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Education and Work: About Education and Work History

Social Security

Child Disability Report

Online

-

www..eocialsecurity.gov

Name: Frank Doe

SSN: 743·99-4143

Education and Work: About Frank Doe's
Education and Work History
We may contact all the schools that Frank Doe attended over the
last 12 months. Schools are excellent sources of important
information.

Schools
Has Frank Doe
ever attended

OVes ONo

school (Including

daycare,
preschool,
Headstart, home
school. Public,
Private or other
educational

programs)?

Vocational Rehabilitation
Has Frank Doe
received
Vocational
Rehabilitation or
other employment
support services to
heJp him or her go
to work?

0 Ves 0 No

Work History
Has Frank Doe
ever worked

OVes ONo

(including

sheltered work)?
; .. '

lr

Contact SSA , How to Move Around This Report

http://eis.ba.ssa.gov/appagesli3820_November06/ewOO2.html

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2115/2007

Page I of2

Welcome

Soeial Security
Online

Child Disability Report

www.socialsecurity.goy Home
Search

Questions?

How to Contact Us?

Welcomel
To complete a Child Disability Report on behalf of a child
applying for Supplemental Security Income (551) 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 551
benefits.
You can complete the Child Disability Report online but you
must contact us to complete the 551 application. The 551
application can't be completed online. You can apply in person or
over the phone, or get more information about 551 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
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Applying in Person or Over the Phone
If you preft;;:r 00;( to do :Ilis report on the Internet, you can use any
of the following ways to complete a Disability Report:
• Call our toll-free number. 1-B00-772-1213. Explain that you
want to file an 551 application on behalf of a child. If you
are deaf Of hard of hearing, c&11 our toli-free "ITf" number,
1-800-325-0778. Representatives are available Monday

http://eis.ba.ssa.gov/appages/i3820_November06/eeOOI.html

2/1512007

Page 2 of2

Welcome
through Friday from 7 a.m. to 7 p.m.

• Go to your local Social Security Office and ask to file an SSI application on
of the child.

• If you have a working printer, print a paper Disability Report-Child from the
Internet. This form is in Portable Document Format (PDF) and requires Adc
Acrobat Reader to open and print it. If you don't have Adobe Acrobat Read.
your computer you can download it at
http://www.adObe.comlaccessibility/index.html.
• If you five 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

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http://eis.ba,ssa.gov/appages/i3820_November06/eeOOI.html

2/15/2007

Page] of2

About this Internet Fonn

Social Sectuity

Child Disability Report

Online

www.socials8Curity.gov

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 Acrobat Reader - to download a free copy. go to
http://www.adobe.com/accessibilitylindex.html.

Privacy Information
The Social Security Administration has access to the information
you provide on this report and is authorized to keep even partially
completed reports. This is for the purpose of helping you
complete the application process or update your information. If
you have decided you want to continue, you can start the report
now, or, if you are undecided, you may do so at a later time. For
more information about completing this report online or other
services provided by the Social Security Administration, please
call our toU-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

http://eis.ba.ssa.gov/appagesli3820 November06/eeOO8.btmJ

2115/2007

About this Internet Fonn

Page 2of2

Budget control number. We estimate that it will take you an average of 120 minutE
respond, but total time required will depend upon the number of questions you ne
answer.
You may send comments on our estimate of the time needed to complete the Chi
Disability Report to: SSA, 1338 Annex Building. Baltimore. MD 21235-0001. Sene
comments relating to our time estimate to this address, not the completed r

The OMB approval number for the Internet Child Disability Report is 0960-0577;
expiration date 01131/2007.

Contacting Social Security by Phone
Call our toll-free number, 1-800·772~1213. If you are deaf or hard of hearing. call.
free "ny" number. 1-800~2s..on8. Representatives are available Monday throu
Friday from 7 a.m. to 7 p.m.

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211512007

Page t of2

What You Will Need

Social Sa'luity

Child Disability Report

Online
www.socialsecurity.goy

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, Sodal Security Number. and date of
birth.
• Your (the applicanfs) 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'1·
• 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 'ast 12 months.
• The type of behavioral or learning testes) that the child had,
and when the testes} 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 testes) that the child had, when
and where the testes) was done. and who ordered it.
• Name(sj of eaGh piescriptioll medicine(s) that the child
takes and the doctor(s) who prescribed it.

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211512007

Page 2 of2

What You Will Need

• 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 I
enough information so that we can contact the child's doctors and hospitals to get
child's medical records. It is important that you give us the names, addresses, anc
of treatment for all the child's doctors and hOspitals. You do not have to get the m.
records.
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2/15/2007

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Education and Work: About Education and Work History

Social Security

Page loft

Child Disability Report

Online

-

www•.,ocialsecurity.gov

Name: Frank Doe

SSN: 743-99-4143

Education and Work: About Frank Doe·s
Education and Work History
We may contact all the schools that Frank Doe attended over the
last 12 months. Schools are excellent sources of important
information.

Schools
Has Frank Doe
ever attended
school (including
daycare,
preschool.
Headstart, home
school, Public,
Private or other
educational
programs)?

OVes ONo

Vocational Rehabilitation
Has Frank Doe
received
Vocational
Rehabilitation or
other employment
support services to
help him or her go
to work?

0 Ves 0 No

Work History
Has Frank Doe
ever worked
(including
sheltered work)?

OVes ONo

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Contact SSA I How to Move Around This Report

http://eis.ba.ssa.gov/appagesli3820_November06/ew002.html

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2/15/2007

Education and Work: More About Education History 2?

