
report a change of address or contact information,
check on the status of your claim.
If the child's prior disability application was denied, contact Social
Security:
Call our toll-free number. 1-800-772-1213. If you are deaf
or hard of hearing, call our toll-free "TTY" number, 1-800325-0778. Representatives are available Monday through
Friday from 7 a.m. to 7 p.m.
Visit your local Social Security Office
Select the Exit button to leave this report. You will be taken to the
Social Security home page.
http:lleis.ba.ssa.gov/appagesli3820~~
November06lmsgO19. html
May Not Be Disabled
Social S x ~ u i t v
Online
Child Disability Report
Child May Not Be Disabled Under Our Rules
We consider a child under age 18 disabled under Social Security
rules if:
He or she has a medically determinable physical or mental
impairment or combination of impairments:
o that cause marked and severe functional limitations,
and
o that can be expected to cause death or has lasted or
can be expected to last for a continuous period of
not less than 12 months.
a
He or she is not working at a job and doing substantial
work.
Unlike other programs, Social Security pays only for total
disability. No benefits are payable for partial disability or for
short-term disability.
If you think the child may qualify, you should discuss your
situation with a Social Security representative as soon as
possible to avoid any possible loss of benefits:
Call our toll-free number, 1-800-772-1213. If you are deaf
or hard of hearing, call our toll-free "TTY number, 1-800325-0778. Representatives are available Monday through
Friday from 7 a.m. to 7 p.m.
Visit your local Social Security Office.
You may choose to go ahead and complete this Disability
Report.
More Information
The above explanation is written in easy to understand language.
For more details, read the official definition as written in the
Social Security Act. Using this link opens a new window. To
return to this page, close the new window.
May Not Be Disabled
Page 2 of 2
Descriptions o f Medical Tests
Child Disability Report
Social S e ~ ~ u i t ~
Descriptions of Medical Tests
SpeechlLanguage Test
This can be any of a series of tests in which a specialist
evaluates a child's speech and language.
Hearing Test
This is a test in which a specialist plays tones of varying
frequencies through earphones worn by the child; the child's
responses help the specialist identify any hearing loss.
Vision Test
This is an eye test that may require reading letters from a chart. It
may also require reading letters through a machine with
adjustable lenses, or it may check side vision with dots of light.
IQ Test
This is a test that measures intellectual functioning. The test is
made up of a series of short tasks that require either a written or
spoken response. The tasks are designed to measure a person's
ability to understand information and solve problems.
EKG (Heart Test)
In this test the patient sits, stands or lies down while wires are
placed on the skin. A machine attached to the other ends of the
wires prints out wavy lines on a chart that shows the electrical
activity of the heart.
Treadmill (Exercise Test)
This is a heart test while the patient exercises. There are
different kinds of exercise methods but the most common is the
treadmill test in which the patient has an EKG recorded as he or
she walks on a treadmill.
Cardiac Catheterization
This is a test of the blood circulation in the heart. In this test the
doctor passes a thin wire into the heart through an artery (usually
through the groin area). Wth this test a doctor can see pictures
of the inside of the heart.
Biopsy
This is a test in which the doctor removes tissue from a part of
the body to see if disease is present.
EEG (Brain Wave Test)
Page 2 of 2
Descriptions of Medical Tests
This test involves placing wires on the scalp. These wires lead to a machine that
measures and records brain wave activity. This test can detect seizure activity ant
problems in the brain.
HIV Test
This is a blood test that detects the presence of the Human ImmunodeficiencyVir
Blood Test (Not HIV)
In this test a technician draws blood, which is tested in a laboratory for abnormalit
Breathing Test
In this test the patient exhales as hard and as long as possible into a machine tha
measures the breathing capacity of the lungs.
X-Ray
This is a test in which a large machine takes pictures of parts of the body with x-r:
MRI ICT Scan
These testing methods are like x-rays but use different methods in making image!
parts of the body. Both methods show soft tissue far better than x-ray. A C T scan
called a CAT scan.
Close this window to return to the report.
Examples o f Condition Descriptions
Stxicia1Sec~uitv
Child Disability Report
Examples of Condition Descriptions
Learning disability and emotional problems. Teacher said
that he is dyslexic and doesn't seem to understand
concepts.
