Effective Dates: 11/17/2023 - Present Previous | Next

TN 24 (11-23)

DI 13005.040 Completion of the Form SSA-454-BK (Continuing Disability Review Report) in Adult and Title XVI Child Continuing Disability Review (CDR) Cases

A. Introduction to completing the form SSA-454-BK in adult cases

The SSA-454-BK (Continuing Disability Review Report) collects information necessary for a CDR and expedited reinstatement (EXR) case. The report records the most current information about the person receiving disability benefit's medical condition since the most recent favorable medical decision or the comparison point decision (CPD). This report collects pertinent information about the beneficiary or recipient's medical and non-medical sources and treatments, work status, educational and vocational training, and current daily activities.

NOTE: 

The field office (FO) should not complete the SSA-454-BK in medical improvement not expected (MINE) and MINE-equivalent cases. For more information on MINE cases, see DI 13005.022.

The FO is responsible for informing the person receiving disability benefits, representative payee, or appointed representative that we will collect information to evaluate continuing eligibility for disability payments and that we will determine whether medical improvement has occurred.

NOTE: 

For an Age-18 medical redetermination, use the SSA-3368-BK (Disability Report - Adult).

For additional information on cases involving- an Age-18 medical redetermination see:

For additional information on cases involving Expedited Reinstatement (EXR), see DI 13005.050, Expedited Reinstatements.

For additional information regarding the CDR process, see DI 13005.005, Basis for Deciding Continuance of Disability.

B. Making a determination for a work CDR

The FO determines whether the person receiving disability benefits qualifies, or is already participating in a trial work period (TWP), an extended period of eligibility (EPE), Section 1619, or other work incentive programs (for example, the Ticket to Work program). The FO must make any work-related determination prior to sending a case to the disability determination services (DDS) for a medical review. If the FO determines the need for a full medical CDR, the FO will initiate the CDR process by establishing the review on the Disability Control File (DCF), if it is not already established.

For cases involving a work-related determination, see:

C. Forms to complete for the CDR

For the CDR, the FO must obtain the following forms:

  • •

    A completed SSA-454-BK (Continuing Disability Review Report) or the i454 completed and submitted online by accessing the link on their mySSA account for an adult without a representative payee,

  • •

    SSA-827 (Authorization to Disclose Information to the Social Security Administration (SSA)), and

  • •

    SSA-3367 (Disability Report – Field Office).For procedures on completing the SSA-3367 , see DI 11005.045. For FO electronic case procedures, see DI 81010.0025.

    NOTE: 

    Obtain the paper CPD folder if the CPD folder is not in the Electronic Disability Collect System (EDCS).

The purpose of the SSA-454–BK (Continuing Disability Review Report) is to obtain all of the information the DDS need, but also to avoid duplicative work by the FO, the person receiving disability benefits, or representative payee. To avoid unnecessary work, follow the guidelines in DI 13005.040D in this section.

For references to forms required for a CDR or EXR, see:

  • •

    DI 81010.242, Unable-to-Locate (UTL) Paper Comparison Point Decision (CPD) Folder;

  • •

    DI 13050.045B.2, Obtain EXR Request Package (for Title II);

  • •

    DI 13050.050B.2, Obtain EXR Request Package (for Title XVI); and

  • •

    DI 13005.040E, Completion of Form SSA-454-BK in Title XVI child cases in this section.

NOTE: 

For procedures on completing the form SSA-3367 (Disability Report – Field Office) in EDCS, see DI 81010.025A.

D. Completing the SSA-454-BK (Continuing Disability Review Report)

The person receiving disability benefits, representative payee, or appointed representative, must answer all questions on the SSA-454-BK (Continuing Disability Review Report). For any questions that the person completing the form does not know the answer, enter “not applicable”, “don’t know”, “none”, or “does not apply”.

1. Page 1 – Top Box for “SSA Use Only”

The top of page 1 includes a space for the FO to add the "Date of your last medical disability decision", for example, the CPD see DI 28010.020. This date is used to inform the person completing this form of the last date a medical CDR was completed.

2. Section 1 – Information About You

This section (Items 1A – 1J) collects basic identifying information about the person receiving disability benefits.

