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pdfInformation About You
r t neCo t p i kS
Social Security Online
Child Disability Report
www.socialsecurity.gov
Name: Frank Doe
SSN: xxx-xx-4170
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)
(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:
Mother
Father
Sister
Brother
Grandparent
Aunt
Uncle
Cousin
Stepmother
Stepfather
Neighbor
Friend
Husband or Wife
Significant Other
If the relationship is "Other" (such as Social Worker, Attorney, Legal Representative), please
specify: :
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 1)
(Street Address
Line 2)
(Street Address
Line 3)
(City, State, ZIP)
Your Daytime
Phone Number:
(
)
-
Extension:
This is my phone number
I don't have a phone, but you can leave a message at this number
Your Email
Address
(Optional):
Your Language Information
Can you speak and
understand English?
Yes
No, my preferred language is
Yes
No
If you cannot speak and
understand English, we
will provide an
interpreter, free of
charge.
Can you read and
understand English?
Continue
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Someone We Can Contact Who Speaks and Understands English
r t neCo t p i kS
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Child Disability Report
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About the Child
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Education and Work
Medical History
Review and Send
Name: Frank Doe
SSN: xxx-xx-4170
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.
✔
Check if 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:
Mother
Father
Sister
Brother
Grandparent
Aunt
Uncle
Cousin
Stepmother
Stepfather
Neighbor
Friend
Husband or Wife
Significant Other
Other (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.
Someone We Can Contact Who Speaks and Understands English
Check if same as Eric Doe's address
✔
(Street Address
Line 1)
(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.
✔
(
Check if the contact's phone number is the same as Eric Doe's phone number
)
-
Extension:
✔
No phone or unknown
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Social Security Online
Child Disability Report
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Sign Off
Name: Frank Doe
SSN: xxx-xx-4170
About the Child
Education and Work
Medical History
Review and Send
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:
91745313
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.
60 Day 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. The child may
lose benefits if we do not receive a signed formal application within 60 days
from when you first started completing an online disability report for
Supplemental Security Income (SSI) for the child.
Print Your Reentry Number
To print or save this page, please use your browser's print function or the
File menu commands.
Continue
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About the Child: Information about
r t neCo t p i kS
Social Security Online
Child Disability Report
www.socialsecurity.gov
Sign Off
About the Child
Name: Frank Doe
SSN: xxx-xx-4170
Education and Work
Medical History
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)?
Yes
No
Does Frank Doe
have a
custodian or
legal guardian
other than you?
Yes
No
Is there another
adult who helps
care for Frank
Doe and can
help us get
information
about the child
if necessary?
Yes
No
Can Frank Doe
speak and
understand
English?
Yes
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.
Review and Send
About the Child: Information about
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About the Child: Custodian or Legal Guardian
r t neCo t p i kS
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Child Disability Report
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Sign Off
About the Child
Name: Frank Doe
SSN: xxx-xx-4170
Education and Work
Medical History
Review and Send
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)
Relationship to
Frank Doe:
Mother
Father
Sister
Brother
Grandparent
Aunt
Uncle
Cousin
Stepmother
Stepfather
Neighbor
Friend
Husband or Wife
Significant Other
Other (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.
✔
(Street Address
Line 1)
Check if the same as Eric Doe's address
About the Child: Custodian or Legal Guardian
(Street Address
Line 2)
(Street Address
Line 3)
(City, State, ZIP)
Daytime Phone
Number:
✔
Check if the same as Eric Doe's phone number
(
We need to be able to
contact this person
during the day.
)
-
Extension:
✔
No phone or unknown
Language Information:
Can this person
speak and
understand English?
Yes
No, she/he prefers this language
Can this person
read and
understand English?
Yes
No
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About the Child: Adult Who Lives With
r t neCo t p i kS
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Child Disability Report
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About the Child
Sign Off
Education and Work
Medical History
Review and Send
Name: Frank Doe
SSN: xxx-xx-4170
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)
Relationship to
Frank Doe:
Mother
Father
Sister
Brother
Grandparent
Aunt
Uncle
Cousin
Stepmother
Stepfather
Neighbor
Friend
Husband or Wife
Significant Other
Other (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)
(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 able to
contact this person
during the day.
(
)
-
Extension:
✔
No phone or unknown
Language
Can this person
speak and
understand English?
Yes
No, she/he prefers this language:
Can this person
read and
understand English?
Yes
No
Delete this Contact
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About the Child: Adult Who Helps Care For
r t neCo t p i kS
Social Security Online
Child Disability Report
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About the Child
Sign Off
Education and Work
Medical History
Review and Send
Name: Frank Doe
SSN: xxx-xx-4170
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
this Adult to
Frank Doe:
Mother
Father
Sister
Brother
Grandparent
Aunt
Uncle
Cousin
Stepmother
Stepfather
Neighbor
Friend
Husband or Wife
Significant Other
Other (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)
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?
Yes
No, She/he speaks these languages
Can this person
read and
understand English?
Yes
No
Delete this Contact
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About the Child: About Illnesses, Injuries, or Conditions
r t neCo t p i kS
Social Security Online
Child Disability Report
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About the Child
Sign Off
Education and Work
Medical History
Review and Send
Name: Frank Doe
SSN: xxx-xx-4170
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.
You indicated that Frank Doe has cancer. If you have not already
done so, please add the type and stage of cancer in the text area
below (for example, Lung cancer, stage 4).
Injury
insult
cancer
Count Characters
You have entered 24
characters
Examples of Condition Descriptions
Check Spelling
About the Child: About Illnesses, Injuries, or Conditions
When did Frank
Doe become
disabled?
January
January
01
01
2000
2000
Enter the closest date
you can remember.
Do any of the
above ever cause
pain or other
symptoms?
Yes
No
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About the Child: Frank Doe's Treatments
r t neCo t p i kS
Social Security Online
Child Disability Report
www.socialsecurity.gov
Sign Off
About the Child
Name: Frank Doe
SSN: xxx-xx-4170
Education and Work
Medical History
Review and Send
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 cancer
Has Frank Doe
gone to a doctor,
hospital, clinic,
or anyone else, or
are any future
visits scheduled,
for the conditions
listed above?
Yes
No
Has Frank Doe
had any medical
tests, or are any
tests scheduled
for the conditions
listed above?
Yes
No
Does Frank Doe
currently take
any prescription
or nonprescription
medicines,
(including over
the counter
medicines, or
herbal
remedies) for
the conditions
listed above?
Yes
No
About the Child: Frank Doe's Treatments
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?
Yes
No
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Summary of Information About the Child
r t neCo t p i kS
Social Security Online
Child Disability Report
www.socialsecurity.gov
About the Child
Sign Off
Name: Frank Doe
SSN: xxx-xx-4170
Education and Work
Medical History
Review and Send
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 Information
Information About You
Eric Doe
100 Main Street
Father
Baltimore, MD 21201
Someone We Can Contact Who Speaks and Understands English
Edit
Edit
Jane Smits
100 Main Street
Baltimore, MD 21202
Frank Doe's Custodian or Legal Guardian
Edit
Legal Guardian
100 Main Street
Baltimore, MD 21201
Adult Who Lives with Frank Doe
Edit
Lives With
100 Main Street
Baltimore, MD 21202
Adult Who Knows about Frank Doe's Condition
Edit
Other Adult
About Frank Doe's Disabling Condition
List of Disabling Conditions
Injury insult cancer
The conditions first bothered Frank Doe on
01/01/2000
Frank Doe's conditions have caused pain or other
symptoms.
Frank Doe's Treatments
Edit
Edit
Frank Doe has gone to a doctor, hospital or clinic.
Edit
Frank Doe has had medical tests.
Edit
Frank Doe has taken prescription and/or
nonprescription medicines.
100 Main Street
Baltimore, MD 21202
Summary of Information About the Child
Edit
Frank Doe has received treatment for mental or
emotional problems.
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About the Child: End of Part 1
r t neCo t p i kS
Social Security Online
Child Disability Report
www.socialsecurity.gov
Sign Off
Name: Frank Doe
SSN: xxx-xx-4170
About the Child
Education and Work
Medical History
Review and Send
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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Welcome
r t neCo t p i kS
Social Security Online
Child Disability Report
www.socialsecurity.gov Home
Questions?
How to Contact Us?
Search
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 Security office
the ability to work at your own pace, stopping when you want and
coming back to finish later
Start the Report
Go Back to the Report I Already Started
Applying in Person or Over the Phone
If you prefer not to do this report 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 or hard
of hearing, call our toll-free "TTY" number, 1-800-325-0778.
Representatives are available Monday 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 behalf of the child.
If you have a working printer, you may print a paper Disability Report
- Child from the Internet. This form is in Portable Document Format
(PDF) and requires Adobe Reader to open and print it. If you don't
have Adobe Reader on your computer you can download a free
Welcome
copy. Use this link to get a free copy of the Adobe Reader.
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 Security's Accessibility Policy
Privacy Policy | Website Policies & Other Important Information | Site Map
Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 223(d), and 1631 of the Social Security Act, as amended, authorize us to collect
the information on this form. Social Security will only use the information you provide to
determine if a child is eligibility for benefit payments. The Privacy Act (5 U.S.C. & 552a(b))
permits us to disclose the information you provide on this form in accordance with approved
routine uses. Giving us this information is voluntary; however, failing to complete the required
fields could prevent us from processing your request. Additional information regarding this
form, routine uses of information, and other Social Security programs, is available on our
internet website, www.socialsecurity.gov, or at your local Social Security office.
What You Will Need
r t neCo t p i kS
Social Security Online
Child Disability Report
www.socialsecurity.gov
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(s) of any medical test(s) that the child had, when and where
the test(s) was done, and who ordered it.
Name(s) of each prescription medicine(s) that the child takes and
the doctor(s) who prescribed it.
Name(s) 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 us enough information so that we can contact the child's doctors
and hospitals to get the child's medical records. It is important that you
give us the names, addresses, and dates of treatment for all the child's
doctors and hospitals. You do not have to get the medical records.
What You Will Need
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Welcome Back
r t neCo t p i kS
Social Security Online
Child Disability Report
www.socialsecurity.gov
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 "About the 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?
Back to where I left off
To the "About the Child" section
To the "Education and Work" section
To the "Medical History" section
To the "Review and Send" section
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Should You Complete This Report
r t neCo t p i kS
Social Security Online
Child Disability Report
www.socialsecurity.gov
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 Internet Report
The OMB approval number for the Internet Child Disability Report is 09600577; expiration date 09/30/2010.
