Form SSA-3441 Disability Report--Appeal

DISABILITY REPORT APPEAL
SSA-3441-BK
PLEASE READ THIS INFORMATION BEFORE COMPLETING THIS REPORT
The office that that makes the disability decision on your case will use the information you provide in this
report to update your disability appeal. Please complete as much of the report as you can.
You may be able to appeal online at www.ssa.gov/disability/appeal.

IF YOU NEED HELP
You can get help from other people, such as a friend or family member. Please do not ask your
healthcare provider to complete this report. If you cannot complete this report, you may contact us at
1-800-772-1213 (TTY 1-800-328-0778). A Social Security Representative will assist you. Have the
information available from the bulleted items below when you call us. If you have an appointment, have
the information available, or the completed report ready when we contact you. If you cannot speak or
understand English, we will provide an interpreter free of charge.
YOUR MEDICAL RECORDS
YOU DO NOT NEED TO ASK DOCTORS OR HOSPITALS FOR ANY MEDICAL RECORDS. If you have
consented to us obtaining medical records from your providers, we will request your records directly from
them. The information that you give us on this report tells us where to request your medical and other
records.

WHAT YOU NEED TO COMPLETE THIS REPORT

•

Names, addresses, and phone numbers of two people (other than your doctors) we can
contact who know about your medical condition(s) and can help with your case, if needed.

•

Information about any education since you last told us about your education.

•

Any prescription or non-prescription medicines you take.

•

Names, address, and phone numbers of any healthcare providers and information about the
medical treatment you received, or testing performed since you last told us about your
medical treatment.

•

If you cannot remember the information about your healthcare providers, the treatment you
received, or the testing performed, you may be able to get that information from the
telephone book, Internet, online medical chart, medical bills, prescriptions, or prescription
medicine containers.

•

If you cannot remember the exact dates, provide the closet date you can remember.

•

Name(s) of organization(s) we can contact that would have medical information about your
condition(s) since you last told us about your other medical information, such as Department
of Veterans Affairs, social services agencies, vocational rehabilitation agencies, welfare
agencies, attorneys, prisons, workers’ compensation, and insurance companies who have
paid you disability benefits.

•

Information about any vocational rehabilitation, employment, or other support services since
you last told us about your support services.

•

ANSWER EVERY QUESTION unless this report indicates otherwise. Provide as much

details as possible. If you do not know an answer, or the answer is “none” or “does not
apply,” please write "don't know," or "none," or "does not apply."

•

Be sure to explain an answer if the question asks for an explanation, or if you want to provide
additional information. If you need more space to answer any question, use Section 10 Remarks.
HOW TO SUBMIT THIS REPORT

Send or bring this completed report to your local Social Security office. If you have internet access, you
can locate your nearest Social Security office by ZIP code at www.socialsecurity.gov/locator. Our offices
are listed under U.S. Government agencies in your telephone directory, or you may call Social Security at
1-800-772-1213 (TTY 1-800-325-0778).

Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 223(d), 1614(a), and 1631 of the Social Security Act, as amended, allow us to
collect this information. Furnishing us this information is voluntary. However, failing to provide all
or part of the information may prevent an accurate and timely decision on any claim filed.
We will use the information to reconsider and review an initial disability determination; review a
continuing disability; and evaluate a request for a hearing. We may also share your information for
the following purposes, called routine uses:
•

To applicants, claimants, prospective claimants, other than the data subject, their authorized
representatives or representative payees, to the extent necessary to pursue Social Security
claims and to representative payees when the information pertains to individuals for whom
they serve as representative payees, for the purpose of assisting the Social Security
Administration in administering its representative payment responsibilities under the Act and
assisting the representative payees in performing their duties as payees, including receiving
and accounting for benefits for individuals for whom they serve as payees; and

•

To Federal, State, or local agencies (or agents on their behalf), for administering cash or
non-cash income maintenance or health maintenance programs (including programs under
the Act).

