Form SSA-454-BK Continuing Disability Review Report

Form Approved
OMB No. 000-0000

Social Security Administration

CONTINUING DISABILITY REVIEW REPORT - ADULT
SSA will use this form to review your medical condition(s) since the date of your last medical disability decision.
For SSA Use Only - Do not write in this box.
Selection date: MM/DD/YYYY
Claim Number: XXX-XX-2469A

WBDOC:

Exc

2

3

Date of your last medical disability decision:

MM/DD/YYYY

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

No

Continue with 1.A.

Yes

STOP!! Call the Social Security office at

410-555-2181

SECTION 1 – INFORMATION ABOUT THE DISABLED PERSON
1.A. Social Security Number, Name, and Address of Disabled Person
If your Name and Address are correct, skip to 1.C. If your Name or Address is
not correct as shown, write an "X" in this box and enter corrections below:

XXX-XX-2469
SEBASTIAN Q PETTIFOGGER
38 FOGGY BOTTOM RD
INDIANAPOLIS IN 31212-0987

▼

DRAFT

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

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

State:

City:

Zip Code:

1.C. DAYTIME PHONE NUMBER

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

Telephone Number:

(area code)

-

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

(phone number)

1.D. ALTERNATE PHONE NUMBER
Telephone Number:

(area code)

-

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

(phone number)

1.E. In the last 12 months, have you used any other names on your medical or educational
records?

SSA 454 ICR version 1 (7-7-2009)

Yes

No

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

DRAFT

Yes

No

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

Yes

No

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

Yes

No

SECTION 3 - MEDICAL RECORDS

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

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

City and State in which you saw this medical provider:

Telephone Number:

(area code)

(phone number)

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

City and State in which you saw this medical provider:

Telephone Number:

(area code)

(phone number)

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

City and State in which you saw this medical provider:

Telephone Number:

(area code)

(phone number)

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

City and State in which you saw this medical provider:

Telephone Number:

(area code)

-

DRAFT

(phone number)

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

City and State in which you saw this medical provider:

Telephone Number:

(area code)

-

(phone number)

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

Yes

No

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

Yes

No

4.A. Since MM/DD/YYYY, have you worked?

Yes

No

4.B. Since MM/DD/YYYY, have you received any education?

Yes

No

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

4.C. What year did you last attend any school? (for example 1982)
4.D. Since MM/DD/YYYY, have you received any type of specialized job,
trade or vocational training?

SSA 454 ICR version 1 (7-7-2009)

Y Y Y Y
Yes

No

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SECTION 5 - VOCATIONAL REHABILITATION, EMPLOYMENT, OR OTHER SUPPORT SERVICES
Complete this section only if you are 18 or older
5.A. Since MM/DD/YYYY , have you participated, or are you participating in:
an individual work plan with an employment network under the Ticket to Work Program;
an individualized plan for employment with a vocational rehabilitation agency or any other organization;
a Plan to Achieve Self-Support;
an individualized education program through an educational institution (if a student age18-21); or
any program providing vocational rehabilitation, employment services, or other support services to help you go to
work?
Yes

No
SECTION 6 - MEDICINES

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

Yes

No

6.B. If you answered yes, please list your medicines below. Look at your medicine containers, if necessary.
1.
2.
3.
4.

DRAFT

5.
6.
7.
8.
9.
SECTION 7 - DAILY ACTIVITIES
Use remarks section if more space is needed
7.A. Describe what you do in a typical day (for example: I get up around 7 a.m., take a shower, eat breakfast,
check emails, etc.)

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

Yes

No

Bathing

Yes

No

Caring for hair

Yes

No

Taking medicine

Yes

No

Preparing meals

Yes

No

Feeding self

Yes

No

Doing Chores
(inside/outside house)

Yes

No

Driving or using public
transportation

Yes

No

Shopping

DRAFT
Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Using arms

Yes

No

Using hands or fingers

Yes

No

Sitting

Yes

No

Seeing, hearing, or
speaking

Yes

No

Concentrating

Yes

No

Remembering

Yes

No

Understanding/following
directions

Yes

No

Completing tasks

Yes

No

Getting along with
people

Yes

No

Managing money
Walking
Standing
Lifting Objects

Please explain any "Yes" answers here. ▼

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

Always

Never

Sometimes

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

7.D. Do you have hobbies or interests?

Yes

No

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

SECTION 8 - REMARKS
Please provide any additional information you did not show in earlier parts of this form. You may also attach any medical
records, copies of prescriptions, or any other records about your medical condition(s) you have at home that you wish to
give us. When you are finished, or if you don't have anything to add, be sure to complete the information below.

DRAFT
SECTION 9 - CONTACTS

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

Daytime Telephone Number:

(area code)

Relationship to Disabled Person:

(phone number)

9.B. When was this report completed (month / day / year)?

M M

/

D D

/

Y Y Y Y

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

Daytime Telephone Number:

-

Relationship to Disabled Person:

-

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Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 223(d), and 1631(e)(1) of the Social Security Act, as amended, authorize us to collect this information. The information
you provide will be used to make a decision on the named claimant's claim. Your response is voluntary. However, failure to provide all
or part of the requested information could prevent an accurate and timely decision on the named claimant's claim.
We rarely use this information provided on this form for any other purpose other than for the reasons explained above. However, we may
use it for the administration and integrity of Social Security programs. We may also disclose information to another person or to another
agency in accordance with approved routine uses, which include but are not limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing rights to Social Security benefits and/or
coverage;
2. To comply with Federal laws requiring the release of information from Social Security records (e.g., to the Government
Accountability Office, General Services Administration, National Archives Records Administration, and the Department of
Veterans Affairs);
3. To make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and local
level;
4. To facilitate statistical research, audit, or investigative activities necessary to assure the integrity of Social Security
programs; and,
5. To contractors for the purpose of assisting SSA in the efficient administration of the Ticket to Work and Self Sufficiency
Program.

DRAFT

We may also use this information you provided in computer matching programs. Matching programs compare our records with records
kept by other Federal, State, or local government agencies. Information from these matching programs can be used to establish or verify
a person's eligibility for Federally-funded and administered benefit programs and for repayment of payments or delinquent debts under
these programs.
A complete list of routine uses for this information is available in Systems of Records Notices 60-0089 and 60-0050. These notices,
additional information regarding this form, and information regarding our programs and systems, are available on-line at www.
socialsecurity.gov or at your local Social Security Office.
The Paperwork Reduction Act
This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of
1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. We
estimate that it will take about 30 minutes to read the instructions, gather the facts, and answer the questions. We estimate that it will take
about 30 minutes for the follow up interview. SEND OR BRING THE COMPLETED REPORT TO YOUR LOCAL SOCIAL
SECURITY OFFICE, THE NEAREST U.S EMBASSY OR CONSULATE OFFICE. You can find your local Social Security
office through SSA's website at www.socialsecurity.gov. Offices are also listed under U.S. Government agencies in your telephone
directory or you may call 1-800-772-1213 (TTY 1-800-325-0778) for the address. You may send comments on our time estimate
above to: SSA, 6401 Security Boulevard, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this
address, not the completed report.
AFTER COMPLETING THIS REPORT, REMOVE THIS SHEET AND KEEP IT
FOR YOUR RECORDS

SSA 454 ICR version 1 (7-7-2009)