Have you spoken
to a Social
Security
representative?
Yes
No
Are you a child
filing for
yourself?
Yes
No
General Information About the Child
What is the child's
name?
Suffix (if any)
Please enter the child's
first name, middle initial,
and last name
What is the child's
Social Security
number?
✔
Please enter the child's
Social Security Number
without dashes.
If the child does not
have one, you need to
get one before you can
fill out this form online.
Child does not have one yet
What is the child's
date of birth?
(Month, Day, Year)
Do you and the
Yes
No
Should You Complete This Report
child both live in
the United States or
the Northern
Mariana Islands?
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 his/her daily
activities?
Yes
Is the child's
illness, injury, or
condition expected
to last for more
than 12 months or
end in death?
Yes
Has the child
previously been
denied SSI
disability benefits?
Yes, more than 60 days ago
No
No
I am not sure
Yes, less than 60 days ago
No
Continue
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Go Ahead
r t neCo t p i kS
Social Security Online
Child Disability Report
www.socialsecurity.gov
Name: Frank Doe
SSN: xxx-xx-4170
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 we do not receive a signed formal
application within 60 days of when you first started to complete
an online disability report for Supplemental Security Income
(SSI).
Start the Report
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Sign Off
r t neCo t p i kS
Social Security Online
Child Disability Report
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: http://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 to 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
process the child's claim. This Disability Report is NOT a formal
application, but it is a required part of the claims process. After you
complete 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 we do not receive a signed formal
application within 60 days of when you first started to complete
an online disability report for Supplemental Security Income
(SSI).
Unable to Come Back?
If, for some reason, you are unable to come back to this report later, you
can use any of the following ways to complete a Child Disability Report:
Call our toll-free number, 1-800-772-1213. Explain that you are
unable to use the online Child Disability Report process and ask the
representative to mail you a paper Disability Report. If you are deaf
or hard of hearing, call our toll-free "TTY" number, 1-800-325-
Sign Off
0778. Representatives are available Monday through Friday 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 Disability Report
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How The Online Child Disability Report Works
r t neCo t p i kS
Social Security Online
Child Disability Report
www.socialsecurity.gov
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
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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 after you've completed this online Report.
General description of how to move around in the
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whatever you entered on that page. Please choose a navigation button
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Under the Paperwork Reduction Act, we are required to tell you how long
How The Online Child Disability Report Works
we think it will take you to do this Report. We estimate that it will take you
an average of 120 minutes.
Special Instructions for Blind Users
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About this Internet Form
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Social Security Online
Child Disability Report
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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:
Internet access
A personal computer with a Web browser that supports 128-bit
encryption
Adobe Reader - If you don't have Adobe Reader on your computer
you can download a free copy. Use this link to get a free copy of
Adobe Reader.
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.
§ 3507, as amended by section 2 of the Paperwork Reduction Act of 1995.
You are not required to answer these questions unless we display a valid
Office of Management and Budget control number. We estimate that it will
take you an average of 120 minutes to respond, but total time required will
depend upon the number of questions you need to answer.
You may send comments on our estimate of the time needed to complete
the Child Disability Report to: SSA, 6401 Security Boulevard, Baltimore,
MD 21235-6401. Send only comments relating to our time
estimate to this address, not the completed form.
About this Internet Form
The OMB approval number for the Internet Child Disability Report is 09600577; expiration date 9/30/2010.
Contacting Social Security by Phone
Call our toll-free number, 1-800-772-1213. If you are deaf or hard of
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Education and Work: Education and Work History Introduction
r t neCo t p i kS
Social Security Online
Child Disability Report
www.socialsecurity.gov
Sign Off
About the Child
Education and Work
Medical History
Review and Send
Name: Frank Doe
SSN: xxx-xx-4170
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
r t neCo t p i kS
Social Security Online
Child Disability Report
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Sign Off
About the Child
Education and Work
Medical History
Review and Send
Name: Frank Doe
SSN: xxx-xx-4170
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 any
school (including
daycare, preschool,
Headstart, home
school, Public,
Private or other
educational
programs)?
Yes
No
Vocational Rehabilitation
Has Frank Doe
received Vocational
Rehabilitation or
other employment
support services to
help him or her go
to work?
Yes
No
Yes
No
Work History
Has Frank Doe ever
worked (including
sheltered work)?
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Education and Work: Why Has Never Attended School
r t neCo t p i kS
Social Security Online
Child Disability Report
www.socialsecurity.gov
Sign Off
About the Child
Education and Work
Medical History
Review and Send
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.
Count Characters
You have entered 0
characters
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Education and Work: About Schools
r t neCo t p i kS
Social Security Online
Child Disability Report
www.socialsecurity.gov
Sign Off
About the Child
Education and Work
Medical History
Review and Send
Name: Frank Doe
SSN: xxx-xx-4170
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 any school?
Yes
School Names and Types
List the names of
the schools that
Frank Doe has
attended over the
last 12 months.
Include daycare,
preschool, Headstart,
kindergarten, home
school, summer school,
afterschool programs,
special education
classes and any Public,
Private or other
educational programs.
Example: George
Washington Elementary
1. School Name:
School Type:
No
Education and Work: About Schools
2. School Name:
School Type:
3. School Name:
School Type:
4. School Name:
School Type:
5. School Name:
School Type:
6. School Name:
School Type:
✔
Check here if you want to add more schools that Frank Doe has attended in the last 12 months.
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Education and Work: More About Schools
r t neCo t p i kS
Social Security Online
Child Disability Report
www.socialsecurity.gov
Sign Off
About the Child
Education and Work
Medical History
Review and Send
Name: Frank Doe
SSN: xxx-xx-4170
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 daycare,
preschool, Headstart,
kindergarten, home
school, summer school,
afterschool programs,
special education
classes and any Public,
Private or other
educational programs.
Example: George
Washington Elementary
7. School Name:
School Type:
8. School Name:
School Type:
9. School Name:
School Type:
10. School Name:
School Type:
Education and Work: More About Schools
11. School Name:
School Type:
12. School Name:
School Type:
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Education and Work: About Preschool/Daycare
r t neCo t p i kS
Social Security Online
Child Disability Report
www.socialsecurity.gov
Sign Off
Education and Work
About the Child
Name: Frank Doe
SSN: xxx-xx-4170
Medical History
Review and Send
Education and Work: About Preschool/Daycare
Please give us as much information as possible.
School Name:
Newtown 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.
1)
2)
3)
(Street Address
(Street Address
(Street Address
(City, State, ZIP)
Phone Number:
(
)
Extension:
Dates Attended:
-
Education and Work: About Preschool/Daycare
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.
From:
Examples:
06/02/2002; 06/02; June
2002; Summer 2002
To:
Delete this Preschool/Daycare
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Education and Work: About School Detail
r t neCo t p i kS
Social Security Online
Child Disability Report
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Sign Off
About the Child
Education and Work
Medical History
Review and Send
Name: Frank Doe
SSN: xxx-xx-4170
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.
1)
2)
3)
(Street Address
(Street Address
(Street Address
(City, State, ZIP)
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.
From:
Examples: 06/02/2002;
06/02; June 2002;
Summer 2002; 3rd
grade
To:
Tests and 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?
Yes
No
I don't know
If yes, name of teacher or counselor:
Has Frank Doe
received speech or
language therapy at
Golden Special
Education?
Yes
No
I 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
speech/language
testing
team evaluations
Yes
No
Education and Work: About School Detail
Delete this School
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Education and Work: Learning and Behavioral Tests at
r t neCo t p i kS
Social Security Online
Child Disability Report
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Sign Off
About the Child
Education and Work
Medical History
Review and Send
Name:
SSN:
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.
List names and
the dates of the
testing that has
taken at :
Examples:
Achievement
testing
1. Name of Test:
Date of Testing:
2. Name of Test:
Date of Testing:
Intelligence testing
Psychological
testing
Speech/language
testing
3. Name of Test:
Date of Testing:
Team evaluations
4. Name of Test:
Date of Testing:
Delete these Tests
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Education and Work: More About Education History
r t neCo t p i kS
Social Security Online
Child Disability Report
www.socialsecurity.gov
Sign Off
About the Child
Education and Work
Medical History
Review and Send
Name: Frank Doe
SSN: xxx-xx-4170
Education and Work: More About Frank Doe's Education
History
You told us earlier that Frank Doe is currently enrolled. If this is not
Change Your Answer
correct, please
What is Frank
Doe's current
grade in school?
Please check all
schools that
Frank Doe is
currently
attending:
✔
✔
✔
✔
✔
✔
Newtown Preschool
Midvale Headstart
Westmore Elementary
Algonquin Summer School
After Five Tutoring
Golden Special Education
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Education and Work: More About Education History 2?
r t neCo t p i kS
Social Security Online
Child Disability Report
www.socialsecurity.gov
Sign Off
About the Child
Education and Work
Medical History
Review and Send
Name:
SSN:
Education and Work: More About 's Education History
You told us earlier that is not currently enrolled. If this is not correct,
Change Your Answer
please
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 go
to school.
Count Characters
You have entered 0
characters
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Education and Work: About Vocational Rehabilitation
r t neCo t p i kS
Social Security Online
Child Disability Report
www.socialsecurity.gov
Sign Off
Education and Work
About the Child
Medical History
Review and Send
Name: Frank Doe
SSN: xxx-xx-4170
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.
1)
2)
3)
(Street Address
(Street Address
(Street Address
(City,State,ZIP)
Phone Number:
(
)
Extension:
File or Record
Number:
List the names
and dates of the
tests that Frank
Doe has had at
this agency.
-
Education and Work: About Vocational Rehabilitation
Examples:
Achievement
testing
Intelligence testing
Psychological
testing
Speech/language
testing
Team evaluations
1. Name of Test:
Date of Test:
2. Name of Test:
Date of Test:
3. Name of Test:
Date of Test:
4. Name of Test:
Date of Test:
Delete this Vocational Rehabilitation Facility
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Education and Work: About Work Experience
r t neCo t p i kS
Social Security Online
Child Disability Report
www.socialsecurity.gov
Sign Off
Education and Work
About the Child
Name: Frank Doe
SSN: xxx-xx-4170
Medical History
Review and Send
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:
Supervisor's
Name:
Address:
Please provide the complete address. Please do NOT use punctuation; for example, no periods or
commas.
