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. Obtain an email address, if available.

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

It is extremely important that the Disability Determination Services (DDS) and Office of Hearings Operations (OHO) 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 the identifying information and language preference about this person in Section 2. Use Section 10 – "Remarks" to document the name, address, phone number, and relationship to the claimant of an additional third party contact who knows about the claimant’s medical conditions and can help with their claim. If the claimant refuses to provide any third party contact, use the Remarks section to document the claimant's decision.

To avoid further delay, for internet appeals that do not require contact with the claimant for other development, do not attempt to obtain an additional third party contact. Instead, annotate the following remark: "Internet/mailed-in claim- no additional third party contact obtained" in the EDCS Remarks section and transfer the appeal.

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., document the person completing this report as:

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  The person who is applying for disability,

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  The person listed in 2.A., or

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  Someone else.

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.

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 them and if they have 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.

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:

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  workers’ compensation

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  vocational rehabilitation services

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  insurance companies who have paid disability benefits

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  prisons and correctional facilities

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  attorneys

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  social service agencies

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  welfare agencies

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  school and education records

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.

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

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 (Work Activity Report – Self-Employment) or SSA-821-BK (Work Activity Report – Employee) and SSA-823 (Report of SGA Determination), as 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 in-person 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 they last told us about education. Record the type, date(s) attended, and degree(s) attained, if any (and if attained, the date of attainment).

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 them go back to work since the last time they 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.

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 they believe was not adequately considered in the prior determination.

Provide the "Date Report Completed" at the bottom of Section 10.