Disability Report - Adult, (Internet Version)

Disability Report - Adult

i3368 Screenshots -- Revised

Disability Report - Adult, (Internet Version)

OMB: 0960-0579

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0960-0579 can be found here:

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INTERNET 3368
SCREENSHOTS

PREPARED BY: LOCKHEED MARTIN
JUNE 25, 2009

Table of Contents
[To update the table of contents, select the message below and press F9]
1. Pages ........................................................................................................................................................................4
1.1. Welcome ............................................................................................................................................................4
1.1.1. Not From iClaim..........................................................................................................................................4
1.1.2. From iClaim ................................................................................................................................................5
1.2. Reentry...............................................................................................................................................................6
1.3. Screening Questions ..........................................................................................................................................7
1.4. Overview ............................................................................................................................................................8
1.4.1. Not From iClaim..........................................................................................................................................8
1.4.2. From iClaim ................................................................................................................................................8
1.5. Report Completer ...............................................................................................................................................9
1.5.1. Completing report for myself.......................................................................................................................9
1.5.2. I am an individual helping someone complete report................................................................................11
1.5.2.1. If “Other” option is chosen.................................................................................................................12
1.5.3. I represent an organization helping someone complete the report ...........................................................10
1.6. Personal Information ........................................................................................................................................13
1.6.1. If user has another phone number............................................................................................................14
1.6.2. If user has other names ............................................................................................................................14
1.6.3. If user prefers another language...............................................................................................................14
1.7. Reentry Number ...............................................................................................................................................15
1.7.1. Not From iClaim........................................................................................................................................15
1.7.2. From iClaim ..............................................................................................................................................16
1.8. Someone We Can Contact About Your Conditions ..........................................................................................17
1.8.1. If no other contact checkbox is selected ...................................................................................................18
1.8.2. If “other” relationship is selected ...............................................................................................................18
1.8.3. If contact person prefers another language ..............................................................................................18
1.9. Your Conditions................................................................................................................................................19
1.10. Doctors ...........................................................................................................................................................20
1.10.1. Tests.......................................................................................................................................................23
1.10.2. If user selects “Other” test ......................................................................................................................23
1.10.3. After user selects Done with this Doctor button ......................................................................................24
1.11. Hospitals.........................................................................................................................................................25
1.11.1. If user selects a test that requires a body part description......................................................................28
1.11.2. If user selects “Other” test ......................................................................................................................28
1.11.3. Hospital Table.........................................................................................................................................29
1.12. Tests...............................................................................................................................................................30
1.12.1. Test Details.............................................................................................................................................31
1.12.1.1. Enter Body Part...............................................................................................................................31
1.12.1.2. Other Test .......................................................................................................................................31

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1.12.1.3. If “Other” doctor sent user for the test .............................................................................................31
1.13. Medicines .......................................................................................................................................................32
1.13.1. If user enters “Other Doctor”...................................................................................................................32
1.13.2. Medicines Table......................................................................................................................................33
1.14. Other Medical Records...................................................................................................................................34
1.14.1. Other Medical Records table ..................................................................................................................36
1.15. Work/Education Introduction ..........................................................................................................................37
1.16. Work Activity...................................................................................................................................................38
1.16.1. Work Activity if user never worked..........................................................................................................38
1.16.2. Work Activity if user stopped working .....................................................................................................38
1.16.2.1. Other reasons .................................................................................................................................38
1.16.2.2. Changes in work activity .................................................................................................................39
1.16.3. Work Activity if user is currently working.................................................................................................39
1.16.3.1. If user says conditions did cause changes to work activity: ............................................................39
1.17. Job History .....................................................................................................................................................41
1.17.1. Job History if user never worked ............................................................................................................41
1.17.2. Job History if user stopped working ........................................................................................................42
1.17.2.1. User selects 1 job ...........................................................................................................................43
1.17.2.2. If user selected “Other” as weight lifted...........................................................................................45
1.17.2.3. If user Supervised People ...............................................................................................................46
1.17.2.4. If user selects 2-5 jobs ...................................................................................................................46
1.17.2.5. If a user selects “more than 5” jobs................................................................................................47
1.17.3. Job History currently working..................................................................................................................50
1.18. Education .......................................................................................................................................................51
1.18.1. Special Training ......................................................................................................................................52
1.18.2. Special Education ...................................................................................................................................52
1.19. Remarks .........................................................................................................................................................53
1.20. Review............................................................................................................................................................54
1.21. Printing Instructions ........................................................................................................................................58
1.21.1. If user answers yes.................................................................................................................................59
1.21.2. If user answers no ..................................................................................................................................60
1.22. Submit ............................................................................................................................................................60
1.23. Receipt ...........................................................................................................................................................61
1.24. Next Steps......................................................................................................................................................65
1.24.1. Not From iClaim......................................................................................................................................65
1.24.2. From iClaim ............................................................................................................................................66