1)
2)
3)
(Street Address
(Street Address
(Street Address
(City,State,ZIP)
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.
From:
Examples:
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.
Count Characters
Examples of job duties
You 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
information that
could pertain to
the child's
condition
Examples of problems on the job
Education and Work: About Work Experience
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.
Count Characters
You have entered 0
characters
✔
Check here if you want to add another job that Frank Doe has done in the last 12 months.
Delete this Job
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Summary of Education and Work
r t neCo t p i kS
Social Security Online
Child Disability Report
www.socialsecurity.gov
Sign Off
About the Child
Education and Work
Medical History
Review and Send
Name: Frank Doe
SSN: xxx-xx-4170
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
Edit
Is currently enrolled in school.
Edit
You did not select the current grade.
Edit
You did not select any schools.
Schools
About Preschool/Daycare at Newtown Preschool
Edit
Newtown Preschool
Teacher Name: Mrs Landis
123 Main St
Baltimore, MD 21202
Add Another Preschool/Daycare
About Midvale Headstart
Midvale Headstart
Teacher Name: Mrs Landis
Testing at Midvale Headstart
Edit
Edit
123 Main St
Baltimore, MD 21202
Has been tested for learning and behavioral problems at Midvale Headstart.
Name: IQ testing
Date: January 2003
Add Another Test
About Westmore Elementary
Westmore Elementary
Teacher Name: Mrs Landis
Testing at Westmore Elementary
Edit
123 Main St
Baltimore, MD 21202
Summary of Education and Work
Edit
Has been tested for learning and behavioral problems at Westmore Elementary.
Name: IQ testing
Date: January 2003
Add Another Test
About Algonquin Summer School
Algonquin Summer School
Teacher Name: Mrs Landis
Testing at Algonquin Summer School
Edit
Edit
123 Main St
Baltimore, MD 21202
Has been tested for learning and behavioral problems at Algonquin Summer School.
Name: IQ testing
Date: January 2003
Add Another Test
About After Five Tutoring
After Five Tutoring
Teacher Name: Mrs Landis
Testing at After Five Tutoring
Edit
Edit
123 Main St
Baltimore, MD 21202
Has been tested for learning and behavioral problems at After Five Tutoring.
Name: IQ testing
Date: January 2003
Add Another Test
About Golden Special Education
Golden Special Education
Teacher Name: Mrs Landis
Testing at Golden Special Education
Edit
Edit
123 Main St
Baltimore, MD 21202
Has been tested for learning and behavioral problems at Golden Special Education.
Name: IQ testing
Date: January 2003
Add Another Test
Add Another School
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
Tests and Services Received:
Reading Comprehension, January 2003
About Frank Doe's Jobs
Edit
You did not enter the city/state/zip for this
agency.
Baltimore, MD
Has had work experience.
Job 1
Edit
Employer Name
You did not enter the supervisor's name
You did not enter the address for this job.
Baltimore,
Summary of Education and Work
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 his/her job.
Add Another Job
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Education and Work: End of Part 2
r t neCo t p i kS
Social Security Online
Child Disability Report
www.socialsecurity.gov
Sign Off
Name: Frank Doe
SSN: xxx-xx-4170
About the Child
Education and Work
Medical History
Review and Send
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 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.
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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Overview of Pages in i3820
Overview of Pages in i3820
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Section: Entry and Exit
Welcome
About this Internet Form
What You Will Need
How The Online Child Disability Report Works
Should You Complete This Report
Go Ahead
Sign Off
Welcome Back
Section: About the Child
Information About You
Print Your Reentry Number
Someone We Can Contact Who Speaks and Understands English
Information About [Child Name]
Adult Who Lives With [Child Name] (conditional)
Custodian or Legal Guardian (conditional)
Adult Who Helps Care For [Child Name] (conditional)
About [Child Name] Illnesses, Injuries, or Conditions
Describe the Effects of [Child Name] Condition on Daily Activities
About [Child Name]: Summary
End of Part 1
Section: Education and Work
Education and Work History Introduction
About [Child Name] Education and Work History
Why [Child Name] Has Never Attended School (conditional)
About [Child Name] Schools
More About [Child Name] Schools (conditional)
About Preschool/Daycare (conditional)
About [School Name] (conditional)
Learning and Behavioral Tests at [School Name] (conditional)
More About [Child Name] Education History 1 (conditional)
More About [Child Name] Education History 2 (conditional)
About [Child Name] Vocational Rehabilition Experience (conditional)
About [Child Name] Job (conditional)
Overview of Pages in i3820
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Summary of [Child Name] Education and Work History
End of Part 2
Section: Medical History
Medical History Introduction
About [Child Name] Doctors and Other Medical Professionals (conditional)
More Doctors and Other Medical Professionals 1 (conditional)
More Doctors and Other Medical Professionals 2 (conditional)
More About [Doctor Name] (conditional)
About [Child Name] Hospitals or Clinics (conditional)
More Hospitals or Clinics (conditional)
About [Hospital Name] (conditional)
Dates of Visits to [Hospital Name] (Inpatient) (conditional)
Dates of Visits to [Hospital Name] (Outpatient) (conditional)
Dates of Visits to [Hospital Name] (Emergency Room) (conditional)
About [Child Name] Visits to [Hospital Name] (conditional)
About [Child Name] Medicines (conditional)
More of [Child Name] Medicines (conditional)
About [Medicine Name] (conditional)
About [Child Name] Medical Tests (conditional)
More About [Test Name] (conditional)
Additional Testing or Examination (conditional)
About Testing at Headstart (conditional)
About Testing at Public or Community Health Dept. (conditional)
About Testing at Child Welfare or Social Service Agency (conditional)
About Testing at Women, Infants and Children (WIC) Program (conditional)
About Testing at Program for Children with Special Health Care Needs (conditional)
About Testing at Mental Health/Mental Retardation Center (conditional)
Other Medical Records
About [Child Name] Tutor Records (conditional)
About [Child Name] Medical Records at Workers Compensation (conditional)
About [Child Name] Counselor Records (conditional)
About [Child Name] Medical Records at a Detention Center (conditional)
About [Child Name] Medical Records at an Insurance Company (conditional)
About [Child Name] Attorney/Lawyer Records (conditional)
About [Child Name] Medical Records at Another Place (conditional)
Other Information
Other Names (conditional)
Summary of [Child Name] Medical History
End of Part 3
Section: Review and Send
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Descriptions of Medical Tests
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Hours of Operation
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Medical History: Medical History Introduction
r t neCo t p i kS
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Name: Frank Doe
SSN: xxx-xx-4170
About the Child
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Medical History
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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
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Name: Frank Doe
SSN: xxx-xx-4170
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
medicine bottles for
doctors' names.
Examples: Dr. Melissa
Scott; Mr. Don Camp
1.
Dr.
Dr.
Medical History: About Doctors and Other Medical Professionals 1
2.
Dr.
Dr.
3.
Dr.
Dr.
4.
Dr.
Dr.
5.
Dr.
Dr.
6.
Dr.
Dr.
7.
Dr.
Dr.
8.
Dr.
Dr.
9.
Dr.
Dr.
10.
Dr.
Dr.
✔
Check 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
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Medical History
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Name: Frank Doe
SSN: xxx-xx-4170
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)
11.
Dr.
Dr.
12.
Dr.
Dr.
13.
Dr.
Dr.
14.
Dr.
Dr.
15.
Dr.
Dr.
16.
Dr.
Dr.
17.
Dr.
Dr.
18.
Dr.
Dr.
19.
Dr.
Dr.
20.
Dr.
Dr.
Medical History: More Doctors and Other Medical Professionals 2
✔
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Medical History: More Doctors and Other Medical Professionals 3
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Medical History
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Name: Frank Doe
SSN: xxx-xx-4170
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)
21.
Dr.
Dr.
22.
Dr.
Dr.
23.
Dr.
Dr.
24.
Dr.
Dr.
25.
Dr.
Dr.
26.
Dr.
Dr.
27.
Dr.
Dr.
28.
Dr.
Dr.
29.
Dr.
Dr.
30.
Dr.
Dr.
Medical History: More Doctors and Other Medical Professionals 3
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SSN: xxx-xx-4170
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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:
Marcus
Dr.
Dr.
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.
1)
2)
3)
(Street Address
(Street Address
(Street Address
(City, State, ZIP)
Phone Number:
(
)
Extension:
What has Frank
Doe been seeing
Dr Marcus Wellby
for?
Include as much detail
as possible. We will ask
-
More about Doctor
for more details about
medicines and tests
later.
Examples:
The child goes
regularly to get
his/her 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.
Count Characters
You have entered 0
characters
What treatments
did Frank Doe
receive from Dr
Marcus Wellby?
Examples:
The child had
physical therapy
weekly for three
months after
surgery.
The child attends
counseling
sessions three
times a week.
The child had
heat treatments
More about Doctor
and massage for
muscle spasms.
Your answer can be no
more than 1000
characters, which is
about 20 lines of typing.
Count Characters
You 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 go?
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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Name: Frank Doe
SSN: xxx-xx-4170
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.
6.
7.
Medical History: About Hospitals or Clinics
8.
9.
10.
✔
Check here if you want to add more hospitals or clinics where Frank Doe has been treated.
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Medical History: More Hospitals or Clinics
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Name: Frank Doe
SSN: xxx-xx-4170
Education and Work
Medical History
Review and Send
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?
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
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Medical History: About Hospital
r t neCo t p i kS
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About the Child
Name: Frank Doe
SSN: xxx-xx-4170
Education and Work
Medical History
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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(s) 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.
1)
2)
3)
(Street Address
(Street Address
(Street Address
(City, State, ZIP)
Phone Number:
We need a phone
number in case we need
to call this hospital or
clinic.
Hospital/Clinic
Record#:
(if known)
(
)
Extension:
-
Medical History: About Hospital
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.
Count Characters
You have entered 0
characters
What type of visits did Frank Doe have at this hospital or clinic?
Inpatient Stay:
Yes
No
Yes
No
Yes
No
Stayed over at least one
night.
Outpatient Stay or
Appointment:
Went home the same
day.
Emergency Room
(ER):
Went to ER and then
went home.