Cerebral palsy. Has trouble walking, uses a wheelchair
most of the time. Has difficulty speaking.
Asthma and allergies. Coughs all of the time. Needs
breathing treatments every day. Allergies include: dogs,
cats, pollen, trees, wheat, and nuts. Develops severe.
scaly rash all over his body.
ADDIHD. Can't sit still. Always talking. Poor impulse
control. Doesn't finish what she started.
Close this window to return to the report
Examples of Job Duties and Problems on the Job
srxial ,~ec.'~ui~
Online
Page 1 of 1
Child Disability Report
w.socialsecuritv.aov
Examples of Job Duties and Problems on the
Job
Examples of Job Duties
Child works at a fast food restaurant cleaning tables and
sweeping the floor. She also fills the napkin, straw
dispensers and keeps the condiments table filled and
orderly.
Child worked at the neighborhood car wash. Some days
he wiped and dried c a n as they came through the washer
Other days he vacuumed them out.
Child delivered the weekly neighborhood newspaper. He
would receive a pile of about 50 papers that he had to put
in plastic bags and then deliver in the neighborhood.
Child picked fruits and vegetables such as beans and
strawberries.
Examples of Problems on the Job
Even with detailed instructions and close supervision, she
frequently made mistakes that had to be corrected by the
manager or other employees.
Customers complained that he did not do a good job,
leaving smears on the car and obvious dirt on the carpets.
He tried delivering papers using his bike, but after a week
he started having frequent asthma attacks toward the last
half of his route and couldn't complete deliveries.
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Hours of Operation
Social ~ u i t v
Child Disability Report
Hours of Operation
This Internet Disability Report is scheduled to shut down for the
day within two hours.
The Disability Report is available during the following hours
(Eastern Time):
Monday through Friday: 5 0 0 AM - 1.00 AM
Saturday: 500 AM - 11:OO PM
Sunday: 8:00 AM - 10:OO PM
Holidays: 5:00 AM - 11:00 PM
If you choose to start the report now and the system shuts down
before you finish it, you will lose only the information on the page
you are working on at the time of the shutdown.
You may want to consider starting the report at another time to
avoid losing any information. If you decide to start this report
later, you should write down this web site so that you can return
to it: http:llwww.socialsecurity.govlchilddisabilityreport
Contact SSA I How to Move Around Thls Reporl
How the Child Disability Application Process Works
Social S e c ~ ~ r i t ~
Child Disability Report
How the Child Disability Application Process
Works
After we receive the child's disability report:
s
We review it to make sure all of the information is
complete. We may contact you for missing or unclear
information.
We will contact you to complete a formal application for
benefits, if you haven't already done one.
We send the child's forms to the State office that
determines if the child is disabled under Social Security
law.
The State office requests medical records from the
hospitals, doctors, and other treatment sources and
information from the child's teachers, schools, and other
people whom you listed as having information about the
child's illnesses, injuries or conditions.
The State office
then reviews all the information it obtains.
The State office uses a three-step process to decide if the child is
disabled under Social Security Law:
Question
I.
Is the child
working?
If Yes
If No
We need information
If the child is not
about the dates worked: working, we go to
the employer's name,
step 2.
address, and phone
number: the supervisor's
name; and job title.
We will ask if the child
gets any extra help in
doing the job, and has
any extra work expenses
because of his or her
illnesses, injuries or
conditions. If, after
considering these items.
the child's earnings
average rnore than the
allowable amount for a
given year, we will
usually find that the child
is not disabled. If we find
How the Child Disability Application Process Works
the child's earnings are
below the limit, we go to
step 2. Click here to view
the allowable monthly
amounts for this year.
2. Does the child have
a medically
determinable
impairment(s) that i s
severe?
The child must have a
medically determinable
impaimlent, and the
impairment(s) must be
severe. A severe
impairment is one that
is more than a slight
abnormality or a
combination of slight
abnormalities that
causes more than
minimal functional
limitations.
If the child has a
medically determinable
impairment(s) that is
severe, we go to step 3.
If the child does
not have a
medically
determinable
impainent(s) that
is severe, we will
find the child not
disabled.
3. Does the child's
impairment(s) meet,
medically equal, or
functionally equal the
listings?
