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pdfDISABILITY REPORT - ADULT - Form SSA-3368-BK
PLEASE READ ALL OF THIS INFORMATION BEFORE YOU BEGIN
COMPLETING THIS FORM
THIS IS NOT AN APPLICATION
IF YOU NEED HELP
If you need help with this form, do as much of it as you can, and your interviewer will help you
finish it. However, if you have access to the Internet, you may access the Disability Report
Form Guide at http://www.socialsecurity.gov/disability/3368/index.htm.
HOW TO COMPLETE THIS FORM
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Please fill out as much of this form as you can before your interview appointment.
Print or write clearly.
DO NOT LEAVE ANSWERS BLANK. If you do not know the answers, or the answer is
"none" or "does not apply," please write: "don't know," or "none," or "does not apply."
IN SECTION 4, PUT INFORMATION ON ONLY ONE DOCTOR/HMO/THERAPIST/
OTHER/HOSPITAL/CLINIC IN EACH SPACE.
Each address should include a ZIP code. Each telephone number should include an area code.
DO NOT ASK A DOCTOR OR HOSPITAL TO COMPLETE THE FORM. However,
you can get help from other people, like a friend or family member.
If your appointment is for an interview by telephone, have the form ready to discuss with us
when we call you.
If your appointment is for an interview in our office, bring the completed form with you or
mail it ahead of time, if you were told to do so.
When a question refers to "you," "your" or the "Disabled Person," it refers to the person who
is applying for disability benefits. If you are filling out the form for someone else, please
provide information about him or her.
Be sure to explain an answer if the question asks for an explanation, or if you want to give
additional information.
If you need more space to answer any questions or want to tell us more about an answer,
please use the "REMARKS" section on Pages 9 and 10, and show the number of the
question being answered.
ABOUT YOUR MEDICAL RECORDS
If you have any medical records and copies of prescriptions at home for the person who is
applying for disability benefits, send them to our office with your completed forms or bring them
with you to your interview. Also, bring any medicine containers with you. If you need the
records back, tell us and we will photocopy them and return them to you.
YOU DO NOT NEED TO ASK DOCTORS OR HOSPITALS FOR ANY MEDICAL
RECORDS THAT YOU DO NOT ALREADY HAVE. With your permission, we will do that
for you. The information we ask for on this form tells us to whom we should send a request for
medical and other records. If you cannot remember the names and addresses of any of the doctors
or hospitals, or the dates of treatment, perhaps you can get this information from the telephone
book, or from medical bills, prescriptions and medicine containers.
Disability Report-Adult-Form SSA-3368-BK
The information that you give us on this form will be used by the office that makes the disability
decision on your disability claim. You can help them by completing as much of the form as you
can.
WHAT WE MEAN BY "DISABILITY"
"Disability" under Social Security is based on your inability to work. For purposes of this claim,
we want you to understand that "disability" means that you are unable to work as defined by the
Social Security Act. You will be considered disabled if you are unable to do any kind of work for
which you are suited and if your disability is expected to last (or has lasted) for at least a year or to
result in death. So when we ask, "when did you become unable to work," we are asking when you
became disabled as defined by the Social Security Act.
The Privacy And Paperwork Reduction Acts
The Social Security Administration is authorized to collect the information on this form under
sections 205(a), 223(d) and 1631(e)(1) of the Social Security Act. The information on this form is
needed by Social Security to make a decision on the named claimant's claim. While giving us the
information on this form is voluntary, failure to provide all or part of the requested information
could prevent an accurate or timely decision on the named claimant's claim. Although the
information you furnish is almost never used for any purpose other than making a determination
about the claimant's disability, such information may be disclosed by the Social Security
Administration as follows: (1) to enable a third party or agency to assist Social Security in
establishing rights to Social Security benefits and/or coverage; (2) to comply with Federal Laws
requiring the release of information from Social Security records (e.g., to the Government
Accountability Office and the Department of Veterans Affairs); and (3) to facilitate statistical
research and such activities necessary to assure the integrity and improvement of the Social
Security programs (e.g., to the Bureau of the Census and private concerns under contract to Social
Security).
We may also use the information you give us when we match records by computer. Matching
programs compare our records with those of other Federal, State, or local government agencies.
Many agencies may use matching programs to find or prove that a person qualifies for benefits
paid by the Federal government. The law allows us to do this even if you do not agree to it.
Explanations about these and other reasons why information you provide us may be used or given
out are available in Social Security offices. If you want to learn more about this, contact any
Social Security office.