In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent debts
under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices (SORN)
60-0089, entitled Claims Folders System, as published in the Federal Register (FR) on April 1,
2003, at 68 FR 15784, and 60-0320, entitled Electronic Disability Claim File, as published in the FR
on December 22, 2003, at 68 FR 71210. Additional information, and a full listing of all of our
SORNs, is available on our website at www.ssa.gov/privacy.
Paperwork Reduction Act
This information collection meets the requirements of 44 U.S.C. § 3507, as amended by Section 2 of the
Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid
Office of Management and Budget control number. We estimate that it will take about 45 minutes to read
the instructions, gather the facts, and answer the questions. Send only comments regarding this
burden estimate or any other aspect of this collection, including suggestions for reducing this
burden to: SSA, 6401, Security Blvd, Baltimore, MD 21235-6401.

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

SOCIAL SECURITY ADMINISTRATION

DISABILITY REPORT – APPEAL
DISABILITY REPORT – APPEAL

Form Approved
OMB No. 0960-0144

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

Related SSN
Number Holder
Anyone who makes or causes to be made a false statement or representation of material fact for use in determining
a payment under the Social Security Act, or knowingly conceals or fails to disclose an event with an intent to affect
an initial or continued right to payment, commits a crime punishable under Federal law by fine, imprisonment, or
both, and may be subject to administrative sanctions.

SECTION 1 – INFORMATION ABOUT YOU
When a question refers to “you” or “your,” it refers to the person applying for disability benefits. If you are
completing this report for someone else, please provide information about them.
1. A. NAME (First, Middle Initial, Last, Suffix)

1. B. SOCIAL SECURITY NUMBER

1.C. Have you used any other names on your medical or educational records? Examples include maiden
name, other married names, other names, or nickname.
󠄈YES
NO
If YES, please list names used:

1.D. MAILING ADDRESS (Street or PO Box) Include apartment number, if applicable.
CITY

STATE/Province

ZIP/Postal Code

COUNTRY (If not USA)

1.E. EMAIL ADDRESS

1. F. DAYTIME PHONE NUMBER(S) where we can call to speak to you or leave a message, if needed. Include area
code or IDD and country code if outside the USA or Canada.

Primary: ________________________________ Secondary: _______________________ (if available)

1.G. Can you speak and understand English?

□ YES

□ NO

If NO, what language is preferred?
If you cannot speak and understand English, we will provide an
interpreter, free of charge
1.H. Can you read and understand English?
□ YES □ NO
1.I. Can you write more you’re your name in English? YES□NO

SECTION 2 – CONTACTS
Is there someone we can contact who can help with your claim, if needed? Examples include a family member, friend, or
neighbor.
□ YES. Please provide the names of two people (other than your doctors) we can contact who know about your
medical condition(s) and can help you with your claim and can help us reach you if you become unavailable.
□ NO. We recommend that you provide at least one contact, if available. Providing the name of someone who
knows you may help us to make a decision on your claim.
2.A. NAME (First, Middle Initial, Last)

2.B. Relationship to the Person in 1.A.

2.C. MAILING ADDRESS (Street or PO Box) Include apartment number, if applicable

CITY

STATE/Province

ZIP/Postal Code

COUNTRY (if not USA)

2.D. DAYTIME PHONE NUMBER (as described in 1.F. above)
2.E. Can this person speak and understand English?
If NO, what language is preferred?

□ YES

□ NO

________________________________________

2.F. NAME (First, Middle Initial, Last)

2.G. Relationship to the Person in 1.A.

2.H. MAILING ADDRESS (Street or PO Box) Include apartment number, if applicable

CITY

STATE/Province

ZIP/Postal Code

COUNTRY (if not USA)

2.I. DAYTIME PHONE NUMBER (as described 1.F. above)
2.J. Can this person speak and understand English?
If NO, what language is preferred?

□ YES

□ NO

________________________________________

SECTION 3 – MEDICAL INFORMATION
3. A. Since you last told us about your medical condition(s)), has there been any CHANGE(S) (for better
or worse) in your conditions?
NO (Go to 3.B) YES (Complete the information below)
Approximate date the change(s) occurred: MM/DD/YYYY

Describe the change(s) in detail:

3. B. Since you last told us about your medical condition(s), do you have any NEW conditions?
NO (Go to 4.A.) YES (Complete the information below)
Approximate date the change(s) occurred: MM/DD/YYYY

Describe your new medical condition(s) in detail:

If you need more space, use Section 10.