An impairment(s)
causes "marked and
severe functional
limitations" if it meets or
medically equals the
severity of a set of
criteria for an
impairment in the
listings, or if it
functionally equals the
listings. The listing of
impairments describes
impairments that are
considered severe
enough to cause
marked and severe
functional limitations.
If the child's impairment
(s) meets or medically
equals the requirements
of a listing or functionally
equals the listings, and is
expected to last for at
least 12 months or result
in death, we will find the
child disabled.
If the child's
impairment(s)
does not meet.
medically equal.
or functionally
equal the listings
or is not expected
to last for at least
12 months or to
result in death, we
will find the child
not disabled.
Close this window to return to the report
How the Online Disability Report Works
Srdal Searib
Page 1 of 2
Child Disability Report
How the Online Disability Report Works
There are time limits for your work on each page. You will
receive a warning after 25 minutes and you can extend your
time on the page. After the third warning on a page, you
must leave this page or your time will run out, and your work
on that page will be lost. If you have turned JavaScript off in
your browser, you will not receive these warnings and, after 30
minutes on a page, your disability report session will end and
your work on the last page will be lost. To avoid this, you must go
to another page of the disability report within 30 minutes.
Important: To move backward page by page in the report,
choose Previous Page at the bottom of the page. Do not use the
Back command on your browser to move backward.
Completing and Saving the Online Disability Report:
In each section of the report you will be asked to enter
information and we will give you instructions and examples
to guide you.
At the end of each section, you will have a chance to
review your answers and add or change information.
The report does not have to be done all at once. After you
fill in your name and address, you will get a Reentry
Number. You will be able to stop working on the report
whenever you want and then use this Reentry Number to
come back to the section where you left off.
After you complete a page, some answers are protected
and cannot be changed by going back to that page. If you
need to make changes to a protected answer on a
completed page, continue with the report. You will be able
to change your answer on the summary page at the end of
the section.
When you have completed the report, you will see a
summary of the information you entered. You can make
any necessary changes and then print a copy of this
summary for your records. If you want a copy of the entire
Disability Report, you will need to print or save each page.
If you do not have enough room to enter all the information
you want to give us on the report, including the Remarks
block in the Review and Send Section, please write the
Hou the Online Disability Report Works
Page 2 of 2
information on a separate sheet of paper and send it to us at the address w
give you after you've completed this report.
ZIP Codes
Do you need to find a ZIP code for an address? Use the Zip Code Lookup. This SI
not operated by Social Security and is not within our control. It may not follow the
privacy, security, or accessibility standards as ours. We are not responsible for tht
content or availability of those sites, their partners, or advertisers.
Special Instructions for Blind Users
How to Move Around in the Disability Report:
To move forward page by page in order in the report, use the Continue butt
the bottom of the page.Do not use the Enter key to move around in the I
or to select from the drop down lists.
To move backward page by page in order in the report, use the Previous P;
button at the bottom of the page. Do NOT use the " B a c k button on your
browser to move backward.
To move from section to section in the report, use the Tabs at the top of the
Using a Tab takes you to the first page of a section. If the Tabs are not "din
you can use them to go to any section at any time.
If you are navigating using only the keyboard or using an assistive dev~cea
need help, vlsit our instructional page for alternative vlews and navigation. I
you select this link, you will leave this secure site and go to a new browser
window. You will automatically return to this page when you close the new
browser window.
Once you have reached a Summary page in a section, you may return to it
using the Return to Summary button at the bottom of a page in that section
Additional buttons, other than "Continue" and "Previous Page", may appear
bottom of a page. These buttons allow you to take an action, such as deleti
page or returning to the summary.
Additional information may appear in a pop-up window. Close this window t
return to the report.
To save or print this page, please use the Save or Print browser commands.
Close this window to return to the report.
How to Complete the Medical Release Form
Social sec~uitv
Page 1 of 2
Child Disability Report
How to Complete the Medical Release Form
1. Read and print the entire form, front and back. The
information on the back explains more about how the form
will be used and explains the possible consequences of
not signing the form. Additional instructions are also on the
form. If you have any questions, please contact us.
2. Be sure the name of the person whose records must be
disclosed (the applicant or beneficiary) is written in the
upper right corner of the form, with hislher own Social
Security Number. Social Security will till in the rest of that
block if needed.
