Form SSA-3368 Disability Report - Adult -- Revised Version

DISABILITY REPORT - ADULT
SSA-3368-BK

PLEASE READ THIS INFORMATION BEFORE COMPLETING THIS REPORT
The information you give us on this report will be used by the office that makes the disability
decision on your disability claim. Completing this report accurately and completely will help us
expedite your claim. Please complete as much of the report as you can.
IF YOU NEED HELP
You can get help from other people, such as a friend or family member. Please do not ask
your health care provider to complete this report. If you cannot complete the report, a Social
Security Representative will assist you. If you have an appointment, please have the
completed report ready when we contact you. If we ask you to do so, please mail the
completed report to us ahead of time.
Note: If you are assisting someone else with this report, please answer the questions as if that
person were completing the report.

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HOW TO COMPLETE THIS REPORT
• Print or write clearly.
• Include a ZIP or postal code with each address.
• Provide complete phone numbers including area code. If a phone number is outside the
United States, also provide International Direct Dialing (100) code and country code.
• If you cannot remember the names and addresses of your health care providers, you may
be able to get that information from the telephone book, Internet, medical bills,
prescriptions, or prescription medicine containers.
• ANSWER EVERY QUESTION, unless the report indicates otherwise. If you do not know
an answer, or the answer is "none" or "does not apply," please write: "don't know," or
"none," or "does not apply."
• 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 question, please use Section 11 - Remarks on the
last page to finish your answer. Write the number of the question you are answering.

YOUR MEDICAL RECORDS
If you have any of your medical records, send or bring them to our office with this completed
report. Please tell us if you want to keep your records so we can return them to you. If you are
having an interview in our office, bring your medical records, your prescription medicine
containers (if available), and the completed report with you.
YOU DO NOT NEED TO ASK DOCTORS OR HOSPITALS FOR ANY MEDICAL RECORDS
THAT YOU DO NOT A LR ADY HAVE. With your ermission, we will request your records.
The information that you give us on this report tells us where to request your medical and
other records.
FORM

SSA-3368-BK (01-2010) ef (04-2010) (Destroy Prior Editions)

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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 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 is expected 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 Act

See Revised Privacy Act Statement Attached

Sections 205(a), 223(d), and 1631(e) (1) of the Social Security Act, as amended, authorize us to
collect this information. The information you provide will be used to make a decision on the named
claimant's claim. While giving us the information on this report 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. We generally use the information you supply for the purpose of making decisions
regarding claims. However, we may use it for the administration and integrity of Social Security
programs. We may also disclose information to another person or to another agency in
accordance with approved routine uses, which include but are not limited to the following: (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
about Social Security records (e.g., to the Government Accountability Office and the Department
of Veterans Affairs); (3) to make determinations for eligibility in similar health and income
maintenance programs at the Federal, State, and local level; and (4) to facilitate statistical
research, audit, or investigative activities necessary to assure the integrity of Social Security
programs.
We may also use the information you provide in computer matching programs. Matching programs
compare our records with records kept by other Federal, State, or local government agencies.
Information from these matching programs can be used to establish or verify a person's eligibility
for Federally-funded or administered benefit programs and for repayment of payments or
delinquent debts under these programs.
Additional information regarding this form, routine uses of information, and our programs and
systems, is available on-line at www.socialsecurlty.gov or at any local Social Security office.

See Revised PRA Attached
This inf rmati n 1\ ti n meets th r uirements 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 THE OFFICE THAT REQUESTED IT. If you do
not have that address, you may call Social Security at 1-800-772-1213 (TIY 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.

AFTER COMPLETING THIS REPORT, REMOVE THIS SHEET AND
KEEP IT FOR YOUR RECORDS

FORM

SSA-3368-BK (01-2010) ef (04-2010)

Form Approved

SOCIAL SECURITY ADMINISTRATION

OMB No. 098IJ-0579

For SSA Use Only- Do not write in this box.

DISABILITY REPORT
ADULT

Related SN _ _ _ _ _ _ _ _ __
Number Holder

If you are filling out this report for someone else, please provide information about him or her. When a
question refers to "you" or "your," it refers to the person who is applying for disability benefits.
SECTION 1 - INFORMATION ABOUT THE DISABLED PERSON
1.A. Name (First, Middle Initial , Last)
1.B. Social Security Number

1.C. Mailing Address (Street or POBox) Include apartment number or unit if applicable.
State/Province

City

ZIP/Postal Code

Country (If not USA)

1.0. Email Address

1.E. Daytime Phone Number, including area code, and the 100 and country codes if you live outside the USA or
Canada.
Phone number

o

Check this box if you do not have a phone or a number where we can leave a message.

