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pdfDISABILITY 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.
HOW TO COMPLETE THIS REPORT
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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 (IDD) 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 ALREADY HAVE. With your permission, 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 (10-2015) UF (10-2015)
Disability Report- Adult-Form SSA-3368-BK
Note: If you are assisting someone else with this report, please answer the questions as if that person
were completing the report.
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.
See Revised Privacy Act and
Privacy Act Statement
PRA Statements Attached
Collection and Use of Personal Information
Sections 205, 223, 1614, and 1631 of the Social Security Act, as amended, allow us to collect this
information. Furnishing us this information is voluntary. However, failing to provide all or part of the
information may prevent us from making an accurate and timely decision on your claim.
We will use the information to determine your eligibility for benefits. We may also share your
information for the following purposes, called routine uses:
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To contractors and other Federal agencies, as necessary, for the purpose of assisting the
Social Security Administration (SSA) in the efficient administration of its programs. We will
disclose information under this routine use only in situations in which SSA may enter a
contractual or similar agreement with a third party to assist in accomplishing an Agency
function relating to this system of records; and
To applicants, claimants, prospective applicants or claimants, other than the data subject, their
authorized representatives or representative payees to the extent necessary to pursue Social
Security claims and to representative payees when the information pertains to individuals for
whom they serve as representative payees, for the purpose of assisting SSA in administering
its representative payment responsibilities under the Act and assisting the representative
payees in performing their duties as payees, including receiving and accounting for benefits for
individuals for whom they serve as payees.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws.
For example, where authorized, we may use and disclose this information in computer matching
programs, in which our records are compared with other records to establish or verify a person’s
eligibility for Federal benefit programs and for repayment of incorrect or delinquent debts under these
programs.
A list of additional routine uses is available in two of our Privacy Act System of Records Notices (SORN)
60-0089, entitled Claims Folders Systems, as published in the Federal Register (FR) on April 1, 2003,
at 68 FR 15784 and 60-0103, entitled Supplemental Security Income Record and Special Veterans
Benefits as published in the FR on January 11, 2006, at 71 FR 1830. Additional information, and a full
listing of all of our SORNs, is available on our website at www.ssa.gov/privacy.
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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 90 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 1-800-325-0778). 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.
AFTER COMPLETING THIS REPORT, REMOVE THIS SHEET
AND KEEP IT FOR YOUR RECORDS
Form SSA-3368-BK (10-2015) UF (10-2015)
Form Approved
OMB No. 0960-0579
SOCIAL SECURITY ADMINISTRATION
For SSA Use Only- Do not write in this box.
Related SSN
DISABILITY REPORT
ADULT
Number Holder
Anyone who makes or causes to be made a false statement or representation of material fact for use in determining a
payment under the Social Security Act, or knowingly conceals or fails to disclose an event with an intent to affect an
initial or continued right to payment, commits a crime punishable under Federal law by fine, imprisonment, or both, and
may be subject to administrative sanctions.
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 PO Box) Include apartment number or unit if applicable.
City
State/Province
ZIP/Postal Code
Country (If not USA)
1.D. Email Address
1.E. Daytime Phone Number, including area code, and the IDD and country codes if you live outside the USA
or Canada.
Phone number
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 where we may reach you, if any.
Alternate phone number
1.G. Can you speak and understand English?
Yes
No
If no, what language do you prefer?
If you cannot speak and understand English, we will provide an interpreter, free of charge.
1.H. Can you read and understand English?
Yes
No
1.I. Can you write more than your name in English?
Yes
No
1.J. Have you used any other names on your medical or educational records? Examples are maiden name, other
Yes
No
married name, or nickname.
If yes, please list them here:
SECTION 2 - CONTACTS
Give the name of someone (other than your doctors) we can contact who knows about your medical conditions, and
can help you with your claim.
2.B. Relationship to you
2.A. Name (First, Middle Initial, Last)
2.C. Daytime Phone Number (as described in 1.E. above)
2.D. Mailing Address (Street or PO Box) Include apartment or unit if applicable.