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1. Pages

1.1. Welcome
1.1.1. Not From iClaim

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1.1.2. From iClaim

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1.2. Reentry
Once a user receives a Reentry Number, the user can log out of the report and come back at a later time.
This is the screen the user sees if user goes to the web site that is given when user gets reentry number
(on Reentry Number page).

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1.3. Screening Questions

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1.4. Overview
1.4.1. Not From iClaim

1.4.2. From iClaim

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1.5. Report Completer
1.5.1. Completing report for myself
If user selects the first radio button, the next step is to click the Next button

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1.5.2. I represent an organization helping someone complete the report
If user selects the second radio button, the following fields appear.

Relationship dropdown options
Select
Government Agency
Law Firm/Attorney
Non-attorney Representative
Not-for-Profit Social Agency
Health Services Agency/Hospital
Insurance Company
For Profit Organization
Nursing care facility
Homeless shelter

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1.5.3. I am an individual helping someone complete report
If user selects the third radio button, the following fields appear.

Relationship dropdown options:
Select Relationship
Husband or Wife
Father
Mother
Child
Brother
Sister
Other Family Member (e.g. aunt)
Friend
Social Service Agency Worker
Legal Representative or Attorney
Other

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1.5.3.1. If “Other” option is chosen

If user selects the “Other” option, the following field appears below the Relationship dropdown.

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1.6. Personal Information

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1.6.1. If user has another phone number
If user says there is another number where user can be reached, the following fields appear below the
question.

1.6.2. If user has other names
If user says he has other names, the following fields appear below the question.

1.6.3. If user prefers another language
If user says he prefers another language, the following field appears below the question.

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1.7. Reentry Number
1.7.1. Not From iClaim

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1.7.2. From iClaim

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1.8. Someone We Can Contact About Your Conditions

Relationship dropdown options
Select Relationship
Husband or Wife
Father
Mother
Child
Brother
Sister
Other Family Member (e.g. aunt)
Friend
Social Service Agency Worker
Legal Representative or Attorney
Other

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1.8.1. If no other contact checkbox is selected

1.8.2. If “other” relationship is selected
If user selects “Other” from the Relationship dropdown, the following field appears below the question.

1.8.3. If contact person prefers another language
If user prefers another language, the following field appears below the question.

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1.9. Your Conditions

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1.10. Doctors
This screenshot shows the screen with all the “yes” radio buttons answered to show all the possible entry
fields that appear when “yes” is selected.

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1.10.1. Tests
If user selects a test that requires specifying a body part, an extra field appears named “Enter Body Part” in which the
user must enter the body part that was tested.

1.10.2. If user selects “Other” test
User will be asked to describe the test and the body part.

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1.10.3. After user selects Done with this Doctor button
A table is shown with the entered data. User can add another doctor by selecting the Add Doctor button below the
table.

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1.11. Hospitals
This screenshot shows the Hospitals page when all of the radio button questions are answered “yes” to show all the
possible entry fields that appear when “yes” is selected.

