Fillable Ssa-454-bk Continuing Disability Review Report

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Ssa-454-bk Continuing Disability Review Report

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Form SSA-454-BK (06-2020) UF
Discontinue Prior Editions
Social Security Administration
Page 1 of 15
OMB No. 0960-0072
CONTINUING DISABILITY REVIEW REPORT
PLEASE READ THIS INFORMATION BEFORE COMPLETING THIS REPORT
The office that reviews your medical condition will use the information in this report. The information will
help that office decide whether you are still disabled. Please complete as much of the report as you can.
IF YOU NEED HELP
You can get help from other people, such as a friend or family member. Please do not ask your health care
provider to complete this report. If you cannot complete the report, a Social Security Representative will
assist you. If you have an appointment, please have the completed report ready when we contact you.
Note: If you are assisting someone else with this report, please answer the questions as if that person were
completing the report.
HOW TO COMPLETE THIS REPORT
• Print or write clearly.
• Include a ZIP or postal code with each address.
• Provide complete phone numbers, including area code. If a phone number is outside the United States,
provide International Direct Dialing (IDD) code and country code.
• If you cannot remember the names and addresses of your health care providers, you may be able to get
that information from the telephone book, Internet, medical bills, prescriptions, or prescription medicine
containers.
• ANSWER EVERY QUESTION, unless the report indicates otherwise. 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 give additional
information.
• If you need more space to answer any question, please use Section 11 - Remarks, on the last page to
finish your answer. Write the number of the question you are answering.
YOUR MEDICAL RECORDS
If you have any of your medical records covering the last 12 months, send or bring them to our office with
this completed report. Please tell us if you want to keep your records so we can return them to you. If you
have a scheduled appointment for an interview, bring your medical records, your prescription medicine
containers (if available), and the completed report with you.
YOU DO NOT NEED TO ASK DOCTORS OR HOSPITALS FOR ANY MEDICAL RECORDS THAT YOU
DO NOT ALREADY HAVE. With your permission, we will request your records. The information that you
give us on this report tells us where to request your medical and other records.
Form SSA-454-BK (06-2020) UF Page 2 of 15
Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 221(i), 223(d), 1614(a), 1631(e), and 1633(c) of the Social Security Act, as amended,
authorize 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 determine eligibility for benefits. We may also share your information for the
following purposes, called routine uses:
• To applicants, claimants, prospective applicants or 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 Social Security Administration (SSA) 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 private medical and vocational consultants for use in making preparation for, or evaluating the results
of, consultative medical examinations or vocational assessments which they were engaged to perform by
SSA or a State agency acting in accord with sections 221 or 1633 of 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 our SORNs are available on our website at
www.ssa.gov/privacy
.
Paperwork Reduction Act Statement
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 (OMB) control number. We estimate that it will take about 60 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.
SEND OR BRING THE COMPLETED REPORT TO YOUR LOCAL SOCIAL SECURITY OFFICE, THE
NEAREST U.S. EMBASSY OR CONSULATE OFFICE. Office addresses are listed under U.S.
Government agencies in your telephone directory or you may call 1-800-772-1213
(TTY 1-800-325-0778) for the address.
AFTER COMPLETING THIS FORM, REMOVE THIS SHEET AND KEEP IT FOR YOUR RECORDS.
Form SSA-454-BK (06-2020) UF
Discontinue Prior Editions
Social Security Administration
Page 3 of 15
OMB No. 0960-0072
CONTINUING DISABILITY REVIEW REPORT
For SSA Use Only - Do not write in this box.
Date of your last medical disability decision:
Claim Number: Number Holder:
Types of Case(s): TITLE II
DIB DWB CDB FZ ESRD HIB
(Check all that apply) TITLE XVI
DI DS DC BI BS BC
If you are filling out this report for the disabled person, please provide information about him or her. When
a question refers to "you", "your", or the "disabled person", it refers to the person receiving disability
benefits.
