Form SSA-455, Disability Update Report Instructions
This form contains 49 fields organized into 1 section. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Name and Address | Text | |
| Address | Text | |
| Claim Number | Text | |
| 1.Within the last 2 years have you worked for someone or been self-employed? Yes | CheckBox | |
| No | CheckBox | |
| If yes, please complete the information below. Work Began (month/year) 1. month | Text | |
| Year | Text | |
| Work Began (month/year) 2. Month | Text | |
| Year | Text | |
| Work Began (month/year) 3. Month | Text | |
| Year | Text | |
| Work Ended (month/year) month | Text | |
| year | Text | |
| Work Ended (month/year) month | Text | |
| year | Text | |
| Work Ended (month/year) month | Text | |
| year | Text | |
| Monthly Earnings | Text | |
| Monthly Earnings | Text | |
| Monthly Earnings | Text | |
| Form SSA-455 (07-2023) Discontinue Prior Editions Social Security Administration DISABILITY UPDATE REPORT Page 1 of 2 O M B Number 0960-0511 Privacy Act Statement Collection and Use of Personal Information Sections 205(ay) and 1631(e)(1)(Ay) and (B) of the Social Security Act, as amended, and Social Security regulations at 20 C.F.R. 404.1589 and 416.989 authorize us to collect this information. We will use the information you provide to further document your claim and permit a determination about continuing disability. Furnishing us this information is voluntary. However, failing to provide us with all or part of the information may prevent an accurate and timely decision on any claim filed. We rarely use the information you supply us for any purpose other than for the reasons explained above. However, we may use the information for the administration of our programs including sharing information: 1. To comply with Federal laws requiring the release of information from our records (e.g., to the Government Accountability Office and Department of Veterans Affairs); 2. To facilitate statistical research, audit, or investigative activities necessary to assure the integrity and improvement of our programs (e.g., to the Bureau of the Census and to private entities under contract with us). A complete list of when we may share your information with others, called routine uses, is available in our Privacy Act Systems of Records Notices entitled, Claims Folders Systems (60-0089) and the Master Beneficiary Record (60-0090). Additional information about this and other system of records notices and our programs are available online at www.socialsecurity.gov or at your local Social Security office. We may share the information you provide to other health agencies through computer matching programs. Matching programs compare our records with records kept by other Federal, State or local government agencies. We use the information from these programs to establish or verify a person’s eligibility for federally funded or administered benefit programs and for repayment of incorrect payments or delinquent debts under these programs | Text | |
| Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget (O M B) control number. The O M B control number for this collection is 0960-0511. We estimate that it will take 15 minutes to read the instructions, gather the facts, and answer the questions. Send only comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401 | Text | |
| Page 2 of 2 2. Check the block which best describes your health within the last 2 years: Better | CheckBox | |
| Same | CheckBox | |
| Worse | CheckBox | |
| No | CheckBox | |
| 3. Within the last 2 years has your doctor told you that you can return to work? Yes | CheckBox | |
| No | CheckBox | |
| 4. Within the last 2 years have you attended any school or work training program(s)? Yes | CheckBox | |
| No | CheckBox | |
| 5. Would you be interested in receiving rehabilitation or other services that could help you get back to work? Yes | CheckBox | |
| No | CheckBox | |
| 6. Within the last 2 years have you been hospitalized or had any surgery? Yes | CheckBox | |
| If yes, please list below: Reason 1 | Text | |
| Date: (month/year) | Text | |
| Date: (month/year) | Text | |
| reason 2 | Text | |
| Date: (month/year) | Text | |
| reason 3 | Text | |
| No | CheckBox | |
| 7. Within the last 2 years have you gone to a doctor or clinic for your condition? Yes | CheckBox | |
| Reason | Text | |
| If yes, show the date and the reason for the visit. 1.Date | Text | |
| Reason | Text | |
| 2.Date | Text | |
| Reason | Text | |
| 3.Date | Text | |
| Telephone Number You are at the end of the form. If you tab again, you will be at the beginning of the form | Text | |
| Date Report Completed (MM/DD/YYYY) | Text |