1.F. Alternate Phone Number - another number wh re we may reach you, if any.
Alternate phone number

1.G. Can you speak and understand English?

DYES

0

NO

If no, what language do you prefer?
If you cannot speak and understand English, we will provide an interpreter, free of charge.

1.1. Can you write more than your name in English?

D YES

D NO

DYES

DNO

1.J. Have you used any other names on your medical or educational records? Examples are maiden name,
other married name, or nickname.
0 YES 0 NO
If yes, please list them here:
SECTION 2 - CONTACTS
iva t e name of so eone (other than your doctors) we can contact who knows about your medical
conditions. and can hel ou with our claim.
2.A. Name (First, Middle Initial, Last)
2.B. Relationship to you

2.C. Daytime Phone Number (as described in 1.E. above)

2.0. Mailing Address (Street or POBox) Include apartment number or unit if applicable.
Slale/Provlnce

2. E. Can this person speak and understand English?

ZIP/Postal Code
DYES

If no. whallanguage is preferred? - - - - - - - - - - - -FORM

SSA-3368-BK (01-2010) ef (04-2010) (Destroy Prior Editions)

Country (If not USA)
D NO

-------PAGE 1

SECTION 2 - CONTACTS (continued)
2.F. Who is completing this report?

o The person who is applying for disability. (Go to Section 3 - Medical Conditions)
o The person listed in 2.A. (Go to Section 3 - Medical Conditions)
o Someone else (Complete the rest of Section 2 below)

2.G. Name (First, Middle Initial, Last)

2.H. Relationship to Person Applying

2.1. Daytime Phone Number

2.J. Mailing Address (Street or POBox) Include apartment number or unit if applicable.
State/Province

City

Zip/Posta! Code Country (If not USA)

SECTION 3 - MEDICAL CONDITIONS
3.A. List all of the physical or mental conditions (including emotional or learning problems) that limit your ability
to work. If you have cancer, please include the stage and type. List each condition separately.

1.

(

'2.

I

3.

!,

'4.

,I

5.

I
If you need more space, go to Section 11 - Remarks on the last page

3.B. What is your height without shoes?

OR

feel

Inches

3.C. What is your weight without snoes?

SECTION 4 - WORK ACTIVITY
4.A . Are you currently work ng?

o No, I have never worked (Go to question 4.B. below)
o No, I have stopped working (Go to question 4.C. below)
4 .F. n page

4.B. When do you believe your condition(s) became severe enough to keep you from working (even though you
have never worked)? (month/day/year)
(Go to Section 5 on page 3)
IF YOU HAVE STOPPED WORKING:
4.C. When did you stop working? (month/day/year)
Why did you stop working?
Because of my condition(s).

o
o Because
of other reasons. Please explain why you stopped working (for example: laid off, early
retirement, seasonal work ended, business closed)

Even though you stopped working for other reasons, when do you believe your
condition(s) became severe enough to keep you from working? (month/day/year)
4.0. Did your condition(s) cause you to make changes in your work activity? (for example:
job duties, hours, or rate of pay)
No (Go to Section 5 - Education and Training on page 3)

o
o Yes

FORM

When did you make changes? (month/day/year)

SSA-3368-BK (01-2010) ef (04-2010)

PAGE 2

SECTION 4 • WORK ACTIVITY (continued)
in any month? Do n t count
4.E. Smce the date In 4.0 . above, have you had gross earnings greater than
1010
sick leave, vacation, or disability pay. (We may contact you for more information.)
D No (Go to Section 5) D Yes (Go to Section 5)

J

IF YOU ARE CURRENTLY WORKING:
4.F. Has your condition(s) caused you to make changes in your work activity? (for example: job duties or hours)

o No
o Yes

When did your condition(s) first start bothering you? (month/day/year)

I OJ ()

When did you make changes? (month/day/year)

4.G. Since your condition(s) first bothered you, have you had gross earnings greater than ~ao... in any month?
Do not count sick leave, vacation, or disability pay. (We may contact you for more information.)
D NO

DYES

SECTION 5 - EDUCATION AND TRAINING
College:

5.A. Check the highest grade of school completed.

o

1

2

3

4

5

6

7

8

9

10

11

o 0 0 0

0

0

0

0

0

0

0

o 0 0

12

GEO

1

2

3

4 or more

0000

Date completed:

S.B. Did you attend special education classes?