3. Do not 611 in the large empty box in the middle of the form;
Social Security will use this space to help the source
identify the information we need.
4. Do not put a check in the empty block under "PURPOSE"
unless Social Security specifically asks you to.
5. INDIVIDUAL SIGN -Sign each form in this block
o An adult should sign his or her own form.
o An individual can sign with an " X if necessary
o If an individual has been declared legally
incompetent, his or her legal guardian or legally
recognized representative should sign the form.
o If the individual whose information is going to be
disclosed is not the one signing the form, be sure to
check the box to the right that shows that person's
authority to sign (parent, guardian, etc.) and then
give proof of that legal relationship to Social
Security. If the subject of disclosure is a minor, then
a custodial parent, guardian or other legally
recognized representative should sign the form.
12 or older but
isstill considered to be a minor under State law, he
or she should sign the form and the parent, guardian
or other legally recognized representative should
sign in the "Parenuguardian sign" area to the right.
o If the subject of the disclosure is age
How to Complete the Medical Release Form
Page 2 o f 2
6. ALWAYS enter the' DATE the form is signed.
7. Enter the address and daytime phone number of the individual signing the 1
8. WITNESS SIGN - The signature of the individual signing the forms must be
witnessed by at least one other individual. Many sources will not honor our
unless it is witnessed.
o The witness can be any competent adult (spouse, social worker, Soc
Security employee, etc.).
o The witness should sign and provide his or her address information i~
the source wants to confirm the signature.
o A second witness is usually only required if the subject of the disclos~
signs with an " X .
Close this window to return to the report.
Contact SSA I How to Move Around This Report
How to Move Around in the Child Disability Report
%cia] ~ e c ' .~ u i ~
Online
Child Disability Report
How to Move Around in the Child Disability
Report
To move forward page by page in order in the report, use
the Continue button at the bottom of the page.
IMPORTANT: DO NOT USE THE ENTER KEY TO MOVE
AROUND IN THE REPORT OR TO SELECT FROM
DROP DOWN LISTS.
To move backward page by page in order in the report,
use the Previous Page button at the bottom of the page
Do NOT use the "Back" button on your browser to
move backward.
If you are navigating using only the keyboard or using an
assistive device and need help, visit our instructional page
for alternative views and. navhation . Note: If you selectthis link, you will leave this secure site and go to a new
browser window. You will automatically return to this page
when you close the new browser window.
Once you have completed the About the Child information,
you can move from section to section in the report using
the Tabs at the top of the page. Using a Tab will take you
to the first page of a section.
Once you have reached a Summary page in a section, you
may return to it by using the Return to Summary button at
the bottom of a page in that section.
Additional buttons, other than Continue and Previous
Page, may appear at the bottom of a page. These buttons
allow you to take an action, such as deleting a page or
returning to the summary.
Additional information may appear in a pop-up window
Close this window to return to the report.
To print this page, please use the Print button at the top of your
browser.
Close this window to return to the report
Internet Security Policy
Social Sx~uity
Child Disability Report
lnternet Security Policy
Is it safe to complete a Child Disability Report over the
Internet?
SSA is taking all reasonable and proper measures, including
encryption, to ensure that your personal information is disclosed
only to you. However, the lnternet is an open system and there is
no absolute guarantee that others will not intercept the personal
information you have entered or requested and decrypted.
Although this possibility is remote, it does exist.
What is encryption?
Encryption means that all information relating to you and your
account is scrambled and locked with a mathematical key during
the electronic transfer. Most browsers have an icon such as a
key or a lock to represent an encrypted mode or session. A
broken key, open lock, or no lock indicates that the session or
mode is not encrypted.
Why is special software necessary to access the lnternet
application?
So that your online request can remain confidential, SSA uses a
security protocol (method) called Secure Sockets Layer (SSL) for
this application. You must use a Web browser that supports SSL.
Netscape Navigator and Microsoft lnternet Explorer are two
browsers that support SSL. Using this security protocol, all
information sent between your computer and our server is
encrypted before being sent on the lnternet.
Why SSL?
SSL provides a high level of security and is the security protocol
supported by more browsers than any other. It is estimated that
about 92% of Web browsers have an SSL browser available for
their use.
I have the right software and I am trying to connect
during your posted business hours, but I still cannot
access your form. Why?