Medical History: About Hospital
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Name: Frank Doe
SSN: xxx-xx-4170
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
Next most recent
overnight stay at
Bayview
Third most recent
overnight stay at
Bayview
From:
To:
From:
To:
From:
To:
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Name: Frank Doe
SSN: xxx-xx-4170
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 Doe 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 of Emergency Room Visits to Hospital
r t neCo t p i kS
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Name: Frank Doe
SSN: xxx-xx-4170
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): 11/17/03,
11/3/03, 10/7/03
Your answer can be no
more than 60
characters.
Count Characters
You have entered 0
characters
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Name: Frank Doe
SSN: xxx-xx-4170
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:
From January 3, 2003 to January 7, 2003
From to
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(s) 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 the
reason for each
visit to Bayview.
Examples:
Had 30 outpatient
visits between
March 2004 and
the present for his
cancer.
Needed monthly
blood transfusions
as outpatient
every month for
the past year.
Had surgery on
Medical History: About Visits to Hospital
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.
Count Characters
You 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 on
March 29, 2003.
Chemotherapy at
the Oncology
Clinic weekly
since Jan. 2003.
Needed 30
stitches on Sept.
14, 2002.
Count Characters
You have entered 0
characters
Medical History: About Visits to Hospital
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.
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Medical History: About Medicines
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SSN: xxx-xx-4170
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Medical History
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Medical History: About Frank Doe's Medicines
Please list all prescription and non-prescription (over-the-counter)
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-thecounter
medicines does
Frank Doe
currently take?
1.
2.
3.
4.
Copy the name directly
from the medicine
container, if you have it.
Examples:
5.
6.
Ritalin
7.
Albuterol
8.
Insulin
Aspirin
9.
Tylenol
10.
Melatonin
11.
12.
13.
14.
15.
✔
Check here to add more medicines for Frank Doe
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Name: Frank Doe
SSN: xxx-xx-4170
Medical History: More of Frank Doe's Medicines
Please list all prescription and non-prescription (over-the-counter)
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-thecounter
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.
23.
24.
25.
26.
27.
Medical History: More Medicines
28.
29.
30.
If Frank Doe has more medicines than this, please include them in the remarks section at the end
of this report.
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Medical History: About Medicine
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SSN: xxx-xx-4170
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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:
What doctor, if
any, told you to
take this
medicine?
(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 he can
behave in school.
To regulate her
blood sugar.
To stop the pain.
Medicine Fifteen
Other: (Title, First Name, Last Name)
Dr.
Dr.
Medical History: About Medicine
Count Characters
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.
Count Characters
You have entered 0
characters
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Name: Frank Doe
SSN: xxx-xx-4170
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.
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
Are there any
other tests Frank
Doe had or will
have?
Speech/Language Test
Hearing Test
Vision Test
IQ Test
EKG (heart test)
Treadmill (exercise test)
Cardiac Catheterization
Biopsy
EEG (brain wave test)
HIV test
Blood test (not HIV)
Breathing test
X-Ray
MRI/CT Scan
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Medical History: About Medical Tests
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SSN: xxx-xx-4170
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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)
Change the Test Name
When was or will
this test be
done?
If you cannot give us the
exact date, be as
specific as possible.
Examples: 10/30/2002,
October 2002, fall 2002
Where was or
where will it be
done?
✔
Unknown
(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
Doe for this test?
If the doctor's name is
not in the list, enter it in
the space provided
below the list.
Other: (Title, First Name, Last Name)
Dr.
Dr.
✔
Unknown
✔
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Medical History: More About Test
Medical History: Additional Testing or Examination
r t neCo t p i kS
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About the Child
Education and Work
Medical History
Review and Send
Name: Frank Doe
SSN: xxx-xx-4170
Medical History: Additional Sources of Testing or
Examination
Has Frank Doe been tested or examined by any of the following?
Headstart (Title V)
Yes
No
I don't know
Public or
Community Health
Department
Yes
No
I don't know
Child Welfare or
Social Service
Agency or WIC
Yes
No
I don't know
Early Intervention
Services
Yes
No
I don't know
Program for
Children with
Special Health Care
Needs
Yes
No
I don't know
Mental
Health/Mental
Retardation Center
Yes
No
I don't know
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Medical History: About Testing at Headstart
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About the Child
Education and Work
Medical History
Review and Send
Name: Frank Doe
SSN: xxx-xx-4170
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"
1)
2)
3)
(Street Address
(Street Address
(Street Address
(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 specific
dates, be as specific as possible.
Examples: 06/02/2002; 06/02; June 2002; Summer 2002.
Test 1:
Test type:
Date:
Examples: vision test,
hearing test, motor skills
test
Test 2:
Test type:
Date:
Test 3:
Test type:
Date:
Test 4:
Test type:
Date:
✔
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Medical History: About Testing at Public/Community Health Dept.
r t neCo t p i kS
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About the Child
Education and Work
Medical History
Review and Send
Name: Frank Doe
SSN: xxx-xx-4170
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 find 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"
1)
2)
3)
(Street Address
(Street Address
(Street Address
(City, State, ZIP)
Phone Number:
(
)
Extension:
File or Record
-
Medical History: About Testing at Public/Community Health Dept.
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:
Test type:
Date:
Examples: vision test,
hearing test, motor skills
test
Test 2:
Test type:
Date:
Test 3:
Test type:
Date:
Test 4:
Test type:
Date:
Check 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 Welfare/Social Service Agency
r t neCo t p i kS
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About the Child
Education and Work
Medical History
Review and Send
Name: Frank Doe
SSN: xxx-xx-4170
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"
1)
2)
3)
(Street Address
(Street Address
(Street Address
(City, State, ZIP)
Phone Number:
(
)
Extension:
File or Record
Number:
-
Medical History: About Testing at Child Welfare/Social 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:
Test type:
Date:
Examples: vision test,
hearing test, motor skills
test
Test 2:
Test type:
Date:
Test 3:
Test type:
Date:
Test 4:
Test type:
Date:
Check here 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
r t neCo t p i kS
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Medical History
Review and Send
Name: Frank Doe
SSN: xxx-xx-4170
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 of 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"
1)
2)
3)
(Street Address
(Street Address
(Street Address
(City, State, ZIP)
Phone Number:
(
)
Extension:
File or Record
-
Medical History: About Frank Doe's Testing at a Women, Infant, Children Program
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:
Test type:
Date:
Examples: vision test,
hearing test, motor skills
test
Test 2:
Test type:
Date:
Test 3:
Test type:
Date:
Test 4:
Test type:
Date:
✔
Check here if you want to add another WIC Program where Frank Doe was tested.
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Medical History: About Testing at Special Health Care Needs
r t neCo t p i kS
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About the Child
Education and Work
Medical History
Review and Send
Name: Frank Doe
SSN: xxx-xx-4170
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 help us find other medical
records.
Name of
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"
1)
2)
3)
(Street Address
(Street Address
(Street Address
(City, State, ZIP)
Phone Number:
(
)
Extension:
File or Record
-
Medical History: About Testing at Special Health Care Needs
Number:
Tests at 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:
Test type:
Date:
Examples: vision test,
hearing test, motor skills
test
Test 2:
Test type:
Date:
Test 3:
Test type:
Date:
Test 4:
Test type:
Date:
Check here if you want to add another Program for Children with Special Health Care Needs
where Frank Doe was tested.
✔
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Medical History: About Frank Doe's Testing at a Mental Health or Mental Retardation Center
r t neCo t p i kS
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About the Child
Education and Work
Medical History
Review and Send
Name: Frank Doe
SSN: xxx-xx-4170
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 find 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 punctuation; for example, no periods or commas.
Example: "On Main St next to the Courthouse"
1)
2)
3)
(Street Address
(Street Address
(Street Address
(City, State, ZIP)
Phone Number:
(
)
Extension:
-
Medical History: About Frank Doe's Testing at a Mental Health or Mental Retardation Center
File or Record
Number:
Tests at 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:
Test type:
Date:
Examples: vision test,
hearing test, motor skills
test
Test 2:
Test type:
Date:
Test 3:
Test type:
Date:
Test 4:
Test type:
Date:
Check here if you want to add another Mental Health or Mental Retardation Center where Frank
Doe was tested.
✔
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Medical History: Other Medical Records
r t neCo t p i kS
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About the Child
Name: Frank Doe
SSN: xxx-xx-4170
Education and Work
Medical History
Review and Send
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.
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?
Yes
No
Does anyone else
have medical
records or
information about
Frank Doe’s
illnesses, injuries
or conditions
(foster parents,
social workers,
counselors,
tutors, school
nurses, detention
centers,
attorneys,
insurance
companies,
and/or worker’s
compensation),
or is scheduled to
see anyone else?
Yes
No
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About Medical Records at Another Place
r t neCo t p i kS
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Child Disability Report
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About the Child
Education and Work
Medical History
Review and Send
Name: Frank Doe
SSN: xxx-xx-4170
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 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"
1)
2)
3)
(Street Address
(Street Address
(Street Address
(City, State, ZIP)
Phone Number:
(
)
Extension:
When did the
child first go?
If you cannot remember
the exact dates, be as
specific as possible.
-
About Medical Records at Another Place
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.
Count Characters
You have entered 0
characters
✔
Check here if you want to add another place that has records for Frank Doe
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Other Information
r t neCo t p i kS
Social Security Online
Child Disability Report
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About the Child
Name: Frank Doe
SSN: xxx-xx-4170
Education and Work
Medical History
Review and Send
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?
Yes
No
Examples: birth name,
adopted name,
nickname
Does Frank Doe
have a medical
assistance or
Medicaid card
issued by the
state?
Yes
No
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
What is Frank Doe's
weight without
shoes?
Pounds
Inches
Ounces
Other Information
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Other Names
r t neCo t p i kS
Social Security Online
Child Disability Report
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Sign Off
Name: Frank Doe
SSN: xxx-xx-4170
About the Child
Education and Work
Medical History
Review and Send
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
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Summary of Medical History
r t neCo t p i kS
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Child Disability Report
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About the Child
Name: Frank Doe
SSN: xxx-xx-4170
Education and Work
Medical History
Review and Send
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, everything you
told us will be included in this report when you transmit it to Social Security.
About Frank Doe's Doctors and Other Medical Professionals
About Dr. Jose Morra
Main Street Doctors Association
You did not provide any reasons for Frank Doe's
visit.