DYES

D NO (Go to S.C.)

Name of School
City

State/Province

Dates attended special education classes:

Country (If not USA)

from

to

S.C. Have you completed any type of specialized job training, trade, or vocational school?
DYES

If "Yes," what type?

Date completed:

ONO

----------------.....

If you need to list other education or training use Section 11 - Remarks on the last page.

SECTION 6 • JOB HISTORY
6.A. List the jobs (up to 5) that you have had in the 15 years before you became unable to work
because of your physical or mental conditions. List your most recent job first.

o

Check here and go to Section 7 on page 5 if you did not work at all in the 15 years before you became unable to
WrK

Job Title

Type of
Bu Jness

Dates Wor ed

From
MM/YY

To

MMJYY

Hours
Per
Day

Days
Per
Week

Rate of Pay
Amount

1

2

-3
4.
5.
FORM

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PAGE 3

Frequency

SECTION 6 - JOB HISTORY (continued)
Check the box below that applies to you.

o

I had only one job in the last 15 years before I became unable to work. Answer the questions below.

o

I had more than one job in the last 15 years before I became unable to work. Do not answer the
questions on this page; go to Section 7 on page 5. (We may contact you for more information.)

IDo not complete this page if you had more than one job

In

the last 15 years before you became unable to work.

I

6.B. Describe this job. What did you do all day? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

(If you need more space, use Section 11 • Remarks on the last page.)

6.C. In this job, did you:
Use machines, tools or equipment?

DYES

Use technical knowledge or skills?

DYES

Do any writing, complete reports, or perform any duties like this?

0

YES

DNa
DNa
DNa

6.0. In this job, how many total hours each day did you do each of the tasks listed:
Task

Hours

Task

Hours

Hours

Task

Walk

Stoop (Bend down & forward at waist.)

Handle large objects

Stand

Kneel (Bend legs to (est Of) knees.)

Write. type or handle small objects

Sit

Crouch (Bend legs & back down & forward.)

Reach

Climb

Crawl (Move on hands & knees.)

6.E. Lifting and carrying (Explain in the box below, what you lifted, how far you carried it, and how often you
did this in your job.)

6.F. Check heaviest weight lifted:

o Less than 10 Ibs. o

10 Ibs.

0

0

20 Ibs.

50 Ibs.

0

100 Ibs. or more

0

Other

6.G. Check weight frequently lifted: (by frequently, we mean from 1/3 to 213 of the workday.)

o Less than 10 Ibs. o

10 Ibs.

0

0

25 Ibs.

50 Ibs. or more

6.H. Did you supervise other people in this job?

0

o

Other

YES (Complete items below.)

0

NO (if No, go to 6.1.)

How many people did you supervise? _ _ _ _ __
What part of your time did you spend supervising people?
Did you hire an fire employees?

6.1. Were you a lead worker?
FORM

0

YES

0

NO

0

YES

0

NO

SSA·3368·BK (01-2010) et (04-2010)

PAGE 4

SECTION 7 • MEDICINES
7. Are you taking any medicines (prescription or non-prescription)?

D YES

(Give the information requested below. You may need to look at your medicine containers.)

D NO

(Go to Section 8 • Medical Treamen!.)

Name of Medicine

If prescribed, give name of
doctor

Reason for medicine

If you need to list other medicines, go to Section 11 • Remarks on the last p age.

SECTION 8 • MEDICAL TRIEATMENT

Have you seen a doctor or other health care professional or received treatment at a hospital or clinic, or do ~ou
have a future appointment scheduled?
B.A. For any physical condition(s)?

DYES D NO
B.B. For any mental condition(s) (Including emotional or learning problems)?

DYES DNO

If you answered "No" to both B.A. and 8.B., go to
Section 9 • Other Medical Information on page 11.

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SSA·336B·BK (01·2010) ef (04·2010) (Destroy Prior Editions)

PAGE 5

SECTION 8 - MEDICAL TREATMENT (continued)
Tell us who may have medical records about any of your phy ical and/or mental condition(s) (including
emotional or learning problems) that limit your ability to work. This includes doctors' offices, hospitals (including
emergency room visits), clinics, and other health care facilities. Tell us about your next appointment, if you
have one scheduled.
8.C. Name of Fadlity or Office

Name of health care professional who treated you

ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROVIDER ABOVE.