We have found that a number of business, government, and
Internet Security Policy
Page 2 o f 2
educational networks do not have their firewalls configured to allow passage of sc
Web traffic. Check with your systems administrator to determine if this is the case
site. If this is the case you will not be able to access this application web site.
Close this window to return to the report.
Limit on the Number o f Tries to Start the Child Disability Report
social Sec~uiw
Online
Page 1 o f 1
Child Disability Report
www.socialsecurity.gov
Limit on the Number of Tries to Start the
Child Disability Report
You have reached the limit on the number of tries to start the
Child Disability Report.
Please contact Social Security to make other arrangements to
complete this report.
To contact Social Security:
Call our toll-free number, 1-800-772-1213. If you are deaf
or hard of hearing, call our toll-free "TTY number, 1-800325-0778. Representatives are available Monday through
Friday from 7a.m. to 7p.m.
Visit your local Social Security office
Select the exit button to leave this report. You will be taken to the
Social Security home page.
Limit the Number of New Reports Started
Social security
Online
Page 1 of 1
Child Disability Report
www.socialsecurity.qov
Limit the Number of New Reports Started
You have reached the limit on the number of requests you can
make to start a new Child Disability Report for this Social
Security Number.
To continue with the report you already started, select the
Sign-In button below. You will need your Reentry Number.
To ensure your privacy, we cannot access your Reentry
Number.
Contact Social Security to make other arrangements to
complete a Child Disability Report. Be sure to tell the
representative that you tried the Internet Child Disability
Report and received this message.
To contact Social Security:
Call our toll-free number, 1-800-772-1213. If you are deaf
or hard of hearing, call our toll-free "TTY" number, 1-800325-0778. Representatives are available Monday through
Friday from 7a.m. to 7p.m.
VISI~your local Sogal Security oftice
Select the Exit button to leave this report. You will be taken to the
Social Security home page.
Please Confirm Your Change of Answer
Social ,‘%mi&
Online
Child Disability Report
Please Confirm
You said earlier that previous statement, and you have now said
that you would like to change your answer.
To confirm, please answer the question again, below
Note: Changing your answer may delete information you have
provided about this question or require you to provide additional
information.
The question you
want to change
CYes
C3 NO
Page 1 of 1
Confirm Deletion
Social LsK~uitv
Online
Child Disability Report
www.socialsecurity.gov
Please Confirm
You chose to delete .
If you choose "Yes. Delete", you will delete this and all of the
information you entered about it.
If you choose "No, Don't Delete", you will return to the page
where you were entering this information, and you will be able to
clear or change any of the information on that page.
Are you sure you want t o delete this ?
Yes, DtWe
4
. No, QOQY Delete
i
Page I o f 1
Hospital Delete Confirmation 1
Social sea&
Child Disability Report
Please confirm
You chose to delete
If you choose "Yes, Delete", you will delete this hospital and all of
the information you entered about it. You will then continue to
pages that ask for information about the next hospital you listed,
if any.
If you choose "No, Don't Delete", you will return to the page
where you were entering hospital information, and you will be
able to clear or change any of the information on that page and
then the following page as well.
Are you sure you want to delete this?
Page 1 of 1
Hospital Delete Confirmation 2
~ o c i Security
a~
Child Disability Report
Please Confirm
You chose to delete
If you choose "Yes, Delete", you will delete this hospital and all of
the information you entered about it. You will then continue to
pages that ask for information about the next hospital you listed,
if any.
If you choose "No, Don't Delete", you will return to the page
where you were entering hospital information, and you will be
able to clear or change any of the information on that page. You
can then choose Previous Page to clear or change information
about this hospital on the previous page.
Are you sure you want to delete this?
Application Denied Less than 60 Days
socialS~L'IU~W
Online
Child Disability Report
Prior Application Denied Less than 60 Days
Ago
Since a prior application for this child was denied within the last
60 days, it may be better for you to appeal that decision rather
than start a new child disability report.
You have the right to file a new application at any time, but filing
a new application is not the same as appealing a decision. If you
disagree with the decision made on your prior application and
you file a new application instead of appealing:
the child might lose some benefits, or not qualify for any
benefits, and
we could deny the new application using the decision on
the child's prior application, if the facts and issues are the
same.
