Form SSA-3368 Disability Report - Adult

Form SSA-3368-BK (XX-XXXX) UF
Discontinue Prior Editions
Social Security Administration

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OMB No. 0960-0579

DISABILITY REPORT - ADULT
PLEASE READ THIS INFORMATION BEFORE COMPLETING THIS REPORT
The office that makes the disability decision on your case will use the information you provide in this report to decide
whether you are disabled. Please complete as much of the report as you can.
You may be able to complete this report online at: https:/www.ssa.gov/benefits/disability/.

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.

IF YOU NEED HELP
You can get help from other people, such as a friend or family member. Please do not ask your healthcare
provider to complete this report. If you cannot complete the report, you may contact us at 1-800-772-1213 (TTY
1-800-325-0778). A Social Security Representative will assist you. Have the information available from the bulleted
items below when you call us. If you have an appointment, please have the information available, or 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. If
you cannot speak or understand English, we will provide an interpreter free of charge.

WHAT YOU NEED TO COMPLETE THIS REPORT
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Names, addresses, and phone numbers of two people (other than your doctors) we can contact who know about
your medical condition(s) and can help with your case, if needed.
Information about any education you have completed.
Information about all the jobs you have had in the last five years.
Any prescription or non-prescription medicines you take.
Names, addresses, and phone numbers of any healthcare providers and information about the medical treatment
you received, or testing performed.
If you cannot remember information about your healthcare providers, the treatment you received, or the testing
performed, you may be able to get that information from the telephone book, the Internet, an online medical chart,
medical bills, prescriptions, or prescription medicine containers.
If you cannot remember exact dates, provide the closest date you can remember.
Name of organization(s) we can contact that would have medical information about your condition(s), such as
social services agencies, welfare agencies, attorneys, prisons, workers' compensation , and insurance companies
who have paid you disability benefits.
Information about any vocational rehabilitation, employment, or other support services.
ANSWER EVERY QUESTION, unless the report indicates otherwise: Provide as much detail as possible. 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 provide additional
information. If you need more space to answer any question, use Section 11 - Remarks.

HOW TO SUBMIT THIS REPORT
SEND OR BRING THE COMPLETED REPORT TO YOUR LOCAL SOCIAL SECURITY OFFICE, OR THE
NEAREST U.S. EMBASSY OR CONSULATE OFFICE. Office addresses are listed under U.S. Government
agencies in your telephone directory, or you may call 1-800-772-1213 (TTY 1-800-325-0778) for the address.

Form SSA-3368-BK (XX-XXXX) UF

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YOUR MEDICAL RECORDS
YOU DO NOT NEED TO ASK DOCTORS OR HOSPITALS FOR ANY MEDICAL RECORDS. If you have consented
to us obtaining medical records from your providers, we will request your records directly from them. The information
that you give us on this report tells us where to request your medical and other records.

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 applicants, claimants, prospective applicants or claimants, other than the data subject, and 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; and
• 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.
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 Systems of Records Notice (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.

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 regarding this burden estimate or any other aspect
of this collection, including suggestions for reducing the burden to: SSA, 6401 Security Blvd, Baltimore, MD
21235-6401. Send only comments relating to our time estimate or any other aspects of this collection to this
address, not the completed form.

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

Form SSA-3368-BK (XX-XXXX) UF

DISABILITY REPORT
ADULT

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For SSA Use Only- Do not write in this box.
Related SSN
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.
SECTION 1 - INFORMATION ABOUT YOU
When a question refers to "you" or "your," it refers to the person who is applying for disability benefits. If
you are completing this report for someone else, provide information about them.
1.B. SOCIAL SECURITY NUMBER
1.A. NAME (First, Middle Initial, Last, Suffix)
1.C. Have you used any other names on your medical or educational records? Examples include maiden
name, other married names, other names, or nickname.
YES
NO
If YES, please list names used:
1.D. MAILING ADDRESS (Street or PO Box) Include apartment number, if applicable.
CITY

STATE/Province

ZIP/Postal Code COUNTRY (If not USA)