3. Section 2 – Someone We Can Contact

This section (Items 2A – 2E) collects:

  • •

    the name,

  • •

    relationship,

  • •

    address,

  • •

    phone number, and

  • •

    language preference

of someone who can assist the person receiving disability benefits with the CDR information, if necessary. This person can be the representative payee, appointed representative, a relative, friend, or any person willing to assist the individual.

4. Section 3 – Medical Information

This section (Items 3A – 3H) collects the following:

  • •

    General medical information to assist us with any records request and information about the illnesses, physical injuries and mental condition(s) that limit the person receiving disability benefit's ability to work.

  • •

    The illnesses, physical injuries and mental condition(s) of a child under age 18 that limit the child’s ability to do the same things as other children of the same age.

  • •

    Information about the person’s medical sources, testing and medications (prescription and non-prescription) within the last 12 months related to physical injuries and mental condition(s) that limit the person’s ability to work. This information is necessary to compare their current condition to the condition at the time of the CPD. The complete names, addresses (including zip code), and telephone numbers of the medical sources are necessary.

    NOTE: 

    The section contains space for up to five treating medical sources. If the person has more than five treating medical sources, add the additional information to Section – 9 Remarks.

  • •

    Information about assistive devices, frequency of use, and prescribing physicians (if any). If a prescribing healthcare provider or physician is listed in this section, the physician’s information should be placed in Item 3D.

5. Section 4 - Work Information

This section (Items 4A – 4B) collects information about any employment or work a person has performed since the last medical disability decision, the CPD. If the individual answers “Yes”, the FO must complete work development before sending the case to the DDS, see DI 13010.000.

6. Section 5 – Support Services

This section (Items 5A – 5C) collects information regarding the person’s participation in any vocational rehabilitation, employment or participation in any type of work support services. If the person is participating in the Ticket to Work program, see DI 55025.010 and DI 14510.003. If the answer to the question is “Yes”, the FO must complete work development before sending the case to DDS, see DI 13010.000. The DDS needs this information to evaluate medical improvement and to determine whether an exception to medical improvement applies. Do not complete this section if the person receiving disability benefits is under age 18.

7. Section 6 – Other Medical Information

This section (Item 6) collects information about any additional sources that have medical information about any of the person’s physical or mental conditions. Examples of other sources include, but are not limited to: social services agencies, welfare agencies, case workers, attorneys, prisons, workers' compensation and insurance companies who have paid you disability benefits. Do not complete this section if the person receiving disability benefits is under age 18.

8. Section 7 – Education, Training and Literacy

This section (Items 7A -7E) collects information about any additional education or training the person has received since the CPD. This section also collects information regarding if the individual can read and write (in any language). If the individual is participating in a vocational rehabilitation program, see DI 14510.003. The DDS need this information to evaluate medical improvement and to determine whether an exception to medical improvement applies. Do not answer these questions in Title XVI childhood cases. Do not complete this section if the person receiving disability benefits is under age 18.

9. Section 8 – Daily Activities

This section collects detailed information about the person’s daily activities. The DDS uses this section to determine how the person’s condition(s) affects the ability to perform substantial gainful activity (SGA). Do not complete this section if the person receiving disability benefits is under age 18.

10. Section 9 – Remarks

This section provides space for any additional information the person completing the form wishes to provide as it relates to the person’s disability.

11. Section 10 – Who Is Completing This Report

This section collects the completion date of this form and the name, relationship, address, phone number, mailing address and email of the person who completed this form if it is not the person receiving disability benefits. This information may be someone who can assist the individual with the CDR information, if necessary. This person can be the representative payee, appointed representative, a relative, friend, or any person willing to assist the person receiving disability benefits.

E. Collecting information for Title XVI child cases

Complete the appropriate questions for the Title XVI childhood case on the form SSA-454-BK (Continuing Disability Review Report). The form SSA-454-BK (Continuing Disability Review Report) identifies the appropriate questions to answer based on the child’s age. Complete the entire SSA-3881-BK (Questionnaire For Children Claiming SSI Benefits) and provide the necessary information for the child CDR on the appropriate age-related function report (SSA-3375-BK through SSA-3379-BK). For electronic FO case procedures, see DI 81010.000.

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0413005040
DI 13005.040 - Completion of the Form SSA-454-BK (Continuing Disability Review Report) in Adult and Title XVI Child Continuing Disability Review (CDR) Cases - 11/17/2023
Batch run: 11/01/2024
Rev:11/17/2023