SECTION 1 - INFORMATION ABOUT THE DISABLED PERSON
1.A. NAME (First, Middle Initial, Last) 1.B. SOCIAL SECURITY NUMBER
1.C. MAILING ADDRESS (Street or PO Box) Include apartment number if applicable
CITY STATE/Province ZIP/Postal Code COUNTRY (if not USA)
1.D. RESIDENT ADDRESS (Street or PO Box) Include apartment number if applicable
CITY STATE/Province ZIP/Postal Code COUNTRY (if not USA)
1.E. DAYTIME PHONE NUMBER, including area code, and the IDD and country codes if you live outside
the USA or Canada.
Phone Number:
Check this box if you have a phone or a number where we can leave a message
1.F. ALTERNATE PHONE NUMBER, including area code where we may reach you, if any.
Alternate Phone Number:
1.G. Can you speak and understand English?
YES NO
If NO, what language do you prefer?
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 than your name in English?
YES NO
1.J. Have you used any other names on your medical or educational records in the last 12 months?
Examples are maiden name, other married names, or nickname.
YES NO
If YES, please list
SECTION 2 - CONTACTS
Give the name of a friend or relative (other than your doctors) we can contact who knows about your
medical conditions, and can help you with your case.
2.A. NAME (First, Middle Initial, Last) 2.B. Relationship to Disabled Person
Form SSA-454-BK (06-2020) UF Page 4 of 15
SECTION 2 - CONTACTS (Continued)
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.E. above)
2.E. Can this person speak and understand English?
YES NO
If NO, what language is preferred?
2.F. Who is completing this report?
The disabled person listed in 1.A. (Go to Section 3 - Medical Condition(s))
The person listed in 2.A. (Go to Section 3 - Medical Condition(s))
Someone else (Complete the rest of Section 2 below)
2.G. NAME (First, Middle Initial, Last) 2.H. Relationship to Disabled Person
2.I. DAYTIME PHONE NUMBER (as described in 1.E. above)
2.J. MAILING ADDRESS (Street or PO Box) Include apartment number if applicable
CITY STATE/Province ZIP/Postal Code COUNTRY (if not USA)
SECTION 3 - MEDICAL CONDITION(S)
3.A. If you are an adult (age 18 or older), list the physical and/or mental condition(s) (including emotional or
learning problems) that limit your ability to work. If you are completing this report for a child (under age
18), list the physical and/or mental condition(s) (including emotional and learning problems) that limit
the child's ability to do the same things as other children the same age. List each physical and/or
mental condition separately.
1.
2.
3.
4.
If you need more space go to Section 11 - Remarks
3.B. What is your height without shoes?
feet inches
OR
centimeters (if outside USA)
3.C. What is your weight without shoes?
pounds
OR
kilograms (if outside USA)
3.D. Do you use an assistive device (for example: eye glasses, hearing aids, braces, canes, crutch(es),
walker, wheelchair, service animal?
Always Sometimes Never
If ALWAYS OR SOMETIMES, please describe what kind, when, and how you use it.
If you need more space, use Section 11 - Remarks
Form SSA-454-BK (06-2020) UF Page 5 of 15
SECTION 4 - MEDICAL TREATMENT
Within the last 12 months, have you seen a doctor or other health care professional, or received treatment
at a hospital or clinic, or do you have a future appointment scheduled:
4.A. For any physical conditions?
YES NO
4.B. For any mental condition(s) (including emotional or learning problems)?
YES NO
If you answered "NO" to both 4.A. and 4.B., go to Section 5 - Medicines on page 11
4.C. Tell us who may have medical records covering the last 12 months about any of your physical or
mental condition(s) (including emotional or learning problems). This includes doctors' offices, hospitals
(including emergency room visits), clinics, and other health care facilities. Tell us about your next
appointment, if you have one scheduled.