1.E. EMAIL ADDRESS
1.F. DAYTIME PHONE NUMBER(S) where we can call to speak with you or leave a message, if needed.
Include area code or IDD and country code if outside the USA or Canada.
Secondary:
(if available)
Primary:
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
SECTION 2 - CONTACTS
Is there someone we can contact who can help with your claim, if needed? Examples include a family
member, friend, or neighbor.
YES Please provide the names of two people (other than your doctors) we can contact who know
about your medical condition(s) and can help you with your claim and can help us reach you if
you become unavailable.
We recommend that you provide at least one contact, if available. Providing the name of
someone who knows you may help us to make a quicker decision on your claim.
2.A. NAME (First, Middle Initial, Last)
2.B. Relationship to the Person in 1.A.
NO

2.C. MAILING ADDRESS (Street or PO Box) Include apartment number, if applicable.
CITY

STATE/Province

2.D. DAYTIME PHONE NUMBER (as described in 1.F. above)

ZIP/Postal Code COUNTRY (if not USA)

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SECTION 2 - CONTACTS (continued)
2.E. Can this person speak and understand English?
YES
If NO, what language is preferred?
2.F. NAME (First, Middle Initial, Last)

NO

2.G. Relationship to the Person in 1.A.

2.H. MAILING ADDRESS (Street or PO Box) Include apartment number, if applicable.
CITY

STATE/Province

ZIP/Postal Code COUNTRY (if not USA)

2.I. DAYTIME PHONE NUMBER (as described in 1.F. above)
2.J. Can this person speak and understand English?

YES

NO

If NO, what language is preferred?
SECTION 3 - MEDICAL INFORMATION
3.A. Separately list each physical and/or mental condition that limits your ability to work.
1.
2.
3.
4.
5.

If you need more space, go to Section 11
3.B. What is your height?

OR
feet

inches

centimeters
OR

3.C. What is your weight?

pounds
kilograms
SECTION 4 - WORK ACTIVITY
4.A. Are you currently working?
NO, I have never worked (Go to question 4.B.)
NO, I have stopped working (Go to question 4.C.)
YES, I am currently working (Go to question 4.F.)
IF YOU HAVE NEVER WORKED:
4.B. When do you believe your conditions(s) became severe enough to keep you from working (even
(Go to Section 5)
though you have never worked)? (MM/DD/YYYY)
IF YOU HAVE STOPPED WORKING:
4.C. When did you stop working? (MM/DD/YYYY)
Why did you stop working?
Because of my condition(s).
Because of other reasons. Please explain why you stopped working. Examples include laid off,
early retirement, seasonal work ended, or 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? (MM/DD/YYYY)

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SECTION 4 - WORK ACTIVITY (continued)
4.D. Did your condition(s) cause you or your employer to make changes in your work activity? Examples
include job duties, hours, or rate of pay.
NO (Go to Section 5)
YES, When did the changes start? (MM/DD/YYYY)
4.E. Since the date in 4.D. above, have you had gross earnings greater than $1,470 before tax in any
month? Do not count sick leave, vacation, or disability pay. (We may contact you for more information.)
YES (Go to Section 5)
NO (Go to Section 5)
IF YOU ARE CURRENTLY WORKING:
4.F. Has your condition(s) caused you or your employer to make changes in your work activity? Examples
include job duties, hours, and rate of pay.
YES
When did the changes start? (MM/DD/YYYY)
NO

When did your condition(s) first start bothering you? (MM/DD/YYYY)

4.G. Since your condition(s) first bothered you, have you had earnings greater than $1,470 before tax in any
month? Do not count sick leave, vacation, or disability pay. (We may contact you for more information.)
YES
NO
SECTION 5 - EDUCATION, TRAINING, AND LITERACY
5.A. Select the highest level of school completed, including homeschooling,online education, and
education received in another country. Select "12" if you completed a graduate equivalency degree (GED).
0

K

1

2

3

4

5

6

7

8

9

10

11

College:
1
2

12

3

4 or more

Date completed:
MM/YYYY
Name of school:
City:

State/Province:

NO (Go to 5.C.)
5.B. Were you in special education?
Dates from:
to
MM/YYYY
MM/YYYY
If YES, select the last grade you were in special education.
K
1
2
3
4
5
6
7
8
Pre K