PAPERWORK REDUCTION ACT: 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
control number. We estimate that it will take about 60 minutes to read the instructions, gather the
facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR
LOCAL SOCIAL SECURITY OFFICE. The office is listed under U. S. Government
agencies in your telephone directory or you may call Social Security at 1-800-772-1213 (TTY
1-800-325-0778). You may send comments on our time estimate above to: SSA, 6401 Security
Boulevard, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to
this address, not the completed form.
PLEASE REMOVE THIS SHEET BEFORE RETURNING THE COMPLETED FORM.
Form Approved
OMB No. 0960-0579
SOCIAL SECURITY ADMINISTRATION
For SSA Use Only
Do not write in this box.
DISABILITY REPORT
ADULT
-
Related SSN
-
Number Holder
SECTION 1- INFORMATION ABOUT THE DISABLED PERSON
A. NAME (First, Middle Initial, Last)
B. SOCIAL SECURITY NUMBER
-
-
C. DAYTIME TELEPHONE NUMBER (If you do not have a number where we can reach you,
give us a daytime number where we can leave a message for you.)
(
)
-
Area Code
Your Number
Message Number
None
Number
NAME
RELATIONSHIP
ADDRESS
(Number, Street, Apt. No.(If any), P.O. Box, or Rural Route)
DAYTIME
PHONE
City
E. What is your
height without
shoes?
State
ZIP
(
)
-
Area Code
Number
F. What is your weight
without shoes?
feet
inches
pounds
G. Do you have a medical assistance card? (For Example, Medicaid
or Medi-Cal) If "YES," show the number here:
H. Can you speak and understand English?
YES
YES
NO
If "NO," what is your preferred
NO
language?
NOTE: If you cannot speak and understand English, we will provide an interpreter, free of charge.
If you cannot speak and understand English, is there someone we may contact who speaks and
YES
NO (If "YES," and that person is the
understands English and will give you messages?
same as in "D" above show "SAME" here. If not, complete the following information.)
NAME
RELATIONSHIP
ADDRESS
(Number, Street, Apt. No.(If any), P.O. Box, or Rural Route)
City
State
I. Can you read and
understand English?
FORM
SSA-3368-BK (3-2008)
YES
ZIP
NO
DAYTIME
PHONE
(
)
Area Code
J. Can you write more than
your name in English?
ef (03-2008) Use 6-2003 and Later editions Until Supply Is Exhausted
Number
YES
NO
PAGE 1
Disability Report-Adult-Form SSA-3368-BK
D. Give the name of a friend or relative that we can contact (other than your doctors) who
knows about your illnesses, injuries or conditions and can help you with your claim.
SECTION 2
YOUR ILLNESSES, INJURIES OR CONDITIONS AND HOW THEY AFFECT YOU
A. What are the illnesses, injuries, or conditions that limit your ability to work?
B. How do your illnesses, injuries, or conditions limit your ability to work?
C. Do your illnesses, injuries or conditions cause you pain
or other symptoms?
D. When did your illnesses, injuries, or
conditions first interfere with your ability to
work?
E. When did you become unable to work because
of your illnesses, injuries, or conditions?
YES
NO
Month
Day
Year
Month
Day
Year
F. Have you ever worked?
YES
NO
G. Did you work at any time after the date your
illnesses, injuries, or conditions first interfered with
your ability to work?
YES
NO
(If "NO," go to
Section 4.)
H. If "YES," did your illnesses, injuries, or conditions cause you to: (check all that apply)
work fewer hours? (Explain below)
change your job duties? (Explain below)
make any job-related changes such as your attendance, help needed, or employers?
(Explain below)
I. Are you working now?
If "NO," when was the last day you worked?
YES
NO
Month
Day
Year
J. Why did you stop working?
FORM
SSA-3368-BK (3-2008)
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PAGE 2
SECTION 3 - INFORMATION ABOUT YOUR WORK
A. List all the jobs that you had in the 15 years before you became unable to work
because of your illnesses, injuries or conditions.
TYPE OF
BUSINESS
(Example,
Restaurant)
JOB TITLE
(Example, Cook)
DATES WORKED
(month & year)
FROM
TO
RATE OF PAY
(Per hour, day,
week,
month or year)
HOURS DAYS
PER
PER
DAY WEEK
$
$
$
$
$
$
B. Which job did you do the longest?
C. Describe this job. What did you do all day? (If you need more space, write in the
"Remarks" section.)
D. In this job, did you:
Use machines, tools or equipment?
YES
NO
Use technical knowledge or skills?
YES
NO
Do any writing, complete reports, or perform duties like this?
YES
NO
E. In this job, how many total hours each day did you:
Walk?
