How to complete an SSA 454 BK (Step by Step)

When filling out a SSA-454-BK, you will need to print or write clearly.  You must answer every question.  If you do not know the answer or the question does not apply, indicate that on the form.

To complete a SSA-454-BK, you will need to provide the following information:

• Section 1 - Information About the Disabled Person
  • Name
  • Social security number
  • Mailing address
  • Phone number
  • Whether you can speak and understand English
  • Whether you used any other names on your medical or educational records in the last 12 months
• Section 2 - Contacts
  • Friend or relative who knows about medical conditions and can help you with your case
  • Relationship to disabled person
  • Mailing address
  • Daytime phone number
  • Whether the person can speak and understand English
  • Indicate who is completing application and, if someone else, provide their contact information
• Section 3 - Medical Condition(s)
  • If you are an adult, list physical and/or mental conditions that limit your ability to work
  • If you are completing for a child, list physical and/or mental conditions that limit a child's ability to do the same things as other children the same age
  • Height without shoes
  • Weight without shoes
  • Whether you use an assistive device such as: eye glasses, hearing aids, braces, canes, crutches, walkers, wheelchairs, service animals
• Section 4 - Medical Treatment
  • Whether you have seen a health care professional or received treatment for any physical conditions in the past 12 months
  • Whether you have seen a health care professional or received treatment for any mental conditions in the past 12 months
  • Who has your medical records for the past 12 months
    • Name of facility or office
    • Name of healthcare professional that treated you
    • Phone number and address
    • Patient ID number
    • Dates of treatments in office, clinic, outpatient facility, emergency room, and overnight hospital stays
    • What medical treatments were treated or evaluated
    • What treatment did you receive for the above conditions
  • Types of tests and dates given: EKG, treadmill, cardiac catheterization, biopsy, hearing test, speech/language test,vision test, breathing test, EEG, HIV test, blood test, X-ray, MRI/CT scan, other
• Section 5 - Medicines
  • Whether you are taking or haven taken in the past 12 months any prescription or non-prescription medicines
    • Name of medicine
    • Any prescribing doctor
    • Reason for medicine
• Section 6 - Other Medical Information
  • Whether anyone else has medical information about your physical or mental condition(s) covering the last 12 months
    • Name or organization
    • Phone number
    • Mailing address
    • Contact person
    • Claim number
    • Dates of first contact, last contact, and next contact
    • Reason for contacts
• Section 7 - Education and Training
  • Whether you have received any education since your last disability decision
  • What year did you last attended school
  • Education received
  • Whether you received any type of specialized job, trade, or vocational training since your last disability decision
    • Name of training facility
    • Phone
    • Mailing address
    • Type of program
    • Date completed
• Section 8 - Vocational Rehabilitation, Employment, or Other Support Services
  • Since your last medical disability decision, whether you have participated in: an individualized work plan with an employment network under the Ticket to Work Program; an individualized work plan with a vocational rehabilitation agency or any other organization; a Plan to Achieve Self-Support; an Individualized Education Program (IEP) through a school (if a student age 18-21); or any program providing vocational rehabilitation, employment services, or other services to help you go to work.
  • Year you last attended school
  • Name of organization or school
  • Name of counselor, instructor, or job coach
  • Address
  • When you began participating in the program
  • Whether you are still participating in the program
  • What types of services, tests, or evaluations were provided
• Section 9 - Daily Activities
  • Describe what you do in a typical day
  • Describe any hobbies or interests
  • Whether you have any difficulting doing any of the following activities and explanations: dressing, bathing, caring for hair, taking medicines, preparing meals, feeding self, doing chores, driving or using public transportation, shopping, managing money, walking, standing, lifting objects, using arms, using hands or fingers, sitting, seeing, hearing, speaking, concentrating, remembering, understanding or following directions, completing tasks, getting along with people
• Section 10 - Work
  • Whether you have worked since the date of your last medical disability decision
• Section 11 - Remarks
  • Any additional information that was not provided earlier in the report
• Date report completed