NAME OF FACILITY OR OFFICE
NAME OF HEALTHCARE PROFESSIONAL THAT
TREATED YOU
ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROFESSIONAL
ABOVE
PHONE NUMBER
PATIENT ID# (if known)
MAILING ADDRESS
CITY STATE/Province ZIP/Postal Code COUNTRY (if not USA)
Dates of Treatment (within the last 12 months)
1. Office, Clinic, or Outpatient
visits
First visit
Last visit
Next scheduled appointment
(if any)
2. Emergency Room Visits
List the most recent date
first
A.
B.
C.
3. Overnight Hospital Stays
A. Date in Date out
B. Date in Date out
C. Date in Date out
What medical conditions were treated or evaluated?
What treatment did you receive for the above conditions? (Do not describe medicines or tests in this box.)
Form SSA-454-BK (06-2020) UF Page 6 of 15
SECTION 4 - MEDICAL TREATMENT (Continued)
Check the boxes below for any tests this provider performed or sent you to within the last 12 months, or
has scheduled you to take. Please give the dates for past and future tests. If you need to list more tests,
use Section 11 - Remarks.
Check this box if no tests by this provider or at this facility.
KIND OF TEST DATES OF TEST(S) KIND OF TEST DATES OF TEST(S)
EKG (heart test)
Treadmill (exercise test)
Cardiac Catheterization
Biopsy (list body part)
Hearing test
Speech/Language Test
Vision Test
Breathing test
EEG (brain wave test)
HIV Test
Blood Test (not HIV)
X-Ray (list body part)
MRI/CT Scan (list body part)
Other
If you do not have any more doctors or hospitals to describe, go to
Section 5 - Medicines on page 11.
4.D. Tell us who may have medical records covering the last 12 months about any of your physical or
mental condition(s) (including emotional or learning problems). This includes doctors' offices, hospitals
(including emergency room visits), clinics, and other health care facilities. Tell us about your next
appointment, if you have one scheduled.
NAME OF FACILITY OR OFFICE
NAME OF HEALTHCARE PROFESSIONAL THAT
TREATED YOU
ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROFESSIONAL
ABOVE
PHONE NUMBER
PATIENT ID# (if known)
MAILING ADDRESS
CITY STATE/Province ZIP/Postal Code COUNTRY (if not USA)
Dates of Treatment (within the last 12 months)
1. Office, Clinic, or Outpatient
visits
First visit
Last visit
Next scheduled appointment
(if any)
2. Emergency Room Visits
List the most recent date
first
A.
B.
C.
3. Overnight Hospital Stays
A. Date in Date out
B. Date in Date out
C. Date in Date out
Form SSA-454-BK (06-2020) UF Page 7 of 15
SECTION 4 - MEDICAL TREATMENT (Continued)
What medical conditions were treated or evaluated?
What treatment did you receive for the above conditions? (Do not describe medicines or tests in this box.)
Check the boxes below for any tests this provider performed or sent you to within the last 12 months, or
has scheduled you to take. Please give the dates for past and future tests. If you need to list more tests,
use Section 11 - Remarks.
Check this box if no tests by this provider or at this facility.
KIND OF TEST DATES OF TEST(S) KIND OF TEST DATES OF TEST(S)
EKG (heart test)
Treadmill (exercise test)
Cardiac Catheterization
Biopsy (list body part)
Hearing test
Speech/Language Test
Vision Test
Breathing test
EEG (brain wave test)
HIV Test
Blood Test (not HIV)
X-Ray (list body part)
MRI/CT Scan (list body part)
Other
If you do not have any more doctors or hospitals to describe, go to
Section 5 - Medicines on page 11.
4.E. Tell us who may have medical records covering the last 12 months about any of your physical or
mental condition(s) (including emotional or learning problems). This includes doctors' offices, hospitals
(including emergency room visits), clinics, and other health care facilities. Tell us about your next
appointment, if you have one scheduled.