City
State/Province
2.E. Can this person speak and understand English?
If no, what language is preferred?
ZIP/Postal Code
Yes
Country (If not USA)
No
If no, what language is preferred?
_______________________________________________________________________________________________
Page 1
2.F. Who is completing this report?
SECTION 2 - CONTACTS (continued)
The person who is applying for disability. (Go to Section 3 - Medical Conditions)
The person listed in 2.A. (Go to Section 3 - Medical Conditions)
Someone else (Complete the rest of Section 2 below)
2.G. Name (First, Middle Initial, Last)
2.H. Relationship to Person Applying
2.I. Daytime Phone Number
2.J. Mailing Address (Street or PO Box) Include apartment number or unit if applicable.
City
State/Province
ZIP/Postal 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.
3.
4.
5.
If you need more space, go to Section 11-Remarks on the last page
3.B. What is your height without shoes?
__________ __________
OR
__________
feet
inches
centimeters (if outside USA)
3.C. What is your weight without shoes?
__________
OR
__________
pounds
kilograms (if outside USA)
3.D. Do your conditions cause your pain or other symptoms?
Yes
No
4.A. Are you currently working?
SECTION 4 - WORK ACTIVITY
No, I have never worked (Go to question 4.B. below)
No, I have stopped working (Go to question 4.C. below)
Yes, I am currently working (Go to question 4.F. on page 3)
IF YOU HAVE NEVER WORKED:
4.B. When do you believe your conditions(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 conditions(s).
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
conditions(s) became severe enough to keep you from working? (month/day/year)
4.D. 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)
Yes When did you make changes? (month/day/year)
Form SSA-3368-BK (10-2015) UF (10-2015)
Page 2
DSFSDF
SECTION 4 - WORK ACTIVITY (continued)
4.E. Since the date in 4.D. above, have you had gross earnings greater than $1,180 in any month? Do not count sick
leave, vacation, or disability pay. (We may contact you for more information.)
No (Go to Section 5)
Yes (Go to Section 5)
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)
No
When did your condition(s) first start bothering you? (month/day/year)
Yes
When did you make changes? (month/day/year)
4.G. Since your condition(s) first bothered you, have you had gross earnings greater than $1,090 in any month? Do not
count sick leave, vacation, or disability pay. (We may contact you for more information.)
No
Yes
SECTION 5 - EDUCATION AND TRAINING
5.A. Check the highest grade of school completed. (Select 12, if you have education
equivalent to high school from another country.)
0
1
2
3
4
5
6
7
8
9
10
11
12
College:
GED
1
2
3
4 or more
Date completed: _____/__________
MM YYYY
Name of school: __________________________________________
City: ______ State/Province: ______ Country (if not USA):__________
5.B. Did you receive attend special education classes, such as
through an Individualized Education Plan (IEP) or
equivalent education?
Dates: from _____/____ to _____/______
MM YYYY
MM YYYY
Yes
No (Go to 5.C
Check the last grade you received special education.
Pre K
K
1
2
3
4
5
6
7
8
9
10
11 12
Reason(s) for IEP or equivalent education: ______________________
The school where you last received special education:
Same as 5A
If different from 5A, complete below.
Name of School: ____________________________________________
City: _________________ State/Province: ________________ Country (If not USA):________________
Dates attended special education classes: from ________ to __________
Form SSA-3368-BK (10-2015) UF (10-2015)
Page x
SECTION 5 - EDUCATION AND TRAINING (continued)
5.C. Have you completed any type of specialized job training, trade, or vocational school?
Yes
No
Date completed: ____/________
MM YYYY
If "Yes," what type? ______________________
5. D. What written language do you use every day in most situations (at home, work, school, in community, etc.)?
_______________
5. E. In the language you identified in 5.D., can you read a simple message, such as a shopping list or short and
simple notes?
Yes
No
5. F. In the language you identified in 5.D., can you write a simple message, such as a shopping list or short and
simple notes?
Yes
No
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.
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 work.