Country (if not USA):
YES (Complete below)

9

10

11

12

Reason(s) for special education:
The school where you were last in special education:
Same as 5.A.
If different from 5.A., complete below.
Name of school:
City:

State/Province:

Country (if not USA):

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SECTION 5 - EDUCATION, TRAINING, AND LITERACY (continued)
5.C. Have you received any type of training (specialized job, trade, or vocational training)?
NO (Go to 5.E.)
NAME OF TRAINING FACILITY

YES (Complete the table below.)
PHONE NUMBER

MAILING ADDRESS
CITY

STATE/Province

ZIP/Postal Code COUNTRY (if not USA)
Date Completed (or scheduled to be completed)

TYPE OF PROGRAM

MM/YYYY
5.D. What written language do you use every day in most situations (at home, work, school, in community,
etc.)?
5.E. READING - 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. WRITING - 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
SECTION 6 - WORK HISTORY
(If you need more space, use Section 11)
6.A. Did you have a job in the last 5 years?
NO (Go to Section 7)
YES (Complete the table below.)
List all the jobs that you have had in the last 5 years:
• Include self-employment
• Include work in a foreign country
• List your most recent job first
Dates Worked
Job Title

1.
2.
3.
4.
5.

Hours Days
Type of Business
Per
Per
From:
To:
MM/YYYY MM/YYYY Day Week

Rate of Pay
Frequency
(per) hour,
Amount day, week,
month, or
year

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SECTION 6 - WORK HISTORY (continued)
Check the box below that applies to you.
I had more than one job. (Do not answer the question in Section 6, go to Section 7. We may contact
you for more information.)
I had only one job. (Complete the questions in 6.B. through 6.E.)
6.B. Information about your work
For the job you listed in 6.A., describe in detail the tasks you did in a typical workday. Examples of tasks
include stocking shelves, greeting customers, scheduling appointments, and maintaining records.

If any of the tasks listed above involved writing or completing reports, describe the type of report you wrote
or completed and how much time you spent on it per workday or workweek.

If any of the tasks listed above involved supervising others, describe who or what you supervised and what
supervisory duties you had. Examples of supervisory duties include performance management, making
schedules, and maintaining time records.

List the machines, tools, and equipment you used regularly when doing this job and explain what you used
them for. Examples of equipment include computer, telephone, forklift, air compressor, and meat slicer.

Tell us about the work-related skills you used in this job and the job duties you completed using these skills.
Examples of work-related skills include reading blueprints to instruct workers on how to build houses and
medical coding to determine the amounts providers should be paid.

Did your job require you to interact with coworkers, the general public, or anyone else?
YES
NO
If YES, describe who you interacted with, the purpose of the interaction, how you interacted, and how much
time you spent doing it per workday or workweek. Examples include answering customer questions on the
telephone for 5 hours per day or showing clients sale properties in person for 4 hours per day.

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SECTION 6 - WORK HISTORY (continued)
6.C. Physical and environmental requirements of your work
Tell us how much time you spent doing the following physical activities in a typical workday. The total
hours/minutes for standing and/or walking and sitting should equal the Hours per Day reported in 6.A.
The example below shows an 8-hour workday with 2 hours standing and/or walking and 6 hours sitting
(8 hours total).
How much of
your workday?
(Hours/Minutes)

Activity
Standing and/or walking
Sitting

Example:
2 hours
6 hours
5 minutes
5 minutes
None
None
2 hours
(both hands)
1 hour
(both hands)
1 hour
(both hands)

Stooping (i.e., bending down & forward at waist)
Kneeling (i.e., bending legs to rest on knees)
Crouching (i.e., bending legs & back down & forward)
Crawling (i.e., moving on hands and knees)
Using fingers to touch, pick, or pinch (e.g., using a mouse, keyboard,
One Hand
Both Hands
turning pages, or buttoning a shirt):
Using hands to seize, hold, grasp, or turn (e.g., holding a large envelope, a
One Hand
Both Hands
small box, a hammer, or water bottle):
Reaching at or below the shoulder:

One Arm

Both Arms

Reaching overhead (above the shoulder):

One Arm

Both Arms

None

Climbing stairs or ramps
None
Climbing ladders, ropes, or scaffolds
None
If you need more space, use Section 11
Tell us about lifting and carrying in this job. Explain what you lifted, how far you carried it, and how often you
did it in a typical workday.

