TN 5 (06-20)

DI 12095.030 SSA-3441-BK (Disability Report - Appeal)

A. Link to the current form SSA-3441-BK

To view the current version, go to SSA-3441–BK.

B. When to use the SSA-3441-BK

Use the SSA-3441-BK for all reconsideration and hearings appeal requests about disability issues. Do not use the SSA-3441-BK for appeals to the Appeals Council.

C. How to complete the SSA-3441-BK

1. Overview

The purpose of this form is to collect updated information about the claimant's impairment(s), such as whether there is any change in the impairment(s) (either for better or worse) and whether there is any new or additional impairment(s). Complete all sections of this form with as much pertinent information as possible to present a full and complete picture of the claimant and his or her impairment(s). Completion of the “yes” or “no” blocks of the questions in Sections 2 through 9 is important especially where a positive answer is appropriate. These responses are valuable in updating the claimant’s disability record about the severity and treatment of his or her impairment(s) for subsequent adjudicators of the claim.

REMINDER: Also, enter updated observations and perceptions information in item 9 and, if applicable, items 10 through 12, on the SSA-3367 (Disability Report - Field Office).

2. Specific items

Follow the instructions below for each section. When there is insufficient space to adequately respond to a question in any section, use Section 10 - Remarks to complete the information. Always identify the relevant question number to which the entry refers before entering a remark in Section 10.

a. For SSA use only

Always complete the blocks for the name(s) and social security number(s) prior to mailing out the form or completing it.

b. Section 1 - Information About the Disabled Person

Enter identifying information about the claimant. Complete the claimant's name(s), social security number(s), and primary and alternative phone numbers where we can leave a message. Try to obtain an email address.

NOTE: If the claimant does not have a telephone, make an effort to obtain a telephone number where we can leave a message for the claimant.

c. Section 2 - Contacts

It is extremely important that the Disability Determination Services (DDS) and Office of Disability Adjudication and Review (ODAR) be able to contact someone who knows about the claimant’s impairment(s) and who can help in completing the claim if we have difficulty contacting the claimant directly.

Enter identifying information and language preference about this person in Section 2. For claimants with limited English proficiency (LEP), also complete an SSA-795 Statement Of Claimant Or Other Person as appropriate (see DI 23040.001, DDS: Interpreters for Individuals with Limited English Proficiency (LEP) or Individuals Requiring Language Assistance).

In questions 2.F. through 2.J., identify who is completing the SSA-3441-BK. SSA employees completing this form should enter their official duty contact information.

d. Section 3 - Medical Conditions

Use Section 3 to record any change in the claimant's impairment(s) and identify new impairment(s) since the previous determination and to specify when those changes occurred. Subsequent development may show that a previous denial was correct, but now an allowance (with a later onset) may be proper because the impairment(s) has worsened. Therefore, ensure that you record all impairments that might affect an adult’s ability to work or a child’s ability to function. Record the changes that have occurred (for better or worse) in the claimant's symptoms, limitations, daily needs, and activities since the last time we obtained this information.

e. Section 4 - Medical Treatment

Enter any other names the claimant may have used on medical and educational records, such as maiden names, in Section 4.A. Use Section 4.B. to record whether the claimant has had any medical treatment since we last asked him or her and if he or she has any future appointments scheduled. When the claimant reports new or upcoming medical treatment, complete a medical treatment provider page (i.e., pages 3-5) for each medical source, including medical sources identified on the last disability report. Include location and dates of tests and the name(s) of the doctor, hospital, or clinic that requested the test.

f. Section 5 - Other Medical Information

This section asks for any other new medical information since the last disability report that is not already listed in section 4. This includes the contact information of any person or organization that may have medical information about physical and mental impairment(s) (including emotional and learning problems), such as:

  • workers’ compensation

  • vocational rehabilitation services

  • insurance companies who have paid disability benefits

  • prisons and correctional facilities

  • attorneys

  • social service agencies

  • welfare agencies

  • school and education records

g. Section 6 - Medicines

Record all prescription and non-prescription medications the claimant is currently taking. For each entry, list the prescribing medical source (if any), the reason the claimant uses the medication, and any side effects. Record "none" if there is nothing to enter, such as if there are no reported side effects.

h. Section 7 - Activities

Record any change in the claimant’s daily activities due to the physical or mental impairment(s) since he or she last told us about daily activities. Provide as much detail as possible.

i. Section 8 - Work and Education

Record whether the claimant has worked or the work has changed since we last asked him or her about the work. If the claimant responds "yes" to question 8.A., prepare an SSA-820-BK or SSA-821-BK, whichever is appropriate. If the SSA-3441-BK is returned by mail with question 8.A. checked “yes”, obtain information on an SSA-820-BK or SSA-821-BK, preferably by direct personal contact or by telephone. Follow the instructions in DI 10505.035 (employment) and DI 10510.025 (self-employment) for processing the claim after completing development of work activity.

Use Section 8.B. to record if the claimant completed or enrolled in any type of GED classes, specialized job training, trade school, vocational school, or college classes since he or she last told us about education. Record the type, date(s) attended, and degree(s) attained, if any (and if attained, the date of attainment).

j. Section 9 - Vocational Rehabilitation, Employment, or Other Support Services

Record whether the claimant has participated in the Ticket to Work Program (TWP) or received services from Vocational Rehabilitation or any other organization(s) to help him or her go back to work since the last time he or she responded about vocational rehabilitation. If the claimant has received such services, record the organization’s name and contact information, including the name of the assigned counselor, instructor, or job coach. See DI 14510.003 Field Office (FO) Procedures for Cases Involving Participation in a Vocational Rehabilitation (VR) or Similar Program.

k. Section 10 - Remarks

When there is insufficient space for adequate response to a question in any part of the form, use this section to complete the response. Always identify the corresponding question to which the entry refers before entering the response. Also, use this section to add any point the claimant would like to emphasize; for example, some aspect of the case that he or she believes was not adequately considered in the prior determination.

The person completing the form must complete the "Date Report Completed" at the bottom of Section 10.

To Link to this section - Use this URL:
DI 12095.030 - SSA-3441-BK (Disability Report - Appeal) - 03/13/2015
Batch run: 06/26/2020