Treatments included: Complete physical
About Dr. Linda Robins
You did not enter the address of this doctor.
Baltimore, MD 21202
Main Street Doctors Association
You did not provide any reasons for Frank Doe's
visit.
Treatments included: Complete physical
About Dr. Wayne Dwyer
You did not enter the address of this doctor.
Baltimore, MD 21202
Main Street Doctors Association
You did not provide any reasons for Frank Doe's
visit.
Treatments included: Complete physical
About Dr. Sue Watson
You did not enter the address of this doctor.
Baltimore, MD 21202
Main Street Doctors Association
You did not provide any reasons for Frank Doe's
visit.
Treatments included: Complete physical
About Dr. Fifth Doctor
You did not enter the address of this doctor.
Baltimore, MD 21202
Main Street Doctors Association
You did not provide any reasons for Frank Doe's
visit.
Treatments included: Complete physical
About Dr. Sixth Doctor
You did not enter the address of this doctor.
Baltimore, MD 21202
Edit
Edit
Edit
Edit
Edit
Summary of Medical History
Main Street Doctors Association
You did not provide any reasons for Frank Doe's
visit.
Treatments included: Complete physical
About Dr. Seventh Doctor
You did not enter the address of this doctor.
Baltimore, MD 21202
Main Street Doctors Association
You did not provide any reasons for Frank Doe's
visit.
Treatments included: Complete physical
About Dr. Eighth Doctor
You did not enter the address of this doctor.
Baltimore, MD 21202
Main Street Doctors Association
You did not provide any reasons for Frank Doe's
visit.
Treatments included: Complete physical
About Dr. Nineth Doctor
You did not enter the address of this doctor.
Baltimore, MD 21202
Main Street Doctors Association
You did not provide any reasons for Frank Doe's
visit.
Treatments included: Complete physical
About Dr. Tenth Doctor
You did not enter the address of this doctor.
Baltimore, MD 21202
Main Street Doctors Association
You did not provide any reasons for Frank Doe's
visit.
Treatments included: Complete physical
About Dr. Samuel Lang
You did not enter the address of this doctor.
Baltimore, MD 21202
Main Street Doctors Association
You did not provide any reasons for Frank Doe's
visit.
Treatments included: Complete physical
About Dr. Jeffrey Ross
You did not enter the address of this doctor.
Baltimore, MD 21202
Main Street Doctors Association
You did not provide any reasons for Frank Doe's
visit.
Treatments included: Complete physical
About Dr. Martha Riley
You did not enter the address of this doctor.
Baltimore, MD 21202
Main Street Doctors Association
You did not provide any reasons for Frank Doe's
visit.
Treatments included: Complete physical
About Dr. Fourteenth Doctor
You did not enter the address of this doctor.
Baltimore, MD 21202
Main Street Doctors Association
You did not provide any reasons for Frank Doe's
visit.
Treatments included: Complete physical
About Dr. Fifteenth Doctor
You did not enter the address of this doctor.
Baltimore, MD 21202
Edit
Edit
Edit
Edit
Edit
Edit
Edit
Edit
Edit
Summary of Medical History
Main Street Doctors Association
You did not provide any reasons for Frank Doe's
visit.
Treatments included: Complete physical
About Dr. Sixteenth Doctor
You did not enter the address of this doctor.
Baltimore, MD 21202
Main Street Doctors Association
You did not provide any reasons for Frank Doe's
visit.
Treatments included: Complete physical
About Dr. Seventeenth Doctor
You did not enter the address of this doctor.
Baltimore, MD 21202
Main Street Doctors Association
You did not provide any reasons for Frank Doe's
visit.
Treatments included: Complete physical
About Dr. Eighteenth Doctor
You did not enter the address of this doctor.
Baltimore, MD 21202
Main Street Doctors Association
You did not provide any reasons for Frank Doe's
visit.
Treatments included: Complete physical
About Dr. Nineteenth Doctor
You did not enter the address of this doctor.
Baltimore, MD 21202
Main Street Doctors Association
You did not provide any reasons for Frank Doe's
visit.
Treatments included: Complete physical
About Dr. Marcus Wellby
You did not enter the address of this doctor.
Baltimore, MD 21202
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
Edit
Edit
Edit
Edit
Edit
Edit
Add Another Doctor
About Frank Doe's Hospitals and Clinics
About City General
Edit
123 Main ST
Hospital/Clinic record #: 12345678
Baltimore, MD 21202
Doctors: Linda Robins
Visits Included: Inpatient visit, Outpatient visit,
Emergency Room visit
Inpatient Stays:
From: January 3, 2003 to: January 7, 2003
Outpatient visits between "No Date Entered" and February 13, 2003
Edit
Emergency Room visits on March 20, 2003
Edit
Edit
Reasons for Visits: Complete Physical
Treatments received: Complete Physical
You did not enter date for next appointment.
About County General
Edit
Hospital/Clinic record #: 12345678
123 Main ST
Summary of Medical History
Edit
Edit
Baltimore, MD 21202
Doctors: Linda Robins
Visits Included: Inpatient visit, Outpatient visit,
Emergency Room visit
Inpatient Stays:
From: January 3, 2003 to: January 7, 2003
Outpatient visits between "No Date Entered" and February 13, 2003
Edit
Emergency Room visits on March 20, 2003
Edit
Reasons for Visits: Complete Physical
Treatments received: Complete Physical
You did not enter date for next appointment.
About University Hospital
Edit
Edit
123 Main ST
Hospital/Clinic record #: 12345678
Baltimore, MD 21202
Doctors: Linda Robins
Visits Included: Inpatient visit, Outpatient visit,
Emergency Room visit
Inpatient Stays:
From: January 3, 2003 to: January 7, 2003
Outpatient visits between "No Date Entered" and February 13, 2003
Edit
Emergency Room visits on March 20, 2003
Edit
Edit
Reasons for Visits: Complete Physical
Treatments received: Complete Physical
You did not enter date for next appointment.
About Hospital Four
Edit
Edit
123 Main ST
Hospital/Clinic record #: 12345678
Baltimore, MD 21202
Doctors: Linda Robins
Visits Included: Inpatient visit, Outpatient visit,
Emergency Room visit
Inpatient Stays:
From: January 3, 2003 to: January 7, 2003
Outpatient visits between "No Date Entered" and February 13, 2003
Edit
Emergency Room visits on March 20, 2003
Edit
Edit
Reasons for Visits: Complete Physical
Treatments received: Complete Physical
You did not enter date for next appointment.
About Hospital Five
Edit
Edit
Edit
Edit
123 Main ST
Hospital/Clinic record #: 12345678
Baltimore, MD 21202
Doctors: Linda Robins
Visits Included: Inpatient visit, Outpatient visit,
Emergency Room visit
Inpatient Stays:
From: January 3, 2003 to: January 7, 2003
Outpatient visits between "No Date Entered" and February 13, 2003
Summary of Medical History
Edit
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
Edit
Edit
123 Main ST
Hospital/Clinic record #: 12345678
Baltimore, MD 21202
Doctors: Linda Robins
Visits Included: Inpatient visit, Outpatient visit,
Emergency Room visit
Inpatient Stays:
From: January 3, 2003 to: January 7, 2003
Outpatient visits between "No Date Entered" and February 13, 2003
Edit
Emergency Room visits on March 20, 2003
Edit
Edit
Reasons for Visits: Complete Physical
Treatments received: Complete Physical
You did not enter date for next appointment.
About Hospital Seven
Edit
Edit
123 Main ST
Hospital/Clinic record #: 12345678
Baltimore, MD 21202
Doctors: Linda Robins
Visits Included: Inpatient visit, Outpatient visit,
Emergency Room visit
Inpatient Stays:
From: January 3, 2003 to: January 7, 2003
Outpatient visits between "No Date Entered" and February 13, 2003
Edit
Emergency Room visits on March 20, 2003
Edit
Edit
Reasons for Visits: Complete Physical
Treatments received: Complete Physical
You did not enter date for next appointment.
About Hospital Eight
Edit
Edit
123 Main ST
Hospital/Clinic record #: 12345678
Baltimore, MD 21202
Doctors: Linda Robins
Visits Included: Inpatient visit, Outpatient visit,
Emergency Room visit
Inpatient Stays:
From: January 3, 2003 to: January 7, 2003
Outpatient visits between "No Date Entered" and February 13, 2003
Edit
Emergency Room visits on March 20, 2003
Edit
Edit
Reasons for Visits: Complete Physical
Treatments received: Complete Physical
You did not enter date for next appointment.
About Hospital Nine
Edit
Hospital/Clinic record #: 12345678
123 Main ST
Summary of Medical History
Edit
Edit
Baltimore, MD 21202
Doctors: Linda Robins
Visits Included: Inpatient visit, Outpatient visit,
Emergency Room visit
Inpatient Stays:
From: January 3, 2003 to: January 7, 2003
Outpatient visits between "No Date Entered" and February 13, 2003
Edit
Emergency Room visits on March 20, 2003
Edit
Reasons for Visits: Complete Physical
Treatments received: Complete Physical
You did not enter date for next appointment.
About Bayview
Edit
Edit
123 Main ST
Hospital/Clinic record #: 12345678
Baltimore, MD 21202
Doctors: Linda Robins
Visits Included: Inpatient visit, Outpatient visit,
Emergency Room visit
Inpatient Stays:
From: January 3, 2003 to: January 7, 2003
Outpatient visits between "No Date Entered" and February 13, 2003
Edit
Emergency Room visits on March 20, 2003
Edit
Edit
Edit
Reasons for Visits: Complete Physical
Treatments received: Complete Physical
You did not enter date for next appointment.
Add Another Hospital/Clinic
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
Edit
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this medication.
About Ibuprofin
Edit
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this medication.
About Alleve
Edit
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this medication.
About Medicine Five
Edit
Edit
Reason for medicine: Headaches
Summary of Medical History
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
Edit
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this medication.
About Medicine Eight
Edit
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this medication.
About Medicine Nine
Edit
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this medication.
About Medicine Ten
Edit
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this medication.
About Medicine Eleven
Edit
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this medication.
About Medicine Twelve
Edit
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this medication.
About Medicine Thirteen
Edit
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this medication.
About Medicine Fourteen
Edit
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this medication.
About Medicine Fifteen
Edit
Edit
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this medication.
Add Another Medicine
About Frank Doe's Medical Tests
Summary of Medical History
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
Edit
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.
