Disability Report - Appeal

If you need more space, use SECTION 10 – REMARKS on the last page.
8. A. Since you last told us about your work, have you worked or has your work changed?
If yes, you will be asked to provide additional information.
Yes No
8. B. Since you last told us about your education, have you completed or are you enrolled in any type of
specialized job training, trade school, or vocational school?
Yes No
If yes, what type? _____________________________________________________________________
Date(s) attended: _____________________________________________________________________
If you need more space, use SECTION 10 – REMARKS on the last page.
9. Since you last told us about your vocational rehabilitation, have you participated, or are you participating in:
an individual work plan with an employment network under the Ticket to Work Program?
an individualized plan for employment with a vocational rehabilitation agency or any other organization?
a Plan to Achieve Self-Support (PASS)?
an individualized education program (IEP) through an educational institution (if a student age 18-21)?
any program providing vocational rehabilitation, employment services, or other support services to help
you go to work?
Yes (Please complete the information below.)
No (Go to SECTION 10 – REMARKS)
If you need more space, use SECTION 10 – REMARKS on the last page.
Form SSA-3441-BK (03-2015) ef (03-2015)
Page 7
SECTION 8 – WORK AND EDUCATION
SECTION 9 – VOCATIONAL REHABILITATION, EMPLOYMENT, OR OTHER SUPPORT SERVICES
SECTION 7 - ACTIVITIES
7. Since you last told us about your activities, has there been any change (for better or worse) in your daily
activities due to your physical or mental conditions? (Examples of daily activities are household tasks,
personal care, getting around, hobbies and interests, social activities, etc.)
Yes
No
Name of Counselor, Instructor, or Job Coach
Address
City State/Province ZIP/Postal Code Country (if not U.S.)
Date when you started participating in the plan or program:
Name of Organization or School
If yes, please describe in detail:
Phone Number
Page 9/10
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