Mailing Address

I

I

StatefProvlnce

City

I

ZIP/Postal Code

Country (If not USA)

I Dates of Treabnent

I

1. OffIce, Clinic or Outpatient visits
First Visit

2. Emergency Room visits
List the most recent dale first

3. Overnight hospital stays
Ust the most recent date first

A.

A. Date in

Date out

B.

B. Date in

Date out

C.

c.

Date out

Last Visit
Next scheduled appointment (if any)
te in

What medical conditions were treated or evaluated?

What treatment did you receive for the above conditions? (Do not describe medicines or tests in this box.)

Check this box If no tests by this provider or at this facility.
Kind of Test

Dates of Tests

Kind of Test

o EKG (heart lest)
o Treadmill (exercise test)
o Cardiac Calheterlzation
o Biopsy (list body part)

ID EEG (brain wave lest)

o Hearing Test
o Speech/Language Test
o Vision Test

o
body part)
o Other (please describe)

o

Dates of Tests

o HIVTesl

o Blood Test (nol HIV)
OX-Ray (lisl body part)
MRI/CT Scan (Us\

rea hi 9 Tas

If you do not have any more doctors or hospitals to describe, go to Section 9 on page 11.

FORM

SSA-3368-BK (01-2010) ef (04-2010)

PAGE 6

SECTION 8· MEDICAL TREATMENT (continued)
TeU us who may have medical records about any of your physical andlor mental condition(s) (including
emotional or learning problems) that limit your ability to work. This includes doctors' offices, hospitals (inc:ludlng
emergency room visits), clinics, and other health care facilities. TeU us about your next appointment, if you
have one scheduled.

8,0. Name of Facility or Office

Name of health care professional who treated you

ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROVIDER A BOVE.
Phone Number

Ipatient 10# (if known)

Mailing Address
ZIP/Postal Code

tate/Province

City

Country (If not USA)

Dates of Treatment
1. Office, Clinic or Outpatient visits
First Visit

2. Emer ency Roo m visit
List the most recent date first

3. Overnight hospital stays
List the most recent date first

A.

A. Dale In

Date out

B

B. Dale In

Date out

c

C. Date in

Date out

Last Visit
Next scheduled app Intmenl (if any)

What medical conditions were treated or evaluated?

What treatment did you receive for the above conditions? (Do not describe medicines or tests in this box.)

TeU us about any tests this provide periormed or sen you 0 , or as cheduled you 0 a e'. Please give the
dates for past and future tests. If you need to list more tests, use Section 11 - Remarks on the last page.

Checl< t his box if no tests by this provider or at this facUlty.
Kind of Test

Dates of Tests

o EKG (heart test)
o Treadmill (exercise test)
o Cardiac Catheterization

o Biopsy (list body part)
o Hearing Tesl
o SpeechfLanguage Test
o Vision Test
tJ

a hi 9

Kind of Test

Dates of Tests

[J EEG (brain wave test)

ID HIV Test

ID Blood Test (not HIV)
OX-Ray (Hst body part)

o MRIICT Scan (lisI body part)
o Other (please describe)

est

If you do not have any more doctors or hospitals to describe, go to Section 9 on page 11.

FORM

SSA·3368·BK (01-2010) et (04-2010)

PAGE 7

SECTION 8 - MEDICAL TREATMENT (continued)
Tell us who may have medical records about any of your phy sical and/or mental condition(s) (including
emotional or learning problems) that limit your ability to work. This includes doctors' offices, hospitals (including
emergency room visits), clinics, and other health care facilities. Tell us about your next appointment, if you
have one scheduled.
8.E. Name of Facility or Office

Name of health care professional who treated you

ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROVIDER ABOVE.
Phone Number

Ipatient 10# (if known)

Mailing Address
ZIPlPostal Code

StalelProvince

City
Dates of Treatment
1. OffIce, Clinic or Outpatient visits
First Visit

Country (If not USA)

2. Emergency Room visits
list the most recent date first

3. Overnight ho pital stays
list the most recent date first

A.

A. Date in

Date out

B.

B. Date in

Date out

C.

C. Date in

Date out

Last Visit

-----------------

Next scheduled appointment (if any)

What medical conditions were treated or evaluated?

What treatment did you receive for the above conditions? (Do not describe medicines or tests in this box.)

e I us about any es s this provider performed or sent you to, or has scheduled you to take. Please give the
dates for past and future tests. If you need to list more tests, use Section 11 - Remarks on the last page.
Check this box if no tests by this provider or at t his f3Clllty.