Add Another Biopsy
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
Edit
Edit
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.
Add Another Other Test
Add Another Type of Test
About Frank Doe's Additional Tests and Examinations
About Testing at Headstart
Edit
Newtown Headstart
You did not enter the address of this
headstart school.
Baltimore,
Add Another Headstart School
About Testing at Health Department
Edit
Baltimore County Health Dept
You did not enter the address of this public
or community health department.
Baltimore,
Add Another Department
About Testing at Child Welfare or Social Service Agency
Edit
Baltimore County Social Services
You did not enter the address of this child
welfare or social service agency.
Baltimore,
Add Another Agency
About Testing at WIC Program
Edit
Baltimore County WIC
Add Another Program (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
Edit
No Child Left Behind
You did not enter the address of this
program for children with special care
needs.
Baltimore,
Add Another Program (Special Health Care)
About Testing at Mental Health or Mental Retardation Center
Edit
Baltimore County Assert
Add Another Center
You did not enter the address of this mental
health or mental retardation center.
Baltimore,
About Frank Doe's Other Medical Records
About Tutor
Edit
You did not enter the name of this tutoring center
Lauren Greene
You did not enter the address of this
tutoring center.
Baltimore,
Add Another Tutor
About Workers' Compensation
Edit
Mr. Smith
You did not enter the contact name for this workers'
compensation office.
You did not enter the address of this
workers' compensation office.
Baltimore,
Add Another Workers' Compensation
About Counselor
Edit
You did not enter the name of this counseling center
Ralph Doe
You did not enter the address of this
counseling center.
Baltimore,
Add Another Counselor
About Detention Center
Edit
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,
Add Another Detention Center
About Insurance Company
Edit
State Farm
You did not enter the contact name for this insurance
company.
You did not enter the address of this
insurance company.
Baltimore,
Add Another Insurance Company
About Attorney/Lawyer
Edit
You did not enter the name of this law firm
Stephen L Miles
Add Another Attorney
You did not enter the address of this law
firm.
Baltimore,
Summary of Medical History
Edit
Add Another Place
Add Another Name
Edit
Previous Page
Continue
End of Part 3
r t neCo t p i kS
Social Security Online
Child Disability Report
www.socialsecurity.gov
Sign Off
Name: Frank Doe
SSN: xxx-xx-4170
About the Child
Education and Work
Medical History
Review and Send
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.
Return to Summary
Contact SSA | How to Move Around This Report
Previous Page
Continue
Definition of Child Disability (SSI)
r t neCo t p i kS
Social Security Online
Child Disability Report
www.socialsecurity.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)
That causes marked and severe functional limitations;
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.
How the Child Disability Application Process Works
r t neCo t p i kS
Social Security Online
Child Disability Report
www.socialsecurity.gov
How the Child Disability Application Process Works
After we receive the child's disability report:
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
1. Is the child
working?
If Yes
We need information about the
dates worked; the employer's
name, address, and phone
number; the supervisor's name;
and job title.
If No
If the child is
not working,
we go to step
2.
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 more
than the allowable amount for a
given year, we will usually find
that the child is not disabled. If we
find 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
If the child has a medically
If the child
determinable impairment(s) that is does not have
severe, we go to step 3.
a medically
How the Child Disability Application Process Works
.
Internet Security Policy
r t neCo t p i kS
Social Security Online
Child Disability Report
www.socialsecurity.gov
Internet 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 Internet 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
Internet 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 Internet 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 Internet.
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 educational
networks do not have their firewalls configured to allow passage of secure
Web traffic. Check with your systems administrator to determine if this is
the case at your 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.
Age Requirement
r t neCo t p i kS
Social Security Online
Child Disability Report
www.socialsecurity.gov
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, 1-800-325-0778.
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.
Exit
A Child Filing for Yourself
r t neCo t p i kS
Social Security Online
Child Disability Report
www.socialsecurity.gov
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, 1-800-325-0778.
Representatives are available Monday through Friday from 7 a.m. to
7 p.m.
Visit your local Social Security Office.
Previous Page
Non-US Residents
r t neCo t p i kS
Social Security Online
Child Disability Report
www.socialsecurity.gov
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.
Exit
Does not match records
r t neCo t p i kS
Social Security Online
Child Disability Report
www.socialsecurity.gov
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, 1-800-325-0778.
Representatives are available Monday through Friday from 7 a.m. to
7 p.m.
Visit your local Social Security Office.
Previous Page
May Not Be Disabled
r t neCo t p i kS
Social Security Online
Child Disability Report
www.socialsecurity.gov
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:
that cause marked and severe functional limitations, and
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.
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, 1-800-325-0778.
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.
Previous Page
Continue with Report
Application Denied Less than 60 Days
r t neCo t p i kS
Social Security Online
Child Disability Report
www.socialsecurity.gov
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 "TTY" number, 1-800-325-0778.
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.
Previous Page
Exit
Application denied more than 60 days
r t neCo t p i kS
Social Security Online
Child Disability Report
www.socialsecurity.gov
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:
You will need to fill out a new child disability report.
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:
It may be better for the child to file an appeal of the denial on
the prior application than to file a new application.
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 "TTY" number, 1-800-325-0778.
Representatives are available Monday through Friday from 7 a.m. to
7 p.m.
Visit your local Social Security Office.
Previous Page
Continue with Report
Check the Social Security Number You Entered
r t neCo t p i kS
Social Security Online
Child Disability Report
www.socialsecurity.gov
Check the Social Security Number You Entered
Our system cannot accept an Internet 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 Internet 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, 1-800-325-0778.
Representatives are available Monday through Friday from 7 a.m. to
7 p.m.
Visit your local Social Security Office.
Previous Page
Exit
Sign-In Problem
r t neCo t p i kS
Social Security Online
Child Disability Report
www.socialsecurity.gov
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, 1-800-325-0778.
Representatives are available Monday through Friday from 7 a.m. to
7 p.m.
Visit your local Social Security Office.
Start a New Report
Reentry Sign-In
Pending report for this SSN
r t neCo t p i kS
Social Security 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.
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, 1-800-325-0778.
Representatives are available Monday through Friday from 7 a.m. to
7 p.m.
Visit your local Social Security Office.
Previous Page
Reentry Sign-In
Start a New Report
Child Disability Report Already Received
r t neCo t p i kS
Social Security 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 office 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, 1-800-325-0778.
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.
Exit
SSI Benefits for Children with Disabilities
r t neCo t p i kS
Social Security Online
Child Disability Report
www.socialsecurity.gov
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, 1-800-325-0778.
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.
Previous Page
Continue
The Child does not have a Social Security Number
r t neCo t p i kS
Social Security 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 Security
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, 1-800-325-0778.
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.
Previous Page
Exit
How to Move Around in the Child Disability Report
r t neCo t p i kS
Social Security Online
Child Disability Report
www.socialsecurity.gov
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 navigation . Note: If 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 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.
How the Online Disability Report Works
r t neCo t p i kS
Social Security Online
Child Disability Report
www.socialsecurity.gov
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 information on a separate sheet
of paper and send it to us at the address we will give you after
you've completed this report.
ZIP Codes
How the Online Disability Report Works
Do you need to find a ZIP code for an address? Use the Zip Code Lookup.
This site is not operated by Social Security and is not within our control. It
may not follow the same privacy, security, or accessibility standards as
ours. We are not responsible for the 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 button at the bottom of the page.Do not use the Enter
key to move around in the report or to select from the
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.
To move from section to section in the report, use the Tabs at the
top of the page. Using a Tab takes you to the first page of a section.
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Contact SSA | How to Move Around This Report
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Examples of Condition Descriptions
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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.
ADD/HD. Can't sit still. Always talking. Poor impulse control. Doesn't
finish what she started.
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Descriptions of Medical Tests
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Descriptions of Medical Tests
Speech/Language 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). With 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)
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 and other problems in the brain.
HIV Test
This is a blood test that detects the presence of the Human
Immunodeficiency Virus.
Descriptions of Medical Tests
Blood Test (Not HIV)
In this test a technician draws blood, which is tested in a laboratory for
abnormalities.
Breathing Test
In this test the patient exhales as hard and as long as possible into a
machine that 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-rays.
MRI / CT Scan
These testing methods are like x-rays but use different methods in making
images of the parts of the body. Both methods show soft tissue far better
than x-ray. A CT scan is also called a CAT scan.
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Examples of Job Duties and Problems on the Job
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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 cars 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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How to Complete the Medical Release Form
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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 his/her own Social Security Number.
3. Do not fill 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.
An adult should sign his/her own form.
An individual can sign with an "X" if necessary.
If an individual has been declared legally incompetent, his/her
legal guardian or legally recognized representative should sign
the form.
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
How to Complete the Medical Release Form
representative should sign the form.
If the subject of the disclosure is age 12 or older but is still
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 "Parent/guardian
sign" area to the right.
6. ALWAYS enter the DATE the form is signed.
7. Enter the address and daytime phone number of the individual
signing the form.
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 request unless it is witnessed.
The witness can be any competent adult (spouse, social
worker, Social Security employee, etc.).
The witness should sign and provide his or her address
information in case the source wants to confirm the signature.
A second witness is usually only required if the subject of the
disclosure signs with an "X".
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Review and Send: Summary
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Child Disability Report
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Sign Off
About the Child
Name: Frank Doe
SSN: xxx-xx-4170
Education and Work
Medical History
Review and Send
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
Information About You
Eric Doe
100 Main Street
Father
Baltimore, MD 21201
Someone We Can Contact Who Speaks and Understands English
Edit
Edit
Jane Smits
100 Main Street
Baltimore, MD 21202
Frank Doe's Custodian or Legal Guardian
Edit
Legal Guardian
100 Main Street
Baltimore, MD 21201
Adult Who Lives with Frank Doe
Edit
Lives With
100 Main Street
Baltimore, MD 21202
Adult Who Knows about Frank Doe's Condition
Edit
Other Adult
About Frank Doe's Disabling Condition
List of Disabling Conditions
Edit
Injury insult cancer
The conditions first bothered Frank Doe on
01/01/2000
Frank Doe's conditions have caused pain or other
100 Main Street
Baltimore, MD 21202
Review and Send: Summary
symptoms.
Frank Doe's Treatments
Edit
Frank Doe has gone to a doctor, hospital or clinic.
Edit
Frank Doe has had medical tests.