NAME OF FACILITY OR OFFICE
NAME OF HEALTHCARE PROFESSIONAL THAT
TREATED YOU
ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROFESSIONAL
ABOVE
PHONE NUMBER
PATIENT ID# (if known)
MAILING ADDRESS
CITY STATE/Province ZIP/Postal Code COUNTRY (if not USA)
Form SSA-454-BK (06-2020) UF Page 8 of 15
SECTION 4 - MEDICAL TREATMENT (Continued)
Dates of Treatment (within the last 12 months)
1. Office, Clinic, or Outpatient
visits
First visit
Last visit
Next scheduled appointment
(if any)
2. Emergency Room Visits
List the most recent date
first
A.
B.
C.
3. Overnight Hospital Stays
A. Date in Date out
B. Date in Date out
C. Date in Date out
What medical conditions were treated or evaluated?
What treatment did you receive for the above conditions? (Do not describe medicines or tests in this box.)
Check the boxes below for any tests this provider performed or sent you to within the last 12 months, or
has scheduled you to take. Please give the dates for past and future tests. If you need to list more tests,
use Section 11 - Remarks.
Check this box if no tests by this provider or at this facility.
KIND OF TEST DATES OF TEST(S) KIND OF TEST DATES OF TEST(S)
EKG (heart test)
Treadmill (exercise test)
Cardiac Catheterization
Biopsy (list body part)
Hearing test
Speech/Language Test
Vision Test
Breathing test
EEG (brain wave test)
HIV Test
Blood Test (not HIV)
X-Ray (list body part)
MRI/CT Scan (list body part)
Other
If you do not have any more doctors or hospitals to describe, go to
Section 5 - Medicines on page 11.
4.F. Tell us who may have medical records covering the last 12 months about any of your physical or
mental condition(s) (including emotional or learning problems). This includes doctors' offices, hospitals
(including emergency room visits), clinics, and other health care facilities. Tell us about your next
appointment, if you have one scheduled.
Form SSA-454-BK (06-2020) UF Page 9 of 15
SECTION 4 - MEDICAL TREATMENT (Continued)
NAME OF FACILITY OR OFFICE
NAME OF HEALTHCARE PROFESSIONAL THAT
TREATED YOU
ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROFESSIONAL
ABOVE
PHONE NUMBER
PATIENT ID# (if known)
MAILING ADDRESS
CITY STATE/Province ZIP/Postal Code COUNTRY (if not USA)
Dates of Treatment (within the last 12 months)
1. Office, Clinic, or Outpatient
visits
First visit
Last visit
Next scheduled appointment
(if any)
2. Emergency Room Visits
List the most recent date
first
A.
B.
C.
3. Overnight Hospital Stays
A. Date in Date out
B. Date in Date out
C. Date in Date out
What medical conditions were treated or evaluated?
What treatment did you receive for the above conditions? (Do not describe medicines or tests in this box.)
Check the boxes below for any tests this provider performed or sent you to within the last 12 months, or
has scheduled you to take. Please give the dates for past and future tests. If you need to list more tests,
use Section 11 - Remarks.
Check this box if no tests by this provider or at this facility.
KIND OF TEST DATES OF TEST(S) KIND OF TEST DATES OF TEST(S)
EKG (heart test)
Treadmill (exercise test)
Cardiac Catheterization
Biopsy (list body part)
Hearing test
Speech/Language Test
Vision Test
Breathing test
EEG (brain wave test)
HIV Test
Blood Test (not HIV)
X-Ray (list body part)
MRI/CT Scan (list body part)
Other
Form SSA-454-BK (06-2020) UF Page 10 of 15
SECTION 4 - MEDICAL TREATMENT (Continued)
If you do not have any more doctors or hospitals to describe, go to
Section 5 - Medicines on page 11.
4.G. Tell us who may have medical records covering the last 12 months about any of your physical or
mental condition(s) (including emotional or learning problems). This includes doctors' offices, hospitals
(including emergency room visits), clinics, and other health care facilities. Tell us about your next
appointment, if you have one scheduled.
