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

View a detailed, filled-out example of Form SSA-454-BK, the Continuing Disability Review Report. Our sample provides a clear guide on how to complete the CDR form, helping you accurately document medical treatments, work history, and daily limitations for your Social Security disability review.
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Completed Form SSA-454-BK for a Continuing Disability Review related to a physical impairment.

Form SSA-454-BK Example: Continuing Disability Review Report

How this form was filled:

This sample of Form SSA-454-BK is for an individual with a physical disability (degenerative disc disease). It details all medical visits, hospitalizations, and therapies since the last review. The form also documents a recent, unsuccessful work attempt and explains how daily activities continue to be significantly limited by the condition.

Information used to fill out the document:

  • Full Name: Jane A. Smith
  • Social Security Number: XXX-XX-1234
  • Mailing Address: 456 Oak Avenue, Anytown, USA, 54321
  • Primary Disabling Condition: Degenerative Disc Disease and Sciatica
  • Date Form Completed: 04/05/2026
  • Orthopedist Visits: Dr. Robert Brown, appointments on 03/15/2025, 09/20/2025, and 02/10/2026 for pain management and follow-up.
  • Physical Therapy: Dr. Emily White, weekly sessions from October 2025 to January 2026 for core strengthening.
  • Hospital/ER Visits: Anytown General Hospital, ER visit on 11/05/2025 for severe back spasms and pain.
  • Current Medications: Gabapentin 300mg, Ibuprofen 800mg (as needed), Cyclobenzaprine 10mg
  • Recent Work Attempt: Part-time receptionist at Local Office Supply from June 2025 to August 2025. Had to stop due to inability to sit for required periods.
  • Daily Activity Limitations: Cannot sit for more than 30 minutes; difficulty lifting over 10 lbs; needs assistance with grocery shopping and housekeeping.
  • Education/Training Since Last Review: None
  • Third-Party Contact: John Smith (Brother), who is aware of the ongoing limitations.

What this filled form sample shows:

  • Comprehensive listing of all medical treatments, including dates and reasons for visits.
  • Honest and detailed description of a recent unsuccessful work attempt, a critical section for CDRs.
  • Clear explanation of how the disability continues to impact daily life and functional abilities.
  • Inclusion of a knowledgeable third-party contact who can corroborate the reported information.

Form specifications and details:

Form Name: Form SSA-454-BK, Continuing Disability Review Report
Agency: Social Security Administration (SSA)
Use Case: Individual undergoing a periodic Continuing Disability Review (CDR) for a physical impairment.
Purpose: To gather up-to-date information about a beneficiary's medical condition, work activity, and daily functioning to determine if they continue to meet disability requirements.
Categories: disability forms, SSA forms
Created: February 10, 2026 11:17 PM
Completed Form SSA-454-BK for a Continuing Disability Review related to a physical impairment.