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1.11.1. If user selects a test that requires a body part description
Refer to “Tests” section under the Doctors screens

1.11.2. If user selects “Other” test
Refer to “Tests” section under the Doctors screens

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1.11.3. Hospital Table
After clicking the Done with this Hospital button, the user will see a table that lists all the hospitals and clinics that the
user has entered so far.

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1.12. Tests
If user did enter tests on the previous pages, the Tests tab will appear with a table listing the information that was
previously entered. To add another test to the list, click the Add Test button.

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If a user did not enter tests on the previous pages, the Tests tab will appear like the following screen. Once a user
selects Done with this Test button, the user sees the Tests screen with the filled in table.

1.12.1. Test Details
1.12.1.1. Enter Body Part
Refer to “Tests” section under the Doctors screens
1.12.1.2. Other Test
Refer to “Tests” section under the Doctors screens
1.12.1.3. If “Other” doctor sent user for the test

If user selects “other” option under the “Who sent you or will send you for this test” question, user sees
the following buttons that allow user to take user back to Doctor or Hospital page and add an additional
doctor or hospital that user may have forgotten to enter.

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1.13. Medicines
If user did not enter any medicines on previous pages, the Medicines tab looks like this.

1.13.1. If user enters “Other Doctor”
If user selects “other” option under the “Who prescribed or suggested this medicine” question, user sees
the following buttons that allow user to take user back to Doctor or Hospital page and add an additional
doctor or hospital that user may have forgotten to enter.

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1.13.2. Medicines Table
If user did enter medicines on previous pages, the Medicines tab will appear with a table listing the information that
was previously entered. To add another medicine to the list, click the Add Medicine button.

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1.14. Other Medical Records

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1.14.1. Other Medical Records table

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1.15. Work/Education Introduction

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1.16. Work Activity
1.16.1. Work Activity if user never worked

1.16.2. Work Activity if user stopped working

1.16.2.1. Other reasons

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If user selects last two radio button options under “Why did you stop working” they will see this:

1.16.2.2. Changes in work activity
If user says condition caused changes in work activity, user is asked

1.16.3. Work Activity if user is currently working

1.16.3.1. If user says conditions did cause changes to work activity:

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1.17. Job History
1.17.1. Job History if user never worked

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1.17.2. Job History if user stopped working

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1.17.2.1. User selects 1 job
Only when a user selects one job does the report ask for job details. When other job amounts are selected, only brief
job descriptions are asked.

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1.17.2.2. If user selected “Other” for weight lifted amounts

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1.17.2.3. If user Supervised People

1.17.2.4. If user selects 2-5 jobs
User is asked to enter information based upon the number of jobs selected. If two jobs are selected, two areas
appear to enter brief descriptions of those jobs.

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1.17.2.5. If a user selects “more than 5” jobs
User sees 5 areas to enter job descriptions as well as a confirmation at the bottom of the screen that user has had
more than 5 jobs.

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1.17.3. Job History currently working
Refer to Job History stopped working for screenshots.

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1.18. Education

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1.18.1. Special Training
If user answers “yes” to special training question, the following fields appear:

1.18.2. Special Education
If user answers “yes” to special education question, the following fields appear:

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1.19. Remarks

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1.20. Review
The Review page shows all of the data that a user has entered in the following format. The edit buttons take the user
back to the original page on which the user entered the information. If a user does click the Edit button on this page, a
“Return to Review” button will appear on the bottom of the page that the user is editing so the user can easily return
to the Review page after editing the necessary data.

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1.21. Printing Instructions

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1.21.1. If user answers yes to printer question
The following text will appear below the question.

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1.21.2. If user answers no
The following text will appear below the question.

1.22. Submit
There is no Submit button at the top to encourage users to read the page.

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1.23. Receipt
This page will be very similar to the Review page. Two exceptions are: the text at the top is only on the Receipt page,
and this page is formatted differently for optimal printing. Users will see all the information that they have entered and
submitted on this page.

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1.24. Next Steps
1.24.1. Not From iClaim

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1.24.2. From iClaim

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File Type	application/pdf
File Title	Table of Contents
Author	Fujitsu
File Modified	2009-06-29
File Created	2009-06-29