Job Title
Type of
Business
Dates Worked
From
MM/YY
To
MM/YY
Hours
Per
Day
Days
Per
Week
Rate of Pay
Amount
Frequency
1.
2.
3.
4.
5.
SECTION 6 - JOB HISTORY (continued)
Check the box below that applies to you.
I had only one job in the last 15 years before I became unable to work. Answer the questions below.
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.)
Do not complete this page if you had more than one job in the last 15 years before you became unable to work.
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?
Yes
No
Use technical knowledge or skills?
Yes
No
Form SSA-3368-BK (10-2015) UF (10-2015)
Page X
DSFSDF
Do any writing, complete reports, or perform any duties like this?
Yes
No
SECTION 6 - JOB HISTORY (continued)
Check the box below that applies to you.
6.D. In this job, how many total hours each day did you do each of the tasks listed:
Task
Hours
Task
Task
Hours
Hours
Walk
Stoop (Bend down & forward at waist.)
Handle large objects
Stand
Kneel (Bend legs to rest on 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:
Less than 10 lbs.
10 lbs.
20 lbs.
50 lbs.
100 lbs. or more
Other
6.G. 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
6.H. Did you supervise other people in this job?
Yes (Complete items below.)
How many people did you supervise?
people?
Did you hire and fire employees?
6.I. Were you a lead worker?
Other
No (if No, go to 6.I.)
What part of your time did you spend supervising
Yes
No
Yes
No
SECTION 7 - MEDICINES
7. Are you taking any medicines (prescription or non-prescription)?
Yes (Give the information requested below. You may need to look at your medicine containers.)
No
(Go to Section 8-Medical Treatment.)
Name of Medicine
Form SSA-3368-BK (10-2015) UF (10-2015)
If prescribed, give name of
doctor
Page x
Reason for medicine
If you need to list other medicines, go to Section 11 - Remarks on the last page.
SECTION 8 - MEDICAL TREATMENT
Have you seen a doctor or other health care professional or received treatment at a hospital or clinic, or do you have a
future appointment scheduled?
8.A. For any physical condition(s)?
Yes
No
8.B. For any mental condition(s) (including emotional or learning problems)?
Yes
No
If you answered "No" to both 8.A. and 8.B., go to Section 9 - Other Medical Information on page 11. (will be
replaced with the appropriate page number the design branch)
Tell us who may have medical records about any of your physical and/or mental condition(s) (including emotional or
learning problems). 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 Facility or Office
Phone
Name of health care professional who treated you
ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROVIDER ABOVE.
Patient ID# (if known)
Mailing Address
City
State/Province
Dates of Treatment
Form SSA-3368-BK (10-2015) UF (10-2015)
Page X
ZIP/Postal Code
Country (if not USA)
DSFSDF
1. Office, Clinic or
Outpatient visits
First Visit
2. Emergency Room visits
3. Overnight hospital stays
List the most recent date first
List the most recent date first
A.
A. Date in
Date out
Last Visit
B.
B. Date in
Date out
Next Scheduled Appointment (if any) C.
C. Date in
Date out
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 the boxes below for 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 of Test
Dates of Tests
Kind of Test
Dates of Tests
EKG (heart test)
EEG (brain wave test)
Treadmill (exercise test)
HIV Test
Cardiac Catheterization
Blood Test (not HIV)
Biopsy (list body part)
X-Ray (list body part)
Hearing Test
MRI/CT Scan (list body
part)
Speech/Language Test
Other (please describe)
Vision Test
Breathing Test
If you do not have any more doctors or hospitals to describe, go to Section 9 on page 11. (will be
replaced with the appropriate page number the design branch)
Tell us who may have medical records about any of your physical and/or mental condition(s) (including emotional or
learning problems). 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.D. Name of Facility or Office
Phone
Name of health care professional who treated you
ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROVIDER ABOVE.