NAME OF FACILITY OR OFFICE
NAME OF HEALTHCARE PROFESSIONAL THAT
TREATED YOU
ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROFESSIONAL
ABOVE
PHONE NUMBER
PATIENT ID# (if known)
MAILING ADDRESS
CITY STATE/Province ZIP/Postal Code COUNTRY (if not USA)
Dates of Treatment (within the last 12 months)
1. Office, Clinic, or Outpatient
visits
First visit
Last visit
Next Scheduled Appointment
(if any)
2. Emergency Room Visits
List the most recent date
first
A.
B.
C.
3. Overnight Hospital Stays
A. Date in Date out
B. Date in Date out
C. Date in Date out
What medical conditions were treated or evaluated?
What treatment did you receive for the above conditions? (Do not describe medicines or tests in this box.)
Check the boxes below for any tests this provider performed or sent you to within the last 12 months, or
has scheduled you to take. Please give the dates for past and future tests. If you need to list more tests,
use Section 11 - Remarks.
Check this box if no tests by this provider or at this facility.
Form SSA-454-BK (06-2020) UF Page 11 of 15
SECTION 4 - MEDICAL TREATMENT (Continued)
KIND OF TEST DATES OF TEST(S) KIND OF TEST DATES OF TEST(S)
EKG (heart test)
Treadmill (exercise test)
Cardiac Catheterization
Biopsy (list body part)
Hearing test
Speech/Language Test
Vision Test
Breathing test
EEG (brain wave test)
HIV Test
Blood Test (not HIV)
X-Ray (list body part)
MRI/CT Scan (list body part)
Other
If you need to list more doctors or hospitals use Section 11 - Remarks and
give the same detailed information as above for each one you list.
SECTION 5 - MEDICINES
5. Are you now taking, or have you taken in the last 12 months, any prescription or non-prescription
medicines?
YES (Complete the following information. Look at your medicine containers, if necessary.)
NO (Go to section 6 - Other Medical Information on page 12.)
NAME OF MEDICINE
IF PRESCRIBED,
GIVE NAME OF DOCTOR
REASON FOR MEDICINE
If you need to list other medicines use Section 11 - Remarks.
If you are under age 18, Skip to Section 11 - Remarks.
Form SSA-454-BK (06-2020) UF Page 12 of 15
SECTION 6 - OTHER MEDICAL INFORMATION
Complete only if you are age 18 years or older
6. Does anyone else have medical information about your physical or mental condition(s) (including
emotional and learning problems) covering the last 12 months, or are you scheduled to see anyone else?
(This may include places such as workers' compensation, vocational rehabilitation, insurance companies
who have paid you disability benefits, prisons, attorneys, social service agencies and welfare agencies.)
YES (Complete the following information.)
NO (Go to SECTION 7 - Education and Training.)
NAME OR ORGANIZATION PHONE NUMBER
MAILING ADDRESS
CITY STATE/Province ZIP/Postal Code COUNTRY (if not USA)
NAME OF CONTACT PERSON CLAIM NUMBER (if any)
Date First Contact (in last 12 months)
Date Last Contact (in last 12 months) Date Next Contact (if any)
Reason(s) for Contacts
If you need to list other people or organizations use Section 11 - Remarks and give the same
detailed information as above for each one you list.
SECTION 7 - EDUCATION AND TRAINING
Complete only if you are age 18 years or older
7.A. Have you received any education since your last disability decision? (See date at top of Page 3.)
YES (Complete the information below.) NO (Go to question 7.B. below.)
NAME OF SCHOOL
DATES OF ATTENDANCE (MM/YYYY)
From To
MAILING ADDRESS
CITY STATE/Province ZIP/Postal Code COUNTRY (if not USA)
TYPE OF PROGRAM/DEGREE
Date Completed (or scheduled
to be completed) MM/YYYY
7.B. Have you received any type of specialized job, trade, or vocational training since your last disability
decision? (See date at top of Page 3.)
