Form SSA-454-BK, Continuing Disability Review Report Completed Form Examples and Samples

Explore comprehensive examples and samples of a filled Form SSA-454-BK, the Continuing Disability Review Report. Our detailed guides provide clear instructions on how to complete the form for your Social Security disability review, helping you accurately report your condition.
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Completed sample of Form SSA-454-BK, Continuing Disability Review Report for a physical impairment.

Form SSA-454-BK Example – Review for Physical Impairment

How this form was filled:

This example shows how to complete the Continuing Disability Review Report for someone with a chronic physical condition, such as a severe back injury. It details recent medical treatments, doctor visits, hospitalizations, medications, and limitations in daily activities to provide the SSA with a clear picture of the claimant's current condition.

Information used to fill out the document:

  • Claimant's Name: Jane M. Smith
  • Social Security Number: XXX-XX-1234
  • Mailing Address: 456 Oak Avenue, Anytown, USA, 12345
  • Phone Number: (555) 123-4567
  • Primary Disabling Condition: Herniated Lumbar Disc, Spinal Stenosis
  • Treating Physician: Dr. Robert Jones (Orthopedist)
  • Physician's Address: 789 Pine Street, Anytown, USA, 12345
  • Date of Last Visit: March 10, 2026
  • Reason for Last Visit: Follow-up for chronic back pain and medication management.
  • Next Scheduled Visit: June 15, 2026
  • Recent Hospitalization: Anytown General Hospital, January 5, 2026, for severe back pain and muscle spasms.
  • Other Medical Treatment: Physical Therapy at 'Rehab Solutions', twice weekly from Feb 2026 to present.
  • Medications: Gabapentin 300mg, Meloxicam 15mg
  • Work Attempt: Part-time data entry, August 2025. Stopped after 3 weeks due to inability to sit for required periods.
  • Daily Limitations: Cannot sit for more than 20 minutes, stand for 10 minutes, or lift over 5 pounds. Needs assistance with grocery shopping and housekeeping.
  • Signature Date: April 20, 2026

What this filled form sample shows:

  • Detailed descriptions of medical sources, including doctors, hospitals, and therapy clinics.
  • Clear and concise reporting of recent medical treatments and hospitalizations.
  • Honest and specific explanation of daily activity limitations caused by the condition.
  • Accurate reporting of any work attempts, explaining why the work stopped.

Form specifications and details:

Use Case: Continuing Disability Review (CDR) for a claimant with a chronic physical impairment.
Form Name: Form SSA-454-BK, Continuing Disability Review Report
Issuing Agency: Social Security Administration (SSA)
Categories: disability forms, SSA forms
Created: February 05, 2026 08:13 PM
Completed sample of Form SSA-454-BK, Continuing Disability Review Report for a physical impairment.