Patient ID# (if known)
Mailing Address
City
State/Province
Form SSA-3368-BK (10-2015) UF (10-2015)
Page x
ZIP/Postal Code
Country (if not USA)
Dates of Treatment
1. Office, Clinic or
Outpatient visits
First Visit
2. Emergency Room visits
3. Overnight hospital stays
List the most recent date first
List the most recent date first
A.
A. Date in
Date out
Last Visit
B.
B. Date in
Date out
Next Scheduled Appointment (if any) C.
C. Date in
Date out
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 of Test
Dates of Tests
Kind of Test
EKG (heart test)
EEG (brain wave test)
Treadmill (exercise test)
HIV Test
Cardiac Catheterization
Blood Test (not HIV)
Biopsy (list body part)
X-Ray (list body part)
Hearing Test
MRI/CT Scan (list body
part)
Speech/Language Test
Dates of Tests
Other (please describe)
Vision Test
Breathing Test
If you do not have any more doctors or hospitals to describe, go to Section 9 on page 11. (will be
replaced with the appropriate page number the design branch)
Tell us who may have medical records about any of your physical and/or mental condition(s) (including emotional or
learning problems). 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
Phone
Name of health care professional who treated you
ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROVIDER ABOVE.
Patient ID# (if known)
Mailing Address
City
State/Province
Dates of Treatment
Form SSA-3368-BK (10-2015) UF (10-2015)
Page X
ZIP/Postal Code
Country (if not USA)
DSFSDF
1. Office, Clinic or
Outpatient visits
First Visit
2. Emergency Room visits
3. Overnight hospital stays
List the most recent date first
List the most recent date first
A.
A. Date in
Date out
Last Visit
B.
B. Date in
Date out
Next Scheduled Appointment (if any) C.
C. Date in
Date out
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 of Test
Dates of Tests
Kind of Test
EKG (heart test)
EEG (brain wave test)
Treadmill (exercise test)
HIV Test
Cardiac Catheterization
Blood Test (not HIV)
Biopsy (list body part)
X-Ray (list body part)
Hearing Test
MRI/CT Scan (list body
part)
Speech/Language Test
Dates of Tests
Other (please describe)
Vision Test
Breathing Test
If you do not have any more doctors or hospitals to describe, go to Section 9 on page 11.
Tell us who may have medical records about any of your physical and/or mental condition(s) (including emotional or
learning problems). 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.F. Name of Facility or Office
Phone
Name of health care professional who treated you
ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROVIDER ABOVE.
Patient ID# (if known)
Mailing Address
City
State/Province
Dates of Treatment
Form SSA-3368-BK (10-2015) UF (10-2015)
Page x
ZIP/Postal Code
Country (if not USA)
1. Office, Clinic or
Outpatient visits
First Visit
2. Emergency Room visits
3. Overnight hospital stays
List the most recent date first
List the most recent date first
A.
A. Date in
Date out
Last Visit
B.
B. Date in
Date out
Next Scheduled Appointment (if any) C.
C. Date in
Date out
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 of Test
Dates of Tests
Kind of Test
EKG (heart test)
EEG (brain wave test)
Treadmill (exercise test)
HIV Test
Cardiac Catheterization
Blood Test (not HIV)
Biopsy (list body part)
X-Ray (list body part)
Hearing Test
MRI/CT Scan (list body
part)
Speech/Language Test
Dates of Tests
Other (please describe)
Vision Test
Breathing Test
If you do not have any more doctors or hospitals to describe, go to Section 9 on page 11. (will be
replaced with the appropriate page number the design branch)
Tell us who may have medical records about any of your physical and/or mental condition(s) (including emotional or
learning problems). 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
Phone
Name of health care professional who treated you
ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROVIDER ABOVE.
Patient ID# (if known)
Mailing Address
City
State/Province
Form SSA-3368-BK (10-2015) UF (10-2015)
Page X
ZIP/Postal Code
Country (if not USA)
DSFSDF
Dates of Treatment
1. Office, Clinic or
Outpatient visits
First Visit
2. Emergency Room visits
3. Overnight hospital stays
List the most recent date first
List the most recent date first
A.
A. Date in
Date out
Last Visit
B.
