TN 1 (02-04)
DI 12095.030 SSA-3441-BK (Disability Report - Appeal)
Most current PDF of SSA-3441–BK.
Obtain the SSA-3441-BK, Disability Report – Appeal, in all appeal requests on disability issues, including those in which forms SSA-782-BK and HA-4486 were formerly used. The SSA-3441-BK calls for identifying all potential sources of medical evidence since the last contact, for updating the information concerning the claimant's condition, including the current effects of the impairment(s), and for identifying any additional impairments that may have occurred since the last contact. See following instructions for completing the SSA-3441-BK.
C. Procedure - Completion of the Disability Report - Appeal, SSA-3441-BK
The general intent of the information on this form is to update the claimant's current condition, including any new or additional impairment(s), and change in the condition (either for better or worse). Complete all items on this form with as much pertinent information as is necessary 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 2-9 is important especially where a positive answer is appropriate. These responses are valuable in updating the claimant’s disability record of the severity and treatment of his or her impairment(s) for subsequent adjudicators of the claim.
Enter updated claimant observations/perceptions information in item 9 of the SSA-3367. Additionally, if applicable, complete items 10-12 on the SSA-3367.
The instructions and description which follow are limited to those sections of the form that warrant explanation.
2. Specific Items
a. Items To Be Completed by SSA
Complete the blocks for the name(s), social security number(s), and level of appeal prior to releasing the form.
b. Section 1 - Information About the Disabled Person
Enter identifying information about the claimant. Obtain the claimant’s telephone number or telephone where a message can be left.
NOTE: It is extremely important that the DDS be able to contact the claimant. If the claimant has no telephone, make an effort to obtain a telephone number where a message can be left. Obtain the name and telephone number of a friend or relative who knows about the claimant’s illnesses, injuries, or conditions and can help in completing the claim.
c. Section 2 - Information About Your Illness, Injuries, or Conditions
The emphasis for completing this section is to record any change in the claimant's condition since the previous determination and specify when those changes occurred. Subsequent development may show that the previous determination was correct, but now an allowance (with a later onset) may be proper because of a worsening medical condition. Therefore, take care to ensure that all impairments that might affect an adult’s ability to work or a child’s ability to function are recorded. Record the changes that have occurred (for better or worse) in the claimant's symptoms, limitations and daily needs and activities since this type of information was last obtained. If the condition has remained stable, enter a statement to that effect.
d. Section 3 - Information About Your Medical Records
Show all pertinent sources of medical information in this section. Identify clinics, laboratories, and other facilities that provide services such as X-ray and laboratory studies, but no actual treatment. List all sources utilized since the last interview, even though they may have been identified on the last disability report.
e. Section 4 - Medications
Indicate all medications the claimant is taking, including those a medical sources(s) has prescribed and any over-the-counter medications to treat the illnesses, injuries, or conditions that the claimant alleges prevent him or her from working (adult) or functioning (child).
Give the names and dosage of medications. If possible, record this information from the prescriptions(s) or prescription containers. If the claimant does not know this information, indicate “medication” and what the medication is for (e.g., back pain, depression, blood pressure, etc.) in the appropriate block.
If the claimant is not experiencing side effects from the medications, enter “none.”
f. Section 5 - Tests
Include the dates the tests were performed and/or the dates of scheduled tests; where the tests were, or will be performed (i.e., clinic, hospital, doctor’s office, etc.); and the name(s) of the doctor, hospital, or clinic that requested the test.
NOTE: Each cited facility or doctor listed in Sections 4 and 5 must also be listed as a medical source in Section 3.
g. Section 6 - Updated Work Information
If the claimant answers question A. “yes,” prepare an SSA-821-F4 or SSA-820-F4 at the time of the interview. When question A. is checked “yes” on an SSA-3441-BK returned by mail, obtain information on an SSA-821-F4 or SSA-820-F4 preferably by direct personal contact or by telephone. Follow the instructions in DI 10501.001 for processing the claim after completing development of work activity.
h. Section 7 - Information About Your Activities
Update this area with any additional information as to how the claimant’s current condition has resulted in changes in his or her daily activities. Make certain to include as much detail as possible.
i. Section 8 - Education/Training Information
Enter information about the claimant’s education and training showing the highest grade completed, details about any special educational classes, and types of schools, such as trade or vocational.
j. Section 9 - Vocational Rehabilitation Information
Indicate if the claimant has participated in the Ticket to Work Program or received services from Vocational Rehabilitation or any other organization(s) to help him or her go back to work. If the claimant has received such services, record the organization’s name, address, assigned counselor, telephone number, date seen, and type of services and/or tests performed.
k. Section 10 - Remarks
When there is insufficient space for adequate response to a question in any previous section, use this section to complete the information being furnished. In doing so, identify the previous question to which the entry refers. Also use the section for any point the claimant would like to emphasize--for example, some aspect of his/her case that he/she feels was not considered in arriving at the prior determination or decision. The information blocks at the end of the Remarks section should be completed by the person who completed the form.