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.
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 |