Stoop? (Bend down & forward at waist.)
Handle, grab, or grasp big objects?
Stand?
Kneel? (Bend legs to rest on knees.)
Reach?
Sit?
Crouch? (Bend legs & back down & forward.)
Write, type, or handle small objects?
Climb?
Crawl? (Move on hands & knees.)
F. Lifting and Carrying (Explain what you lifted, how far you carried it, and how often you did this.)
G. Check heaviest weight lifted:
Less than 10 lbs
10 lbs
20 lbs
50 lbs
100 lbs. or more
Other
H. Check weight frequently lifted: (By frequently, we mean from 1/3 to 2/3 of the workday.)
Less than 10 lbs
10 lbs
25 lbs
50 lbs. or more
I. Did you supervise other people in this job?
Other
YES (Complete items below.)
How many people did you supervise?
NO (If NO, go to J.)
What part of your time was spent supervising people?
Did you hire and fire employees?
J. Were you a lead worker?
FORM
SSA-3368-BK (3-2008)
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YES
NO
YES
NO
PAGE 3
SECTION 4 - INFORMATION ABOUT YOUR MEDICAL RECORDS
A. Have you been seen by a doctor/hospital/clinic or anyone else for the illnesses,
YES
NO
injuries or conditions that limit your ability to work?
B. Have you been seen by a doctor/hospital/clinic or anyone else for emotional or
mental problems that limit your ability to work?
YES
NO
If you answered "NO" to both of these questions, go to Section 5.
C. List other names you have used on your medical records.
Tell us who may have medical records or other
information about your illnesses, injuries or conditions.
D. List each DOCTOR/HMO/THERAPIST/OTHER. Include your next appointment.
1 NAME
DATES
STREET ADDRESS
FIRST VISIT
CITY
STATE
PHONE (
)
Area Code
-
ZIP
-
PATIENT ID # (If known)
LAST VISIT
NEXT APPOINTMENT
Phone Number
REASONS FOR VISITS
WHAT TREATMENT WAS RECEIVED?
2 NAME
DATES
STREET ADDRESS
FIRST VISIT
CITY
STATE
PHONE (
)
Area Code
-
ZIP
-
PATIENT ID # (If known)
LAST VISIT
NEXT APPOINTMENT
Phone Number
REASONS FOR VISITS
WHAT TREATMENT WAS RECEIVED?
FORM
SSA-3368-BK (3-2008)
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PAGE 4
SECTION 4 - INFORMATION ABOUT YOUR MEDICAL RECORDS
DOCTOR/HMO/THERAPIST/OTHER
3. NAME
DATES
STREET ADDRESS
FIRST VISIT
CITY
STATE
PHONE (
)
-
Area Code
ZIP
-
PATIENT ID # (If known)
LAST VISIT
NEXT APPOINTMENT
Phone Number
REASONS FOR VISITS
WHAT TREATMENT WAS RECEIVED?
If you need more space, use Section 9 - Remarks.
E. List each HOSPITAL/CLINIC. Include your next appointment.
1.
HOSPITAL/CLINIC
TYPE OF VISIT
DATES
DATE IN
DATE OUT
DATE FIRST VISIT
DATE LAST VISIT
INPATIENT
STAYS
NAME
(Stayed at least
overnight)
STREET ADDRESS
OUTPATIENT
VISITS
STATE
CITY
ZIP
(Sent home same
day)
PHONE
(
)
-
Area Code
Phone Number
Next appointment
DATES OF VISITS
EMERGENCY
ROOM VISITS
Your hospital/clinic number
Reasons for visits
What treatment did you receive?
What doctors do you see at this hospital/clinic on a regular basis?
FORM
SSA-3368-BK (3-2008)
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PAGE 5
SECTION 4-INFORMATION ABOUT YOUR MEDICAL RECORDS
HOSPITAL/CLINIC
2.
HOSPITAL/CLINIC
TYPE OF VISIT
INPATIENT
STAYS
NAME
DATES
DATE IN
DATE OUT
DATE FIRST VISIT
DATE LAST VISIT
(Stayed at least
overnight)
STREET ADDRESS
OUTPATIENT
VISITS
STATE
CITY
ZIP
(Sent home same
day)
PHONE
(
)
DATES OF VISITS
EMERGENCY
ROOM VISITS
-
Area Code
Phone Number
Next appointment
Your hospital/clinic number
Reasons for visits
What treatment did you receive?
What doctors do you see at this hospital/clinic on a regular basis?
If you need more space, use Section 9 - Remarks.