&rial Security
Online

Page t of2

Child Disability Report

-

www.8ocialsecurity.gov

Name:

SSN:

Education and Work: More About's
Education History

You told us earlier that Is not currently enrolled. If this is not correct,
please
What is the
highest grade
that completed?
Please explain
why is not
enrolled in
school now:
Your answer can be
no more than 1000
characters, which is
about 20 lines of
typing. If you need
more space,
continue in the
Remarks section at
the end of this form.
Examples:
• quit school
• expelled from

school

• too disabled to

1'.;' tl') school.

l;tl;§itildff# •

You

have entered 0
characters

http://eis,ba.ssa.gov/appagesJi3820_November06/ew008b.html

2/1512007

Medical History: Additional Testing or Examination

Social8eL'urity

Online

Page 1 of 1

Child Disability Report

www.50cialsecurity.gov

Name: Frank Doe
SSN: 743-99-4143

Medical History: Additional Sources of
Testing or Examination

Has Frank Doe been tested or examined by any of the following?
Headstart (Tltte V)

DYes ONo

Public or
Community Health
Department

0

Child Welfare or
Social Service
Agency

0 Yes 0 No 0 I don't know

Women, Infants
and Children (WIC)
Program

() Yes

Program for
Children with
Special Health
Care Needs

0 Yes 0 No 0 I don't know

Mental
Health/Menta I
Retardation Center

0 Yes 0 No 0 I don't know

Yas

0

0

No

No

I don't know

0

0

I don't know

I don't know

Can tact SSA ! How to Move Around This Report

. http://eis.ba.ssa.gov/appages/i3820.. November06/mhO 12.html

2115/2007

Request for Hearing by Administrative Law Judge

Social Security
Online

Page 1 of3

Internet Appeal
l

www.socialsecurHy.gov

Name: John Public
SSN: ux-xx-0285

Request for Hearing by Administrative Law
Judge
Please enter your Appeal Request Information.

Items marked with an asterisk ( *) are required.

Claimant Name:

John G Public

(First. Middle. Last)

* Claimant Address:
Please provide a complete address. including apartment number if applicable. Please
do NOT use punctuation; for example. no periods or commas. Example: 528 Dawn St
Apt 101. If the address on your notice is correct. please enter it exactly as it appears on
the denial notice.

* (Street Line 1)
(Street Line 2)
(Street Line 3)
(Street Line 4)

,I

* (City, State,
ZIP Code)

21087

Claimant
Telephone
Number:
Example: (111) 222­
3333

Claimant Fax
Number:
(If known)

Claimant SOCial
Security Number
(SSN):

xxx-xx-0285

http://eis.ba.ssa.gov/appagesliAppeals_July_2008/ap008hr.html

- . - - - _....

1111/2010

_---------------­

Request for Hearing by Administrative Law Judge

Page 2 of3

Claimant Claim
Number:
(I' different from
SSN):

What is the Claim
Number?
Wage Earner
Name

Sufflx (If any)

(If different from

Claimant):

(First. Middle. last)
Who is the Wage

Earner?
I REQUEST A HEARING BEFORE AN ADMINISTRAnVE LAW JUDGE.
Enter a brief
explanation of the
reason for your
appeal. 205
character maximum.
This is about 4 lines
of typing.

* I disagree with the detennlnatlon made on my claim because:

An Administrative Law Judge of the Social Security Administration's Office of Disability
Adjudication and Review will be appointed to conduct the hearing or other proceedings
in your case. You will receive notice of the time and place of a hearing at least 20 days
before the date set for a hearing.

* I have
additional
evidence to
submit:

OVes ONo

If yes, you will be asked to give us the name and address of the source of additional
evidence in Part 2 of the Internet Appeal process. For more information about how to
submit additional evidence, use the link Submitting Additional Eykfence,

Do you wish to appear at a hearing?
* Select one
answer:

01 wish to appear at a hearing.

o I do not wish to appear at a hearing and I request that a decision be
made based on the evidence In my case. (Complete WaIver of
Your Right to Personal Appearance Before an AU. HA-4808.)

http://eis.ba.ssa.gov/appagesliAppea1s_July_200S/apOOShr.html

111112010

Request for Hearing by Administrative Law Judge

Page 3 of3

You have a right to be represented at the hearing. Use this link if you want to know

more about representatives.

* Do you

currently have a

representative?

* Select one
answer:

01 am completing this form as the Claimant.

01 am completing this form as the Claimant's Representative.

Select the Continue button to review your information before
sending it to the Social Security Administration. Select the
Previous button if you want to review the previous page of
instructions.

Contact Us I How 110 Moye Arpmd Jbis Reood

http://eis.ba,ssa.gov/appagesliAppea1s_July_2008/ap008br.html

1111/2010

Medical History: Other Medical Records

Name: Frank Doe
SSN: xxx-xx-4170

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 (Le.,
doctors' offices or hospitals).

Doesan,oq~ ••'"
h"l'e" ...ecI.c~1

records.or ,.",,'

III,qnn,.tlon ..~t
Fra"kI)Q.~s ". ,
IIIne"M,'injutl.,.
or con,dltlon.
(fOster parents,
social workers,

CQunselC)rs, ,
' ...tora, schtM)1
nu...··f.det.ntlon
centerS,
attomeys,
ins,urance

companl.s,
and/or work,....s

compensation),
or I. scheduled to
see al'lyon. else?

Contact SSA I HoW to Moye Around This Report

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