Kind of Test

Date of Tests

o EKG (heart test)
o Treadmill (exercise test)
o Cardiac Catheterization
o Biopsy (ltst body part)
o Hearing Test
o Speech/Language Test
o Vision Tesl
'0

Kind of Test

Dates of Tests

o EEG (brain wave test)
o HIVTesl
o Blood Test (not HIV)
o X-Ray (list body part)
o MRIICT Scan (list body part)

o Other (please descnbe)

B aathing Te

If you 0 not hav e any more d oct ors or hospitals t o d escribe, go to Sect io n 9 on page 11.

FORM

SSA-3368-BK (01-2010) ef (04-2010)

PAGE 8

SECTION B - MEDICAL TREATMENT (continued)
Tell us who may have medical records about any of your physical and/or mental condition(s) (including
emotional or learning problems) that limit your ability to work. This includes doctors' offices, hospitals (ineluding
emergency room visits), clinics, and other health care facilities. Tell us about your next appointment, if you
have one scheduled.
B.F. Name of Facility or Office

Name of health care professional who treated you

ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROVIDER ABOVE.
Phone Number

Ipatient 10# (if known)

Mailing Address
ZIPlPostal Gode

State/Province

City

Country (If not USA)

Dates of Treatment

1. Office, Clinic or Outpatient visits
First Visit

2. Emergency Room vlsits
Ust the most recent date first

list the most recent date first

A

A. Date in

Dale out

B

B. Dale In

Dale out

c

c.

Date out

3. Overnight hospital stays

Last Visit

Next scheduled appointment (if any)

Date In

What medical conditions were treated or evaluated?

What treatment did you receive for the above conditions? (Do not describe medicines or tests in this box.)

Tell us about any tests this provider performed or sent you to, or has scheduled you to take. Please give the
dates for past and future tests. If you need to list more tests, use Section 11 - Remarks on the last page.

Check this box If no tests by this provider or at this facility.
Kind ofTe t

o EKG (heart test)
o Treadmlll (exercise lest)
o Cardiac Catheterization

o Biopsy (list body part)
o Hearing Test

o SpeechlLanguage Test
o Vision Test
o Breathing Tesl

Dates of Tests

Dates of Tests

KInd of Test

o EEG (brain wave lest)
o HIVTest
o Blood Test (not HIV)
o X-Ray (list body part)
o MRIICT Scan (list body part)

o Other (please deSCribe)

I

I

If you do not have any more doctors or hospitals to describe, go to Section 9 on page 11.

FORM

SSA-3368-BK (01-2010) ef (04-2010)

PAGE 9

SECTION 8 - MEDICAL TREATMENT (continued)
Tell us who may have medical records about any of your physical andlor mental condition(s} (including
emotional or learning problems) that limit your ability to work. This includes doctors' offices, hospitals (including
emergency room visits), clinics, and other health care facilities. Tell us about your next appointment, if you
have one scheduled.
8.G. Name of Facility or Office

Name of health care professional who treated you

ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROVIDER ABOVE.
Phone Number

IpatienllD# (If known)

Mailing Address
ZIP/Postal Code

State/Province

City

Country (If not USA)

Dates of Treatment
1. OffIce, Clinic or Outpatient visits
First Visit

2. Emergency Room visits
List the most recent date first

3. Overnight hospital stays
List the most recent date first

A.

A. Date in

Date out

B.

B. Date in

Date out

C.

C. Date in

Date out

Last Visit
Next scheduled appointment (if any)

What medical conditions were treated or evaluated?

What treatment did you receive for the above conditions? (Do not describe medicines or tests in this box.)

Tell us about any tests his provider performed or sent you to, or has scheduled you to take. Please give the
dates for past and future tests. If you need to list more tests, use Section 11 - Remarks on the last page.

o Check this box if no tests by this provider or at this facility.
Kind of Test

Dates of Tests

o EKG (heart test)
o Treadmill (exercise test)
o Cardiac Catheterization
o Biopsy (list body part)
o Hearing Tesl
o SpeechlLanguage Test
o Vision Test
10

Kind of Test

D

~ates

of Tests

EEG (brain wave test)
HIV Test
Blood Test (not HIV)

o
o
o X-Ray (fist body part)
o MRlfCT Scan (nst body part)
o Other (please describe)

Breathing Test

If you have been treated by more than five doctors or hospitals, use Section 11 - Remarks on the last
page and give the same detailed information as above for each healthcare provider.