So, if you disagree with the decision made on the child's prior
application, you should file an appeal within 60 days of the date
of the denial letter.
To appeal you can:
Call our toll-free number, 1-800-772-1213. If you are deaf
or hard of hearing, call our toll-free "ll-Y"number, 1-800325-0778. Representatives are available Monday through
Friday from 7 a.m. to 7 p.m.
Visit your local Social Security Office
Select the exit button to leave this report. You will be taken to the
Social Security home page.
Application denied more than 60 days
Social Security
Page 1 of 1
Child Disability Report
Prior Application Denied More than 60 Days
Ago
There are two things you should think about before continuing:
If the child's prior application was denied more than 60
days ago:
o You will need to fill out a new child disability report
o Please give us all the information requested even if
you told us about it before. The forms you gave us
before may have been sent to permanent storage.
By giving all the information on this new report, you
can speed up the child's application.
If the denial was not appealed within 60 days and a good
reason exists for not filing an appeal within 60 days:
o It may be better for the child to file an appeal of the
denial on the prior application than to file a new
application.
o Contact Social Security as explained below. We will
ask you to sign a statement explaining why you are
late in filing the child's appeal.
To contact Social Security:
Call our toll-free number, 1-800-772-1213. If you are deaf
or hard of hearing, call our toll-free " T Y number, 1-800325-0778. Representatives are available Monday through
Friday from 7 a.m. to 7 p.m.
Visit your local Social Security Office
Sign-In Problem
Social ~ecirity
Child Disability Report
Sign-In Problem
We could not find a match for the Social Security Number and
Reentry Number you entered.
Please check the numbers and sign in again. You can retry no
more than 3 times. After 3 times your Child Disability Report will
be locked. You can start the Disability Report over again or call
us to help you file your claim. To ensure your privacy, we cannot
access your Reentry Number.
To contact Social Security:
Call our toll-free number, 1-800-772-1213. If you are deaf
or hard of hearing, call our toll-free "TTY number, 1-800325-0778. Representatives are available Monday through
Friday from 7 a.m. to 7 p.m.
Visit your local Social Security Office
Definition of Child Disability (SSI)
Child Disability Report
stddl~ ~ ~ ~ r i t \ i
Online
www.socialsecurily.gov
Social Security's Definition of Disability for
Children Applying for SSI
We consider a child disabled if:
The child has a physical or mental impairment (or
combination of impairments)
o That causes marked and severe functional
limitations;
o And has lasted or is expected to last for at least 12
consecutive months, or to result in death.
The child is not working at a job and doing substantial
work.
More Information
The above explanation is written in easy to understand language
For more details, read the official definition as written in the
Social Security Act.
Close this window to return to the report
Special Instructions for Users Who Are Blind
Social sec~uitv
Online
Child Disability Report
Special Instructions for Users Who Are Blind
The following instructions are for users with screen readers like
JAWS and Window-Eyes and Browser based readers like Home
Page Reader.
Filling out the report is best accomplished in a Forms or MSAA
mode that allows the user to tab to controls and fill in input
boxes, radio buttons, check boxes and list boxes. Instructional
text usually occurs at the beginning of screens and can be
accessed in non-MSAA or virtual cursor mode. Tab indices have
also been added to allow for tabbing through text. Additionally,
consistent headers have been set up to access questions and
examples/instructions more easily. All headers that are at the 3
level will have additional help text. Additionally, the titles of each
page are header level 1, and they will have general help
information.
There is a time limit on all pages. Unless you have turned
JavaScript off in your browser, you will receive a warning after 25
minutes on a page. The warning includes instructions for
extending your time on the page for an additional 30 minutes.
After the third warning, you must move to another page, or your
time will run out and your work on that page will be lost.
At the end of most screens there is a continue button to allow the
user to go to the next page and a Previous Page button to return
to the previous page. The hotkey ALT + C is associated with the
Continue button and ALT + P for the previous page. Press Alt +
C or ALT + P and then press Enter to move forward or back.
Close this window to return to the report.
SSI Benefits for Children with Disabilities
social ~ e r ~ u i t v
Online
Child Disability Report
SSI Benefits for Children with Disabilities
Non-Medical Rules
SSI is a program that pays monthly benefits to people with low
incomes and limited assets who are 65 or older, or blind, or
disabled. Children can qualify if they meet Social Security's
definition of disability for SSI children and if their income and
assets fall within the eligibility limits.