Form SSA-3441-BK

SECTION 4 – MEDICAL TREATMENT
4. A. Since you last told us about your medical treatment, have you seen or received treatment
from a healthcare provider (doctor, hospital, clinic, psychiatrist, nurse practitioner, therapist,
physical therapist, or other medical professional), or do you have a future appointment
scheduled?
NO (Go to 4.B.)
YES (Complete the chart(s) below)
Only list the healthcare providers you have seen since you last told us about your medical treatment
or are scheduled to see in the future. You may find this information on medical bills, online medical
chart, or the Internet.

4.A.1.
NAME OF FACILITY OR
OFFICE

NAME OF HEALTHCARE PROVIDER THAT TREATED YOU

What medical conditions were treated or evaluated?

PHONE NUMBER

DATE FIRST SEEN:

DATE LAST SEEN:

______ / ________
MM
YYYY

______ / ________
MM
YYYY

DATE OF NEXT
APPOINTMENT:
(IF KNOWN)
______ / ________
MM
YYYY

ADDRESS
CITY

4.A.2.
NAME OF FACILITY OR
OFFICE

STATE/Province ZIP/Postal
Code

COUNTRY (if not USA)

NAME OF HEALTHCARE PROVIDER THAT TREATED YOU

What medical conditions were treated or evaluated?

PHONE NUMBER

ADDRESS

Form SSA-3441-BK

DATE FIRST SEEN:

DATE LAST SEEN:

______ / ________
MM
YYYY

______ / ________
MM
YYYY

DATE OF NEXT
APPOINTMENT:
(IF KNOWN)
______ / ________
MM
YYYY

CITY

. 4.A.3.
NAME OF FACILITY OR
OFFICE

STATE/Province ZIP/Postal
Code

COUNTRY (if not USA)

NAME OF HEALTHCARE PROVIDER THAT TREATED YOU

What medical conditions were treated or evaluated?

PHONE NUMBER

DATE FIRST SEEN:

DATE LAST SEEN:

______ / ________
MM
YYYY

______ / ________
MM
YYYY

DATE OF NEXT
APPOINTMENT:
(IF KNOWN)
______ / ________
MM
YYYY

ADDRESS
CITY

STATE/Province ZIP/Postal
Code

If you need to list more facilities or healthcare providers, use Section 10.

Form SSA-3441-BK

COUNTRY (if not USA)

4.B. Since you last told us about your medical treatment, did any of the healthcare providers listed in 4.A. order
any medical tests for you? Include tests performed and scheduled in the future.
NO (Go to Section 5)
YES (Select tests from the chart below)

TEST

NAME OF HEALTHCARE PROVIDER

Blood test (not HIV)
Breathing test
Cardiac
catheterization
EEG (brain wave test)
EKG (heart test)
Hearing test
HIV test
Speech/language test
Treadmill (exercise test)
Vision test
Psychological/IQ test
Biopsy (list body part):
MRI/CT scan (list body
part):

X-ray (list body part):
Other – please
specify:

If you need to list more tests, use Section 10.

Form SSA-3441-BK

DATE OF TEST
MM/YYYY

SECTION 5 – OTHER MEDICAL INFORMATION
5. Since you last told us about your other medical information, does anyone else (other than your
healthcare providers) have your medical information? Examples include Department of Veterans
Affairs, social service agencies, vocational rehabilitation agencies, welfare agencies, attorneys,
prisons, workers' compensation, and insurance companies who have paid you disability benefits.
NO (Go to Section 6)
YES (Complete the information below)
NAME OR ORGANIZATION

PHONE NUMBER

ADDRESS
CITY

STATE/Province

ZIP/Postal Code

NAME OF CONTACT PERSON
Date of First Contact

CLAIM NUMBER (if any)
Date of Last Contact

Reason(s) for Contacts

If you need to list other people or organizations, use Section 10.

*

Form SSA-3441-BK

COUNTRY (if not USA)

Date of Next Contact (if any)

SECTION 6 – MEDICINES
6. Are you currently taking any prescription or non-prescription medicine(s)?
NO (Go to Section 7)
YES (Complete the information below. You may need to look at your medicine containers).

