SSDI and YOU: Answer a few simple questions to see if you qualify

Name *

First Name

Last Name

How old are you? *

Under 50 years old

50 - 54

55 - 59

60 or older

Date of Birth *

MM

DD

YYYY

When was the last time you worked? *

Select the option which best describes your situation. If you would like, use the Remarks section below to explain more fully.

I last worked less than 6 months ago

I last worked between 6 months and one year ago

I last worked over a year ago

I last worked 2 - 5 years ago

It's been over 5 years since I last worked

I've never worked

I'm still working

Date of Disability *

When did your disability begin?

MM

DD

YYYY

Which of the following best describes your past work? *

I spent my days on my feet, usually lifting up to around 25 lbs. but sometimes lifting up to 50 lbs. or more

I spent my days on my feet, usually lifting up to around 10 lbs. but sometimes lifting up to around 20 lbs.

I spent my days mostly sitting down

I spent my days some other way (please explain in Remarks below)

Description of Overall Work History *

Select the option which best describes you. If you would like, use the Remarks section below to explain more fully.

I have a strong work history with few, if any, gaps in employment. I have always considered myself a worker.

Work has come and gone, but employment gaps have been relatively few and far between.

My work history is fair; I have worked, on average, about one year out of every two.

My work history is patchy with lots of lengthy employment gaps.

I have no work history.

15-Year Work History Details *

I've maintained the same job for the past 15 years

In the last 15 years, I've had more than one job, but all of my jobs have been the same or very similar

In the last 15 years, I've had different jobs, but they have been mostly in the same field

In the last 15 years, I've had different jobs in different fields

In the last 15 years, I've performed a wide range of different types of work

Other (please explain in Remarks below)

Disability Type *

My disability is only PHYSICAL

My disability is only MENTAL

My disability is BOTH physical and mental

Assistive Devices *

I have a medical need for a WHEELCHAIR, WALKER, TWO CANES, or TWO CRUTCHES

I have a medical need for one cane or one crutch

I use an assistive device even though none have been prescribed

I don't use any assistive devices

Duration of Impairment(s) *

My impairment(s) is/are terminal

My impairment(s) is/are expected to last indefinitely (not expected to get better/go away)

My impairment(s) is/are expected to get better/go away, but is expected to last for at least one year

My impairment is not expected to last at least one year

Treatment *

I am being treated by numerous doctors (MDs, DOs, etc.) and doing everything I possibly can medically to get better.

I am getting some treatment for my impairment(s), but could stand to get more

I am not being treated for my impairment(s)

Support of Doctors *

I have at least one doctor who would be willing to write a letter, or complete a form, on my behalf to support my disability claim

I do NOT have at least one doctor who would be willing to write a letter, or complete a form, on my behalf to support my disability claim

I do not know; I would need to check with my doctor(s)

Representation *

We need to know if you are already represented in your disability claim

I am not already represented and am looking for representation

I am not already represented and am not looking for representation

I am already represented but I am looking for alternative representation

I am already represented I am not looking for alternative representation

Case Status *

I have not yet filed for disability

I have filed an initial application and have not received a decision

I have filed an initial application, which has been denied

I have filed a Request for Reconsideration and have not received a second decision

I have filed a Request for Reconsideration, which has also been denied

I have filed a Request for Hearing and am waiting for a hearing to be scheduled

I have filed a Request for Hearing and a hearing is scheduled

I have received a Notice of Decision - Unfavorable and have not yet appealed

I have received a Notice of Decision - Unfavorable and have already appealed to the Appeals Council

Phone *

Please enter a working phone number (cell or landline)

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