As its name implies, Supplemental Security Income supplements
a person's income up to a certain level. The level varies from one
state to another and can go up every year based on cost-of-living
increases. Your local Social Security office can tell you more
about the SSI benefit levels in your state.
Rules For Children Under 18
We consider the parent's income and assets when deciding if a
child under 18 qualifies for SSI. This applies to children who live
at home, or who are away at school but return home occasionally
and are subject to parental control. We refer to this process as
"deeming" of income and assets.
Filing for Benefits
Please contact your local Social Security office before completing
the Internet Disability Report to get more information about your
child's specific situation and for a full explanation of the
"deeming" process.
You should contact us right away to protect your child's rights to
benefits.
Call our toll-free number, 1-800-772-1213. If you are deaf
or hard of hearing, call our toll-free "TTY" number, 1-800325-0778. Representatives are available Monday through
Friday from 7 a.m. to 7 p.m.
Visit your local Social Security office.
If you decide to continue, we may later determine that your child
is not eligible for SSI benefits.
SSI Benefits for Children with Disabilities
Page 2 of 2
The Child does not have a Social Security Number
Social ~ec'~uitv
~,
Online
Child Disability Report
www.socialsecurity.gov
The Child Does Not Have a Social Security
Number
In order for you to complete this Report on behalf of a child, the
child must have a Social Security Number. You can read more
about Social Securii Numbers for Children.
To contact a Social Security representative:
Call our toll-free number, 1-800-772-1213. If you are deaf
or hard of hearing, call our toll-free "TTY number, 1-800325-0778. Representatives are available Monday through
Friday from 7 a.m. to 7 p.m.
Visit your local Social Security Office.
Select the exit button to leave this report. You will be taken to the
Social Security home page.
Pending report for this SSN
Social ~ e c ~ ~ r i t v
Online
<
Child Disability Report
www.socialsecurity.gov
There Is a Pending Report for the Social
Security Number
Based on the Social Security Number entered, a report has
already been started for this child.
a
If you haven't already started a Child Disability Report,
check the Social Security Number and enter it again using
the Previous Page button below.
To continue the report, select the Reentry Sign-In button
below. You will need your Reentry Number. To ensure
your privacy, we cannot access your Reentry Number.
You can start over by selecting the Start a New Report
button below. You will lose all of the information you
entered before.
Starting a new report will NOT extend the time you have to
complete and sign a formal application for Supplemental
Security Income (SSI). The child may lose benefits if we do
not receive a signed application within 60 days from when
you first started completing an online disability report.
To contact Social Security:
Call our toll-free number, 1-800-772-1213. If you are deaf
or hard of hearing, call our toll-free "TTY" number, 1-800325-0778. Representatives are available Monday through
Friday from 7 a.m. to 7 p.m.
Visit your local Social Security Office.
Age Requirement
Social Sec~uity
Child Disability Report
This Report is Only for Persons Under Age
18 Who Are Applying for SSI Disability
Payments
This report is only for persons under age 18 who are applying for
SSI disability payments. We consider any person age 18 and
over to be an adult. If you are age 18 or over, complete the Adult
Disability Report.
For more information on these programs:
See Social Security's Office of Disability web site,
Call our toll-free number, 1-800-772-1213. If you are deaf
or hard of hearing, call our toll-free "TTY" number, 1-800325-0778. Representatives are available Monday through
Friday from 7 a.m. to 7 p.m.
Visit your local Social Security Office.
Select the exit button to leave this report. You will be taken to the
Social Security home page.
Service not available
s ~ L ~ u ~Child
~
Disability Report
S O C ~ ~ ~
Online
www.socialsecurity.gov
This Service Is Not Available At This Time
Please try again during business hours.
This sewice is available during the following hours (Eastern
Time):
Monday through Friday: 5:00 AM - 1.00 AM
Saturday: 5:00 AM - 11:00 PM
Sunday: 8:00 AM - 10:OO PM
Holidays: 5:00 AM - 11:OO PM
Select the exit button to leave this report. You will be taken to the
Social Security home page.