Edit
Edit
Frank Doe has taken prescription and/or
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
Edit
Is currently enrolled in school.
Edit
You did not select the current grade.
Edit
You did not select any schools.
Schools
About Preschool/Daycare at Newtown Preschool
Edit
Newtown Preschool
Teacher Name: Mrs Landis
123 Main St
Baltimore, MD 21202
Add Another Preschool/Daycare
About Midvale Headstart
Midvale Headstart
Teacher Name: Mrs Landis
Testing at Midvale Headstart
Edit
Edit
123 Main St
Baltimore, MD 21202
Has been tested for learning and behavioral problems at Midvale Headstart.
Name: IQ testing
Date: January 2003
Add Another Test
About Westmore Elementary
Westmore Elementary
Teacher Name: Mrs Landis
Testing at Westmore Elementary
Edit
Edit
123 Main St
Baltimore, MD 21202
Has been tested for learning and behavioral problems at Westmore Elementary.
Name: IQ testing
Date: January 2003
Add Another Test
About Algonquin Summer School
Algonquin Summer School
Teacher Name: Mrs Landis
Testing at Algonquin Summer School
Edit
123 Main St
Baltimore, MD 21202
Review and Send: Summary
Edit
Has been tested for learning and behavioral problems at Algonquin Summer School.
Name: IQ testing
Date: January 2003
Add Another Test
About After Five Tutoring
After Five Tutoring
Teacher Name: Mrs Landis
Testing at After Five Tutoring
Edit
Edit
123 Main St
Baltimore, MD 21202
Has been tested for learning and behavioral problems at After Five Tutoring.
Name: IQ testing
Date: January 2003
Add Another Test
About Golden Special Education
Golden Special Education
Teacher Name: Mrs Landis
Testing at Golden Special Education
Edit
Edit
123 Main St
Baltimore, MD 21202
Has been tested for learning and behavioral problems at Golden Special Education.
Name: IQ testing
Date: January 2003
Add Another Test
Add Another School
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
Tests and Services Received:
Reading Comprehension, January 2003
About Frank Doe's Jobs
Edit
You did not enter the city/state/zip for this
agency.
Baltimore, MD
Has had work experience.
Job 1
Edit
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 his/her job.
Add Another Job
You did not enter the address for this job.
Baltimore,
About Frank Doe's Doctors and Other Medical Professionals
About Dr. Jose Morra
Edit
Main Street Doctors Association
You did not provide any reasons for Frank Doe's
You did not enter the address of this doctor.
Baltimore, MD 21202
Review and Send: Summary
visit.
Treatments included: Complete physical
About Dr. Linda Robins
Main Street Doctors Association
You did not provide any reasons for Frank Doe's
visit.
Treatments included: Complete physical
About Dr. Wayne Dwyer
You did not enter the address of this doctor.
Baltimore, MD 21202
Main Street Doctors Association
You did not provide any reasons for Frank Doe's
visit.
Treatments included: Complete physical
About Dr. Sue Watson
You did not enter the address of this doctor.
Baltimore, MD 21202
Main Street Doctors Association
You did not provide any reasons for Frank Doe's
visit.
Treatments included: Complete physical
About Dr. Fifth Doctor
You did not enter the address of this doctor.
Baltimore, MD 21202
Main Street Doctors Association
You did not provide any reasons for Frank Doe's
visit.
Treatments included: Complete physical
About Dr. Sixth Doctor
You did not enter the address of this doctor.
Baltimore, MD 21202
Main Street Doctors Association
You did not provide any reasons for Frank Doe's
visit.
Treatments included: Complete physical
About Dr. Seventh Doctor
You did not enter the address of this doctor.
Baltimore, MD 21202
Main Street Doctors Association
You did not provide any reasons for Frank Doe's
visit.
Treatments included: Complete physical
About Dr. Eighth Doctor
You did not enter the address of this doctor.
Baltimore, MD 21202
Main Street Doctors Association
You did not provide any reasons for Frank Doe's
visit.
Treatments included: Complete physical
About Dr. Nineth Doctor
You did not enter the address of this doctor.
Baltimore, MD 21202
Main Street Doctors Association
You did not provide any reasons for Frank Doe's
visit.
Treatments included: Complete physical
About Dr. Tenth Doctor
You did not enter the address of this doctor.
Baltimore, MD 21202
Main 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
Edit
Edit
Edit
Edit
Edit
Edit
Edit
Edit
Edit
Review and Send: Summary
Treatments included: Complete physical
About Dr. Samuel Lang
Main Street Doctors Association
You did not provide any reasons for Frank Doe's
visit.
Treatments included: Complete physical
About Dr. Jeffrey Ross
You did not enter the address of this doctor.
Baltimore, MD 21202
Main Street Doctors Association
You did not provide any reasons for Frank Doe's
visit.
Treatments included: Complete physical
About Dr. Martha Riley
You did not enter the address of this doctor.
Baltimore, MD 21202
Main Street Doctors Association
You did not provide any reasons for Frank Doe's
visit.
Treatments included: Complete physical
About Dr. Fourteenth Doctor
You did not enter the address of this doctor.
Baltimore, MD 21202
Main Street Doctors Association
You did not provide any reasons for Frank Doe's
visit.
Treatments included: Complete physical
About Dr. Fifteenth Doctor
You did not enter the address of this doctor.
Baltimore, MD 21202
Main Street Doctors Association
You did not provide any reasons for Frank Doe's
visit.
Treatments included: Complete physical
About Dr. Sixteenth Doctor
You did not enter the address of this doctor.
Baltimore, MD 21202
Main Street Doctors Association
You did not provide any reasons for Frank Doe's
visit.
Treatments included: Complete physical
About Dr. Seventeenth Doctor
You did not enter the address of this doctor.
Baltimore, MD 21202
Main Street Doctors Association
You did not provide any reasons for Frank Doe's
visit.
Treatments included: Complete physical
About Dr. Eighteenth Doctor
You did not enter the address of this doctor.
Baltimore, MD 21202
Main Street Doctors Association
You did not provide any reasons for Frank Doe's
visit.
Treatments included: Complete physical
About Dr. Nineteenth Doctor
You did not enter the address of this doctor.
Baltimore, MD 21202
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
Edit
Edit
Edit
Edit
Edit
Edit
Edit
Edit
Edit
Review and Send: Summary
About Dr. Marcus Wellby
Edit
Main Street Doctors Association
You did not provide any reasons for Frank Doe's
visit.
Treatments included: Complete physical
Add Another Doctor
You did not enter the address of this doctor.
Baltimore, MD 21202
About Frank Doe's Hospitals and Clinics
About City General
Edit
123 Main ST
Hospital/Clinic record #: 12345678
Baltimore, MD 21202
Doctors: Linda Robins
Visits Included: Inpatient visit, Outpatient visit,
Emergency Room visit
Inpatient Stays:
From: January 3, 2003 to: January 7, 2003
Outpatient visits between "No Date Entered" and February 13, 2003
Edit
Emergency Room visits on March 20, 2003
Edit
Edit
Reasons for Visits: Complete Physical
Treatments received: Complete Physical
You did not enter date for next appointment.
About County General
Edit
Edit
123 Main ST
Hospital/Clinic record #: 12345678
Baltimore, MD 21202
Doctors: Linda Robins
Visits Included: Inpatient visit, Outpatient visit,
Emergency Room visit
Inpatient Stays:
From: January 3, 2003 to: January 7, 2003
Outpatient visits between "No Date Entered" and February 13, 2003
Edit
Emergency Room visits on March 20, 2003
Edit
Edit
Reasons for Visits: Complete Physical
Treatments received: Complete Physical
You did not enter date for next appointment.
About University Hospital
Edit
Edit
123 Main ST
Hospital/Clinic record #: 12345678
Baltimore, MD 21202
Doctors: Linda Robins
Visits Included: Inpatient visit, Outpatient visit,
Emergency Room visit
Inpatient Stays:
From: January 3, 2003 to: January 7, 2003
Outpatient visits between "No Date Entered" and February 13, 2003
Edit
Emergency Room visits on March 20, 2003
Edit
Reasons for Visits: Complete Physical
Treatments received: Complete Physical
Edit
Edit
Review and Send: Summary
You did not enter date for next appointment.
About Hospital Four
Edit
123 Main ST
Hospital/Clinic record #: 12345678
Baltimore, MD 21202
Doctors: Linda Robins
Visits Included: Inpatient visit, Outpatient visit,
Emergency Room visit
Inpatient Stays:
From: January 3, 2003 to: January 7, 2003
Outpatient visits between "No Date Entered" and February 13, 2003
Edit
Emergency Room visits on March 20, 2003
Edit
Edit
Reasons for Visits: Complete Physical
Treatments received: Complete Physical
You did not enter date for next appointment.
About Hospital Five
Edit
Edit
123 Main ST
Hospital/Clinic record #: 12345678
Baltimore, MD 21202
Doctors: Linda Robins
Visits Included: Inpatient visit, Outpatient visit,
Emergency Room visit
Inpatient Stays:
From: January 3, 2003 to: January 7, 2003
Outpatient visits between "No Date Entered" and February 13, 2003
Edit
Emergency Room visits on March 20, 2003
Edit
Edit
Reasons for Visits: Complete Physical
Treatments received: Complete Physical
You did not enter date for next appointment.
About Hospital Six
Edit
Edit
123 Main ST
Hospital/Clinic record #: 12345678
Baltimore, MD 21202
Doctors: Linda Robins
Visits Included: Inpatient visit, Outpatient visit,
Emergency Room visit
Inpatient Stays:
From: January 3, 2003 to: January 7, 2003
Outpatient visits between "No Date Entered" and February 13, 2003
Edit
Emergency Room visits on March 20, 2003
Edit
Edit
Reasons for Visits: Complete Physical
Treatments received: Complete Physical
You did not enter date for next appointment.
About Hospital Seven
Edit
Edit
Hospital/Clinic record #: 12345678
Doctors: Linda Robins
Visits Included: Inpatient visit, Outpatient visit,
Emergency Room visit
Inpatient Stays:
123 Main ST
Baltimore, MD 21202
Review and Send: Summary
Edit
Edit
From: January 3, 2003 to: January 7, 2003
Outpatient visits between "No Date Entered" and February 13, 2003
Edit
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
Edit
Edit
123 Main ST
Hospital/Clinic record #: 12345678
Baltimore, MD 21202
Doctors: Linda Robins
Visits Included: Inpatient visit, Outpatient visit,
Emergency Room visit
Inpatient Stays:
From: January 3, 2003 to: January 7, 2003
Outpatient visits between "No Date Entered" and February 13, 2003
Edit
Emergency Room visits on March 20, 2003
Edit
Edit
Reasons for Visits: Complete Physical
Treatments received: Complete Physical
You did not enter date for next appointment.