B. Date in
Date out
Next Scheduled Appointment (if any) C.
C. Date in
Date out
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 of Test
Dates of Tests
Kind of Test
Dates of Tests
EKG (heart test)
EEG (brain wave test)
Treadmill (exercise test)
HIV Test
Cardiac Catheterization
Blood Test (not HIV)
Biopsy (list body part)
X-Ray (list body part)
Hearing Test
MRI/CT Scan (list body
part)
Speech/Language Test
Other (please describe)
Vision Test
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.
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.)
Yes (Please complete the information below.)
No (If you are receiving Supplemental Security Income (SSI) and have been asked to complete this report,
go to Section 10 - Vocational Rehabilitation; if not, go to Section 11 on the last page.)
Name of Organization
Phone Number
Mailing Address
City
State/Province
Form SSA-3368-BK (10-2015) UF (10-2015)
Page x
ZIP/Postal Code
Country (if not USA)
Name of Contact Person
Date of First Contact
Claim or ID number (if any)
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 page and give the same
detailed information as above for each one you list.
A.
•
•
•
•
•
COMPLETE THIS SECTION ONLY IF YOU ARE ALREADY RECEIVING SSI.
SECTION 10 - VOCATIONAL REHABILITATION, EMPLOYMENT, OR OTHER SUPPORT
SERVICES
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?
Yes (Complete the following information)
No (Go to Section 11)
10.B. Name of Organization or School
Name of Counselor, Instructor, or Job Coach
Phone
Mailing Address
City
State/Province
ZIP/Postal Code
Country (if not USA)
10.C. When did you start participating in the plan or program?
SECTION 10 - VOCATIONAL REHABILITATION, EMPLOYMENT, OR OTHER SUPPORT SERVICES
(continued)
10.D. Are you still participating in the plan or program?
Yes, I am scheduled to complete the plan or program on:
No. I completed the plan or program on:
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).
Form SSA-3368-BK (10-2015) UF (10-2015)
Page X
DSFSDF
If you need to list another plan or program use Section 11 Remarks and give the same detailed information as above.
SECTION 11 - REMARKS
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
Form SSA-3368-BK (10-2015) UF (10-2015)
month, day, year
Page x
SSA will insert the following revised Privacy Act Statement into the form as soon
as possible:
Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 223(d), 1614(a), and 1631 of the Social Security Act, as amended, allow us to
collect this information. Furnishing us this information is voluntary. However, failing to
provide all or part of the information may prevent an accurate and timely decision on any claim
filed.
We will use the information to determine eligibility for benefits. We may also share your
information for the following purposes, called routine uses:
•
To contractors and other Federal agencies, as necessary, for the purpose of assisting the
Social Security Administration (SSA) in the efficient administration of its programs; and
•
To applicants, claimants, prospective applicants or claimants, other than the data subject,
their authorized representatives or representative payees to the extent necessary to pursue
Social Security claims and to representative payees when the information pertains to
individuals for whom they serve as representative payees, for the purpose of assisting
SSA in administering its representative payment responsibilities under the Act and
assisting the representative payees in performing their duties as payees, including
receiving and accounting for benefits for individuals for whom they serve as payees.
In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices
(SORN) 60-0089, entitled Claims Folders System, as published in the Federal Register (FR) on
April 1, 2003, at 68 FR 15784, and 60-0320, entitled Electronic Disability Claim File, as
published in the FR on December 22, 2003, at 68 FR 71210. Additional information, and a full
listing of all of our SORNs, is available on our website at www.ssa.gov/privacy.
SSA will insert the following revised PRA Statement into the form as soon
as possible:
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 90
minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. 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 1800-325-0778). You may send comments regarding this burden estimate or any other
aspect of this collection, including suggestions for reducing this burden to: SSA, 6401
Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time
estimate to this address, not the completed form.
| File Type | application/pdf |
| File Title | Disability Report- Adult |
| Subject | Disability Report- Adult |
| Author | SSA |
| File Modified | 2019-11-20 |
| File Created | 2019-10-08 |