We are processing your request
Social , ~ ~ u i t ~
Child Disability Report
We Are Processing Your Request
Please wait a moment before selecting the Continue button
We Cannot Match Your ZIP Code
Page 1 of I
Child Disability Report
Social ~ m ~ u i ~
We Cannot Match Your ZIP Code
We are unable to verify this ZIP code. Please check the number
you entered and make sure it is correct. If the Post Office
recently gave your area a new ZIP code, it may not be on our
records yet. In that case, use the prior ZIP code for your current
address.
Please contact Social Security to make other arrangements to
complete a disability report if:
this is your correct ZIP code and not a new code recently
given to your area by the Post Office, or
this is a new ZIP code recently given by the Post Office
and you don't know the prior ZIP code.
To contact Social Security:
Call our toll-free number, 1-800-772-1213. If you are deaf
or hard of hearing, call our toll-free "TTY" number, 1-800325-0778. Representatives are available Monday through
Friday from 7 a.m. to 7 p.m.
Call or visit your Social Security office. To find your local
Social Security office, close this window and use the link
given on the prior page.
TO reenter your ZIP code, close this window and type it in again
Close this window to return to the report
Message for Death and Celebrity
Social S~L'IU~Q
Child Disability Report
We Cannot Process Your Request
The information you entered does not match our records. If the
information that you provided is correct, then it may be necessary
to correct the child's Social Security record.
To resolve the discrepancy, please contact a Social Security
representative:
Call our toll-free number, 1-800-772-1213. If you are deaf
or hard of hearing, call our toll-free "TTY" number, 1-800325-0778. Representatives are available Monday through
Friday from 7 a.m. to 7 p.m.
Visit your local Social Security office
Select the Exit button to leave this report You w~llbe taken to the
Social Security home page.
Page 1 of 1
Message for Systems Failure
social~
~ u i t v
Child Disability Report
We Cannot Process Your Request at This
Time
We are sorry for the inconvenience but we cannot process your
request at this time.
If you still wish to complete the Internet Disability Report, you
may try again later.
If you want to know about other options for completing this
disability report, you may:
Call our toll-free number,l-800-772-1213. If you are deaf
or hard of hearing, call our toll-free "TTY number, 1-800325-0778. Representatives are available Monday through
Friday from 7 a.m. to 7 p.m.
Visit your local Social Security office
Select the Exit button to leave this report. You will be taken to the
Social Security home page.
Entered a new Doctor
Social seclwiw
Online
Page I of 1
Child Disability Report
www.socialsecurity.gov
You Have Entered a New Doctor. Please
Complete the Next Page.
Entered a new Hospital or Clinic
Page 1 of 1
Child Disability Report
Social ~ e c ' ~ u i ~
Online
www.socialsecurity.gov
You Have Entered a New Hospital or Clinic.
Please Complete the Next Page.
Reached limit on number o f requests
Page 1 of I
Child Disability Report
social ~ e c ~ ~ t ~
You Have Reached the Limit on the Number
of Requests to Enter the Child Disability
Report
We have not been able to match the information you entered with
our records.
To resolve the discrepancy:
Call our toll-free number, 1-800-772-1213. If you are deaf
or hard of hearing, call our toll-free " T Y " number, 1-800325-0778. Representatives are available Monday through
Friday from 7 a.m. to 7 p.m.
Visit your local Social Security office.
Select the Exit button to leave this report. You will be taken to the
Social Security home page.
Page 1 of 1
Non-US Residents
Social ~ec~uitv
Child Disability Report
You or the Child Do Not Live in the United
States
This Internet Child Disability Report cannot be used by people
who live outside of the United States or the Northern Mariana
Islands. You need to contact a Social Security representative to
make other arrangements to apply for benefits.
To contact Social Security, see our Service Around the World
web page.
Select the exit button to leave this report. You will be taken to the
Social Security home page.
-
Page 1 of 1
Your Session has Expired
Child Disability Report
Social ~ e ~ ~ r i t v
Online
Your Session Has Expired
Only the information you entered on the last page has been lost.
All of the other information you entered during this session will be
available when you return to the report.
If you would like to continue completing the Child Disability
Report, you may try again by selecting the Return to Report
button below.
Select the Exit button to leave this report. You will be taken to the
Social Security home page.
| File Type | application/pdf |
| File Modified | 2007-04-06 |
| File Created | 2007-04-06 |