About Hospital Nine
Edit
Edit
123 Main ST
Hospital/Clinic record #: 12345678
Baltimore, MD 21202
Doctors: Linda Robins
Visits Included: Inpatient visit, Outpatient visit,
Emergency Room visit
Inpatient Stays:
From: January 3, 2003 to: January 7, 2003
Outpatient visits between "No Date Entered" and February 13, 2003
Edit
Emergency Room visits on March 20, 2003
Edit
Edit
Reasons for Visits: Complete Physical
Treatments received: Complete Physical
You did not enter date for next appointment.
About Bayview
Edit
Edit
123 Main ST
Hospital/Clinic record #: 12345678
Baltimore, MD 21202
Doctors: Linda Robins
Visits Included: Inpatient visit, Outpatient visit,
Emergency Room visit
Inpatient Stays:
From: January 3, 2003 to: January 7, 2003
Outpatient visits between "No Date Entered" and February 13, 2003
Edit
Emergency Room visits on March 20, 2003
Edit
Reasons for Visits: Complete Physical
Treatments received: Complete Physical
Edit
Edit
Review and Send: Summary
You did not enter date for next appointment.
Add Another Hospital/Clinic
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
Edit
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this medication.
About Ibuprofin
Edit
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this medication.
About Alleve
Edit
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this medication.
About Medicine Five
Edit
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this medication.
About Medicine Six
Edit
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this medication.
About Medicine Seven
Edit
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this medication.
About Medicine Eight
Edit
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this medication.
About Medicine Nine
Edit
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this medication.
About Medicine Ten
Edit
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this medication.
About Medicine Eleven
Edit
Review and Send: Summary
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this medication.
About Medicine Twelve
Edit
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this medication.
About Medicine Thirteen
Edit
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this medication.
About Medicine Fourteen
Edit
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this medication.
About Medicine Fifteen
Edit
Edit
Reason for medicine: Headaches
Side effects: None
You did not indicate which doctor or medical professional prescribed this medication.
Add Another Medicine
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
Edit
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.
Add Another Biopsy
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
Edit
Edit
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.
Add Another Other Test
Add Another Type of Test
About Frank Doe's Additional Tests and Examinations
About Testing at Headstart
Edit
Newtown Headstart
You did not enter the address of this
headstart school.
Review and Send: Summary
Baltimore,
Add Another Headstart School
About Testing at Health Department
Edit
Baltimore County Health Dept
You did not enter the address of this public
or community health department.
Baltimore,
Add Another Department
About Testing at Child Welfare or Social Service Agency
Edit
Baltimore County Social Services
You did not enter the address of this child
welfare or social service agency.
Baltimore,
Add Another Agency
About Testing at WIC Program
Edit
Baltimore County WIC
You did not enter the address of this
Women, Infants and Children (WIC)
program.
Baltimore,
Add Another Program (WIC)
About Testing at Special Health Care Program
Edit
No Child Left Behind
You did not enter the address of this
program for children with special care
needs.
Baltimore,
Add Another Program (Special Health Care)
About Testing at Mental Health or Mental Retardation Center
Edit
Baltimore County Assert
Add Another Center
You did not enter the address of this mental
health or mental retardation center.
Baltimore,
About Frank Doe's Other Medical Records
About Tutor
Edit
You did not enter the name of this tutoring center
Lauren Greene
You did not enter the address of this
tutoring center.
Baltimore,
Add Another Tutor
About Workers' Compensation
Edit
Mr. Smith
You did not enter the contact name for this workers'
compensation office.
Add Another Workers' Compensation
About Counselor
You did not enter the address of this
workers' compensation office.
Baltimore,
Review and Send: Summary
Edit
You did not enter the name of this counseling center
Ralph Doe
You did not enter the address of this
counseling center.
Baltimore,
Add Another Counselor
About Detention Center
Edit
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,
Add Another Detention Center
About Insurance Company
Edit
State Farm
You did not enter the contact name for this insurance
company.
You did not enter the address of this
insurance company.
Baltimore,
Add Another Insurance Company
About Attorney/Lawyer
Edit
You did not enter the name of this law firm
Stephen L Miles
You did not enter the address of this law
firm.
Baltimore,
Add Another Attorney
About Medical Records at Another Place
Edit
Name
You did not enter the contact name for another
place.
Add Another Place
You did not enter the address of another
place.
Baltimore,
Other Information
Other Names
Add Another Name
Other Information
Edit
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.
Previous Page
Contact SSA | How to Move Around This Report
Continue
Review and Send: Additional Remarks
r t neCo t p i kS
Social Security Online
Child Disability Report
www.socialsecurity.gov
Sign Off
Name: Frank Doe
SSN: xxx-xx-4170
About the Child
Education and Work
Medical History
Review and Send
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.
Count Characters
You have entered 0
characters
Review and Send: Additional Remarks
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Continue
Review and Send: Send the Report
r t neCo t p i kS
Social Security Online
Child Disability Report
www.socialsecurity.gov
Sign Off
Name: Frank Doe
SSN: xxx-xx-4170
About the Child
Education and Work
Medical History
Review and Send
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.
Previous Page
Contact SSA | How to Move Around This Report
Send
Review and Send: Instructions for Printing the Cover Sheet
r t neCo t p i kS
Social Security Online
Child Disability Report
www.socialsecurity.gov
Name: Frank Doe
SSN: xxx-xx-4170
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?
Yes
No
Previous Page
Contact SSA | How to Move Around This Report
Continue
Review and Send: Print Coversheet
r t neCo t p i kS
Social Security Online
Child Disability Report
www.socialsecurity.gov
Sign Off
Name: Frank Doe
SSN: xxx-xx-4170
About the Child
Education and Work
Medical History
Review and Send
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 information
below 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 Release - 827 (Please sign and date)
___ Medical Evidence
___ School Records
___ Other (please list below):
Mail or bring to:
SOCIAL SECURITY ADMINISTRATION
1010 Park Ave
Suite 200
Baltimore, MD 21201
(866) 931-9942
Review and Send: Print Coversheet
Previous Page
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Continue
Review and Send: Print the Medical Release Form
r t neCo t p i kS
Social Security Online
Child Disability Report
www.socialsecurity.gov
Sign Off
About the Child
Education and Work
Medical History
Review and Send
Name: Frank Doe
SSN: xxx-xx-4170
Review and Send: Print the Medical Release Form
You also need to print and sign a medical release form SSA-827
Authorization to Release Information to SSA. 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:
1. Use the link below to access the medical release form. The medical
release form is in Portable Document Format (PDF) and requires
Adobe Reader to open and print it. If you don't have Adobe Reader
on your computer you can download a free copy. Use this link to get
a free copy of the Adobe Reader .
2. Print the medical release form. You must print BOTH
sides, front and back.
3. Sign and date the medical release form.
Note: This medical release must 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 the signed and dated medical release form along with
the cover sheet for the Child Disability Report to Social Security at
the address we will give you. DO NOT take any forms to the child’s
doctors or schools.
5. 5. If you already have copies of medical records from the child’s
doctor, you can send or bring them to us. However, we do not
recommend that you delay the case by requesting medical records
yourself. We can do this for you.
Here are instructions for completing the medical release
form.
Please print one copy
Authorization to Disclose Information to SSA
If you have printing problems:
Please try again. If you are still unable to print the form, please continue.
Contact Social Security at the address and phone number we will give you
later to tell us that you could not print the medical release form.
Review and Send: Print the Medical Release Form
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Continue
Review and Send: Confirmation
r t neCo t p i kS
Social Security Online
Child Disability Report
www.socialsecurity.gov
Name: Frank Doe
SSN: xxx-xx-4170
Review and Send: Confirmation
Thank you.
We have received Frank Doe's Child Disability Report on April 7, 2009 at
8:22AM 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 office 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 1-800-325-0778. 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
office is below. If you do not see an address below, use the Office
Locator to find where you should send or take them.
SOCIAL SECURITY ADMINISTRATION
1010 Park Ave
Suite 200
Baltimore, MD 21201
Review and Send: Confirmation
(866) 931-9942
You can mail or bring these documents to a different Social Security office.
You can use 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 do not receive these papers within 60 days from when you
first started completing an online disability report.
What to expect:
It takes about 120 days to process an application for disability
payments, but every 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 more information or to set up an interview. We may need you
to fill out additional forms.
If we need more medical evidence, we may ask Frank Doe to see a
doctor for a special exam. We will pay for this exam.
If you have copies of any of Frank Doe's medical records, mail or
bring them to 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
address or phone number.
For more information on the disability process, go to How the Disability
Application Process Works.
Continue
Contact SSA | How to Move Around This Report
Review and Send: Survey
r t neCo t p i kS
Social Security Online
Child Disability Report
www.socialsecurity.gov Home
Name: Frank Doe
SSN: xxx-xx-4170
Questions?
How to Contact Us?
Search
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. How easy or hard was it for you to fill out the Child Disability Report?
Very Easy
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Somewhat Hard
Very 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:
Did not understand what information I needed to give.
Too many questions to answer.
Problems of my own (Could not find Information needed; was interrupted).
Computer too slow.
Problems typing and/or changing information.
Problems moving from one place to another on the report or from one place to another on a
page.
✔
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3. Which section of the Child Disability Report was the hardest to fill out?
About the Child (Identifying information, description of the child's medical condition)
Education/Work History (Education and jobs the child had)
Medical History (Doctors, hospitals, tests, medications, etc.)
4. Did you fill out the Child Disability Report because you are applying for disability
benefits for your own child or someone else's child?
Applying for benefits for my child
Applying for a child in my care, that is not my child or stepchild
Helping someone else
5. Overall, how would you rate the Child Disability Report as an Internet Service?
Review and Send: Survey
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Very Good
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Finished
Contact SSA | How to Move Around This Report
| File Type | application/pdf |
| File Title | Information About You |
| File Modified | 2013-07-22 |
| File Created | 2010-05-24 |