FORM

SSA-3368-BK (01-2010) ef (04-2010)

PAGE 10

SECTION 9 - OTHER MEDICAL INFORMATION
9. Does anyone else have medical information about your physical and/or mental condition(s) (including
emotional and learning problems), or are you scheduled to see anyone else? (This may include places such as
workers' compensation , vocational rehabilitation, insurance companies who have paid you disability benefits,
prisons, attorneys, social service agencies and welfare.)

o YES
o NO

(Please complete the information below.)
(If you are receiving Supplemental Security Income (551) and have been asked to complete this report, go to
Section 10· Vocational RehabUltalion; if noL go 10 Section 11 on the lasl page .)

I

Name of Organization

Phone Number

Mailing Address

State/Province

Cily

Name of Contact Person

ZIP/Postal Code

Country (if not USA)

Claim or 10 number (if any)

Date of First Contact

Date of Last Contact

Date of Next Contact (if any)

Reasons for Contacts

If you need to list other people or organizations use Section 11 - Remarks on the last pag e and give the
same detailed information as above for each one you list.

COMPLETE THIS SECTION ONLY IF YOU ARE ALREADY RECEIVING 551.
SECTION 10 - VOCATIONAL REHABILITATION, EMPLOYMENT, OR OTHER SUPPORT SERVICES

10.A. 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 a school (if a student age 18-21); or
Any program providing vocational rehabilitation, employment services, or other support services to help
you go to work?

o YES (Complete the following information)

0

NO (Go to Section 11)

10.B. Name o f Organization or School
Name of Counselor, Instructor. or Job Coach

Phone Number

Mailing Address

tate/Province

City

10 . . When

y

Z/PlPoslal Code

Country (if not USA)

in the plan

FORM SSA-3368-BK (01·2010) ef (04·2010)

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SECTION 10· VOCATIONAL REHAB'ILITATlON, EMPLOYMENT, OR OTHER SUPPORT SERVICES

(continued)
10.0. Are you still participating in the plan or program?

o YES, I am scheduled to complete the plan or program on :
o NO. I completed the plan or program on:
o NO. I stopped participating in the plan or program before completing it because:

10.E. List the types of services, tests, or evaluations that you received (for example: intelligence or psychological
testing, vision or hearing test, physical exam, work evaluations, or classes).

If you need to list another plan or program use Section 11 • Remarks and give the same detailed
information as above.
SECTION 11 • R EMARKS

Please write any additional information you did not give in earlier parts of this report. If you did not have enough
space in the sections of this report to write the requested information, please use this space to tell us the
additional information requested in those sections. Be sure to show the section to which you are referring .

Date Report Completed

(01

/year
PAGE 12

SSA will insert the following revised Privacy Act and PRA Statements into the form at its next
scheduled reprinting:
Privacy Act Statement
Collection and Use of Personal Information

Section 205(a), 223(d), and 1631(e)(1) of the Social Security Act, as amended, authorize us to
collect this information. We will use the information you provide to make a decision on the
named claimant’s claim.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information could prevent us from making an accurate and timely decision on the named
claimant’s claim.
We rarely use the information you supply for any purpose other than to make decisions regarding
claims. We may also disclose information to another person or to another agency in accordance
with approved routine uses, which include but are not limited to the following:
1. To enable a third party or an 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 Department of
Veterans’ Affairs);
3. To make determinations for eligibility in similar health and income maintenance
programs at the Federal, State, and local level; and,
4. To facilitate statistical research, audit, or investigative activities necessary to assure
the integrity and improvement of 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 provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, State, or local government
agencies. Information from these matching programs can be used to establish or verify a person’s
eligibility for federally-funded or administered benefit programs and for repayment of payments
or delinquent debts under these programs.
A complete list of routine uses for this information is available in Systems of Records Notice
entitled, Claims Folders Systems, 60-0089. This notice, additional information regarding this
form, and information regarding our programs and systems, are available on-line at
www.socialsecurity.gov or at your local Social Security office.

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
control number. We estimate that it will take about 20 minutes to read the instructions, gather
the facts, and answer the questions.
SEND OR BRING THE COMPLETED FORM TO THE OFFICE THAT REQUESTED
IT. You can find your local Social Security office through SSA’s website at
www.socialsecurity.gov. Offices are also listed under U. S. Government agencies in your
telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-3250778). You may send comments on our time estimate above to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address,
not the completed form.