Select the heaviest weight lifted:
Less than 1 lb.
50 lbs. or more

Less than 10 lbs.
100 lbs. or more

10 lbs.

20 lbs.

Other

Select the weight frequently lifted (i.e., 1/3 to 2/3 of the workday):
Less than 1 lb.
50 lbs. or more

Less than 10 lbs.
Other

10 lbs.

25 lbs.

Did your job expose you to any of the following? Check all that apply.
Outdoors
Extreme heat (non-weather related)
Extreme cold (non-weather related)
Wetness
Humidity
Hazardous substances
Moving mechanical parts
High, exposed places
Heavy vibration
Loud noise
Other
If one or more boxes are checked, tell us about the exposure(s) and how often you were exposed.

Form SSA-3368-BK (XX-XXXX) UF

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SECTION 6 - WORK HISTORY (continued)
6.D. Explain how your medical conditions affect your ability to do this job.

SECTION 7 - MEDICINES
7. Are you currently taking any prescription or non-prescription medicine(s)?
NO (Go to Section 8)
YES (Complete the information below. You may need to look at your medicine containers.)
IF PRESCRIBED, GIVE DOCTOR
REASON FOR MEDICINE
NAME OF MEDICINE
NAME (IF KNOWN)
(IF KNOWN)

If you need to list more medicines, use Section 11.

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SECTION 8 - MEDICAL TREATMENT
8.A. Have you seen or received treatment from a health care provider (doctor, hospital, clinic, psychiatrist,
nurse practitioner, therapist, physical therapist, or other medical professional), or do you have a future
appointment scheduled?
NO (Go to Section 9)
YES (Complete the chart(s) below)
You may find this information on medical bills, online medical chart, or the internet.
i.
NAME OF FACILITY OR OFFICE

NAME OF HEALTH CARE PROVIDER THAT
TREATED YOU

What medical conditions were treated or evaluated?
PHONE NUMBER

DATE FIRST SEEN: DATE LAST SEEN: DATE NEXT SEEN: (IF KNOWN)
MM/YYYY

MM/YYYY

MM/YYYY

STREET ADDRESS
CITY

STATE/Province

ii.
NAME OF FACILITY OR OFFICE

ZIP/Postal Code COUNTRY (if not USA)

NAME OF HEALTH CARE PROVIDER THAT
TREATED YOU

What medical conditions were treated or evaluated?
PHONE NUMBER

DATE FIRST SEEN: DATE LAST SEEN: DATE NEXT SEEN: (IF KNOWN)
MM/YYYY

MM/YYYY

MM/YYYY

STREET ADDRESS
CITY

STATE/Province

iii.
NAME OF FACILITY OR OFFICE

ZIP/Postal Code COUNTRY (if not USA)

NAME OF HEALTH CARE PROVIDER THAT
TREATED YOU

What medical conditions were treated or evaluated?
PHONE NUMBER

DATE FIRST SEEN: DATE LAST SEEN: DATE NEXT SEEN: (IF KNOWN)
MM/YYYY

MM/YYYY

MM/YYYY

STREET ADDRESS
CITY

STATE/Province

ZIP/Postal Code COUNTRY (if not USA)

Form SSA-3368-BK (XX-XXXX) UF

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SECTION 8 - MEDICAL TREATMENT (continued)
iv.
NAME OF FACILITY OR OFFICE

NAME OF HEALTH CARE PROVIDER THAT
TREATED YOU

What medical conditions were treated or evaluated?
PHONE NUMBER

DATE FIRST SEEN: DATE LAST SEEN: DATE NEXT SEEN: (IF KNOWN)
MM/YYYY

MM/YYYY

MM/YYYY

STREET ADDRESS
CITY

STATE/Province

v.
NAME OF FACILITY OR OFFICE

ZIP/Postal Code COUNTRY (if not USA)

NAME OF HEALTH CARE PROVIDER THAT
TREATED YOU

What medical conditions were treated or evaluated?
PHONE NUMBER

DATE FIRST SEEN: DATE LAST SEEN: DATE NEXT SEEN: (IF KNOWN)
MM/YYYY

MM/YYYY

MM/YYYY

STREET ADDRESS
CITY

STATE/Province

ZIP/Postal Code COUNTRY (if not USA)

If you need to list more facilities or health care providers, use Section 11.