NAME OF MEDICINE

IF PRESCRIBED,
GIVE DOCTOR
NAME (IF KNOWN)

REASON FOR MEDICINE
(IF KNOWN)

If you need to list more medicines, use Section 10.

Form SSA-3441-BK

SIDE EFFECTS
(IF ANY)

SECTION 7 - ACTIVITIES
7. Since you last told us about your activities, has there been any change (for better or worse) in your daily
activities due to your medical conditions? Examples of daily activities include household chores, preparing
meals, personal care, getting around, hobbies and interests, social activities, etc.
NO (Go to 8.A.) YES (Complete the information below)
Describe these changes in detail:

If you need more space, use Section 10.

SECTION 8 – WORK AND EDUCATION
8. A. Since you last told us about your work, have you worked or has your work changed?
NO (Go to 8.B)

YES (Complete the information below)

Explain in detail. We may ask you to provide additional information.

8.B. Since you last told us about your education, have you enrolled in or completed any classes? Examples
include GED classes, specialized job training, trade school, vocational school, college classes or online education.

NO (Go to Section 9)

YES (Complete the information

below)

NAME OF SCHOOL

DATE(S) OF ATTENDANCE
_______/_________ to _________/______________
MM
YYYY
MM
YYYY

ADDRESS
STATE/Province

CITY
TYPE OF PROGRAM/DEGREE

ZIP/Postal Code

COUNTRY (if not USA)

Date Completed (or scheduled to be completed)
____________/__________
MM
YYYY

If you need more space, use Section 10

Form SSA-3441-BK

COMPLETE THIS SECTION ONLY IF YOU ARE ALREADY RECEIVING SSI
SECTION 9 – SUPPORT SERVICES
Provide the information about your participation in support services, if applicable. Examples of support services
may include:
• An Individualized Education Plan (IEP) through a school (if a student aged 18-21)
• An individualized work plan with an employment network under the Ticket to Work Program
• A Plan to Achieve Self-Support (PASS)
• An individualized plan for employment with a vocational rehabilitation agency or any other organization

9.A. Since you last told us about your support services, have you participated or are you participating in any
support services mentioned above or any other vocational rehabilitation, employment services, or other support
services to help you go to work?
NO (Go to Section 10)
YES (Complete the information below)
FACILITY OR ORGANIZATION NAME

PHONE NUMBER

COUNSELOR, INSTRUCTOR, OR JOB COACH NAME

ADDRESS (Street or PO Box) Include Suite, Building, etc.

CITY

STATE/Province

ZIP/Postal Code

COUNTRY (If not USA)

9.B. Are you still participating in the plan or program? (Select answer below)

□ YES

Date began:

___________

Expected completion date:

___________

MM/YYYY

□ NO

Date began:

___________

MM/YYYY

Date stopped:

MM/YYYY

___________
MM/YYYY

Reason stopped:

9.C. Since you last told us about your support services, what types of services, tests, or evaluations
were provided?
Select all that apply:

Psychological/IQ test

Vision test

Work classes

Hearing test

Work evaluation

If you need to list another plan or program, use Section 10.

Form SSA-3441-BK

Other – Please explain:

SECTION 10 – REMARKS
Please provide any additional information you did not give in earlier parts of this report. If you did not
have enough space in the sections of this report to provide the requested information, please use this
space to provide the additional information requested in those sections. Be sure to include the section
and question number to which you are referring.

Form SSA-3441-BK (03-2015) ef (03-2015)

Page x

SECTION 11 – WHO IS COMPLETING THIS REPORT
Date Report Completed (MM/DD/YYYY)

Who is completing this report?
The person listed in 1.A.
The person listed in 2.A.
The person listed in 2.F.
Someone else (Complete the information below)
NAME (First, Middle Initial, Last)

Relationship to the Person in 1.A.

MAILING ADDRESS (Street or PO Box) Include the apartment number, if applicable.

CITY

STATE/Province

ZIP/Postal Code

COUNTRY (if not USA)

DAYTIME PHONE NUMBER where we may reach you or leave a message, if needed. Include the area code or IDD and
country code if outside the USA or Canada.

Form SSA-3441-BK