F. Does anyone else have medical records or information about your illnesses, injuries,
or conditions (Workers' Compensation, insurance companies, prisons, attorneys,
welfare), or are you scheduled to see anyone else?
YES
NO
(If "YES," complete information below.)
NAME
DATES
STREET ADDRESS
FIRST VISIT
CITY
STATE
(
PHONE
)
Area Code
ZIP
-
-
LAST VISIT
NEXT APPOINTMENT
Phone Number
CLAIM NUMBER (if any)
REASONS FOR VISITS
If you need more space, use Section 9 - REMARKS.
FORM
SSA-3368-BK (3-2008)
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PAGE 6
SECTION 5 - MEDICATIONS
Do you currently take any medications for your illnesses, injuries or conditions?
If "YES," please tell us the following: (Look at your medicine containers, if necessary.)
IF PRESCRIBED, GIVE
NAME OF DOCTOR
NAME OF MEDICINE
REASON FOR
MEDICINE
YES
NO
SIDE EFFECTS
YOU HAVE
If you need more space, use Section 9 - Remarks.
SECTION 6 - TESTS
Have you had, or will you have, any medical tests for illnesses, injuries, or conditions?
YES
If "YES," please tell us the following: (Give approximate dates, if necessary.)
NO
KIND OF TEST
WHEN WAS/
WILL TESTS
BE DONE?
(Month, day, year)
WHERE DONE?
(Name of Facility)
WHO SENT YOU FOR
THIS TEST?
EKG (HEART TEST)
TREADMILL (EXERCISE TEST)
CARDIAC CATHETERIZATION
BIOPSY -- Name of body part
HEARING TEST
SPEECH/LANGUAGE TEST
VISION TEST
IQ TESTING
EEG (BRAIN WAVE TEST)
HIV TEST
BLOOD TEST (NOT HIV)
BREATHING TEST
X-RAY -- Name of body part
MRI/CT SCAN -- Name of body
part
If you have had other tests, list them in Section 9 - Remarks.
FORM
SSA-3368-BK (3-2008)
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PAGE 7
SECTION 7-EDUCATION/TRAINING INFORMATION
A. Check the highest grade of school completed.
College:
Grade school:
0
1
2
3
4
5
6
7
8
9
10
11
12 GED
1
2
3
4 or more
Approximate date completed:
B. Did you attend special education classes?
YES
NO
(If "NO," go to part C)
NAME OF SCHOOL
ADDRESS
(Number, Street, Apt. No.(if any), P.O. Box or Rural Route)
City
State
DATES ATTENDED
ZIP
TO
TYPE OF PROGRAM
C. Have you completed any type of special job training, trade or vocational school?
YES
NO
If "YES," what type?
Approximate date completed:
SECTION 8 - VOCATIONAL REHABILITATION, EMPLOYMENT,
or OTHER SUPPORT SERVICES INFORMATION
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;
•
an individualized education program through an educational institution (if a student age 18-21); or
•
any program providing vocational rehabilitation, employment services, or other support services to help
•
you go to work?
YES (Complete the information below)
NO
NAME OF ORGANIZATION OR SCHOOL
NAME OF COUNSELOR OR INSTRUCTOR
ADDRESS
(Number, Street, Apt. No.(if any), P.O. Box or Rural Route)
City
DAYTIME PHONE NUMBER
(
)
Area Code
DATES SEEN
SSA-3368-BK (3-2008)
ZIP
Number
TO
TYPE OF SERVICES,
TESTS OR EVALUATIONS
PERFORMED
FORM
State
ef (03-2008)
(IQ, vision, physicals, hearing, workshops, classes, etc.)
PAGE 8
SECTION 9 - REMARKS
Use this section for any additional information you did not show in earlier parts of this
form. When you are finished with this section (or if you don't have anything to add),
be sure to go to the next page and complete the blocks there.
FORM
SSA-3368-BK (3-2008)
ef (03-2008)
PAGE 9
SECTION 9 - REMARKS
Name of person completing this form if other than the disabled
person (Please print)
Date Form Completed (Month, day, year)
E-Mail Address of person completing this form (optional)
If the person completing this form is other than the disabled person or the person identified in Section 1. Item D.,
please complete the following information.
Daytime Telephone Number
Relationship to Disabled Person
(
Address (Number and street)
City
)
State
ZIP
FORM
SSA-3368-BK (3-2008)
ef (03-2008)
PAGE 10
| File Type | application/pdf |
| File Title | Disability Report - ADULT - Form SSA-3368-BK |
| File Modified | 2009-04-29 |
| File Created | 2008-03-24 |