Form SSA-3368-BK (XX-XXXX) UF

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SECTION 8 - MEDICAL TREATMENT (continued)
8.B. Did any of the providers listed in 8.A. order any medical tests for you? Include tests already performed
and scheduled in the future.
NO (Go to Section 9)
YES (Select tests from the chart below)
TEST

NAME OF HEALTHCARE PROVIDER OR FACILITY

Blood test (not HIV)
Breathing test
Cardiac catheterization
EEG (brain wave test)
EKG (heart test)
Hearing test
HIV test
Speech/language test
Treadmill (exercise test)
Vision test
Psychological/IQ test
Biopsy (list body part):
MRI/CT scan (list body part):
X-ray (list body part):
Other - please specify:
If you need to list more tests, use Section 11.

DATE OF TEST
(MM/YYYY)

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SECTION 9 - OTHER MEDICAL INFORMATION
9. Does anyone else (other than your medical providers) have your medical information? Examples include
social service agencies, welfare agencies, attorneys, prisons, workers' compensation, and insurance
companies who have paid you disability benefits.
NO (Go to Section 10)
YES (Complete the information below)
NAME OF ORGANIZATION

PHONE NUMBER

MAILING ADDRESS
ZIP/Postal Code

STATE/Province

CITY
NAME OF CONTACT PERSON

COUNTRY (if not USA)

CLAIM 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
SECTION 10 - SUPPORT SERVICES
Provide information about your participation in support services, if applicable. Examples of support services
can include:
• An Individualized Education Program (IEP) through a school (if a student aged 18-21)
• An individual work plan with an employment network under the Ticket to Work Program
• A Plan to Achieve Self-Support (PASS)
• An individualized plan for employment with a vocational rehabilitation agency or any other organization
10.A. Have you participated or are you participating in any support services mentioned above or any other
vocational rehabilitation, employment services, or other support services to help you to go to work?
YES (Complete the information below)

NO (Go to Section 11)

10.B. FACILITY OR ORGANIZATION NAME

PHONE NUMBER

COUNSELOR, INSTRUCTOR, OR JOB COACH NAME
MAILING ADDRESS (Street or PO Box) Include Suite, Building, etc.
CITY

STATE/Province

ZIP/Postal Code

COUNTRY (if not USA)

10.C. Are you still participating in the plan or program? (Select answer below)
YES

Date began:

Expected completion date:
MM/YYYY

NO

Date began:

MM/YYYY
Date stopped:

MM/YYYY
Reason stopped:

MM/YYYY

Form SSA-3368-BK (XX-XXXX) UF

SECTION 10 - SUPPORT SERVICES (continued)
10.D. What types of services, tests, or evaluation were provided?
Select all that apply:
Vision test
Psychological/IQ test
Work classes
Hearing test

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Work evaluation

Other - Please explain:
If you need to list another plan or program, use Section 11
SECTION 11 - REMARKS
Please provide 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 provide the requested information, please use this space to
provide the additional information requested in those sections. Be sure to include the section and question
number to which you are referring.

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SECTION 12 - WHO IS COMPLETING THIS REPORT
Date Report Completed (MM/DD/YYYY)
Who is completing this report?
The person listed in 1.A.
The person listed in 2.A.
The person listed in 2.F.
Someone else (Complete the following section below)
NAME (First, Middle Initial, Last)

Relationship to the Person in 1.A.

MAILING ADDRESS (Street or PO Box) Include the apartment number, if applicable.
CITY

STATE/Province

ZIP/Postal Code

COUNTRY (if not USA)

DAYTIME PHONE NUMBER where we may reach you or leave a message, if needed. Include the area
code or IDD and country code if outside the USA or Canada.