YES (Complete the information below.) NO
NAME OF TRAINING FACILITY PHONE NUMBER
MAILING ADDRESS
CITY STATE/Province ZIP/Postal Code COUNTRY (if not USA)
TYPE OF PROGRAM
Date Completed (or scheduled
to be completed) MM/YYYY
Form SSA-454-BK (06-2020) UF Page 13 of 15
7.C. What written language do you use every day in most situations (at home, work, school, in community,
etc.)?
7.D. In the language you identified in 7.C., can you read a simple message, such as a shopping list or short
and simple notes?
YES NO
7.E. In the language you identified in 7.C., can you write a simple message, such as a shopping list or short
and simple notes?
YES NO
If you need to list other education information or training facilities use
Section 11 - Remarks and give the same detailed information as above.
SECTION 8 - VOCATIONAL REHABILITATION, EMPLOYMENT, OR OTHER SUPPORT SERVICES
Complete only if you are age 18 years or older.
8.A. Since the date of your last medical disability decision (see date on top of Page 3), have you
participated, or are you participating, in:
• an individualized work plan with an employment network under the Ticket to Work Program;
• an individualized plan for employment with a vocational rehabilitation agency or any other
organization;
• a Plan to Achieve Self-Support (PASS);
• an Individualized Education Program (IEP) through a school (if a student age 18-21); or
• any program providing vocational rehabilitation, employment services, or other support services to
help you go to work?
YES (Complete the information below.) NO (Go to Section 9 - Daily Activities)
If YES, what year did you last attend any school?
NAME OF ORGANIZATION OR SCHOOL
NAME OF COUNSELOR, INSTRUCTOR OR JOB COACH PHONE NUMBER
MAILING ADDRESS
CITY STATE/Province ZIP/Postal Code COUNTRY (if not USA)
8.B. When did you start participating in the plan or program?
8.C. Are you still participating in the plan or program?
YES, I am scheduled to complete the plan or program on:
(date to be completed)
NO, I completed the plan or program on:
(date completed)
NO, I stopped participating in the plan before completing it because:
8.D. What types of services, tests, or evaluations were provided (for example: intelligence or psychological
testing, vision or hearing tests, physical exam, work evaluations, or classes?)
If you need to list another plan or program use Section 11 - Remarks and
give the same detailed information as above
Form SSA-454-BK (06-2020) UF Page 14 of 15
SECTION 9 - DAILY ACTIVITIES
Complete only if you are age 18 years or older.
9.A. Describe what you do in a typical day (for example: I get up around 7 A.M., take a shower, eat
breakfast, etc.).
If you need more space, go to Section 11 - Remarks
9.B. Do you have hobbies or interests?
YES
NO
If YES, please describe what they are and how much time you spend doing them.
9.C. Do you ever have difficulty doing any of the following? (Please explain any "Yes" answers.)
Dressing
YES NO
Bathing
YES NO
Caring for hair
YES NO
Taking medicines
YES NO
Preparing Meals
YES NO
Feeding Self
YES NO
Doing chores (inside/outside house)
YES NO
Driving or using public transportation
YES NO
Shopping
YES NO
Managing money
YES NO
Walking
YES NO
Standing
YES NO
Lifting Objects
YES NO
Using arms
YES NO
Using hands or fingers
YES NO
Sitting
YES NO
Seeing, hearing, or speaking
YES NO
Concentrating
YES NO
Remembering
YES NO
Understanding or following directions
YES NO
Completing tasks
YES NO
Getting along with people
YES NO
Form SSA-454-BK (06-2020) UF Page 15 of 15
SECTION 10 - WORK
Complete only if you are age 14 years or older.
10. Since the date of your last medical disability decision have you worked? (see date at top of Page 3)
YES (If yes, we may contact you for additional information) NO
SECTION 11 - REMARKS
Please write 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 write the requested information, please use this space to tell us the additional requested in those
sections. Be sure to show the section to which you are referring.
Date Report Completed (MM/DD/YYYY)
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Completed 3 July 2020

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