i3368 Screenshots (Revised for PRW NPRM)

SSA-3368 /i3368 Screenshots

i3368-Contact Information for John Doe/ Section 1- Information About You

Update instructions as follows:

“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.”

Add “Primary” with text box to include number.

Add “Secondary (if available)” with text box to include number.

Remove “Another phone number where we may reach you.”

i3368-Other Names/ Section 1- Information About You

Modify example list as follows: Examples include maiden name, other married name, other names, or nickname.

Change instructions to the following:

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 with your claim and help us reach you if you become unavailable.

Add the ability to enter two contacts.

No. 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.

Add section to provide an additional contact with Name, Relationship to You, Address of the person, Daytime phone number of this person, and Preferred Language.

i3368- Other Contact / Section 2- Contacts

Paper- Section 3- Medical Information/ i3368- Conditions

Update the instructions to read “Separately list each physical and/or mental condition that limits your ability to work.”

Remove this question.

Modify the Height and Weight questions to read as follows:

“What is your height?” Add text and radio button to include “OR centimeters”

“What is your weight?” Add text and radio button to include “OR kilograms”

I3368-Currently Working

Select yes

Edit instructional text as follows: “We need to know whether you or your employer made any changes in your work as a result of your conditions.”

Edit the language on the More Info screen to include “Examples include job duties, hours, or rate of pay.”

Modify question to read as follows:

Has your condition(s) caused you or your employer to make changes in your work activity?

If yes, modify question to read as follows:

“When did the changes start? (MM/DD/YYYY)”

Select No

Edit instructional text as follows: “We need to know whether you or your employer made any changes in your work as a result of your conditions.”

Edit the language on the More Info screen to include “Examples include job duties, hours, or rate of pay.”

Modify question to read as follows:

Has your condition(s) caused you or your employer to make changes in your work activity?

Edit instructions to say, “We need to know more about your reasons for stopping working and whether you or your employer made any changes in your work as a result of you condition(s).”

Modify the last radio button option “Because of other reasons” to say:

“Because of other reasons. Please explain the other reasons why you stopped working. Examples include laid off, early retirement, seasonal work ended, or business closed.”

Modify the question to read as follows: “Did your condition(s) cause you or your employer to make changes in your work activity?

Edits needed to the More Info screen to include the following language: “Examples include job duties, hours, or rate of pay.”

If yes, modify the question to read as follows: “When did the changes start?”

i3368- Work Activity for John Doe (Stopped Working) /Section 4- Work Activity

Edit i3368 section title to “Education, Training, and Literacy”

I3368 Education and Training / Section 5- EDUCATION, TRAINING, AND LITERACY

Change section Title to: “Education, Training and Literacy”

Modify section to read as follows:

Instructions should read, “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).”

Keep drop-down box to select grade level.

Add “College 1, 2, 3, 4” to the drop-down box selections.

Modify title: “Last Grade You Received Special Education” to “Last Grade You Were in Special Education:”

Modify- “Did you receive special education, such as through an Individualized Education Plan (IEP) or equivalent education to “Were you in special education?”

Add “Dates from: MM/YYYY to MM/YYYY” after this question.

Remove this question.

Change this question to a statement:

“The school where you were last in special education.”

Keep radio button for “Same school as above.”

Add radio button and text: “If different from school above.”

Keep School Name and Location of School

Edit instructions for the Reason(s) for IEP or equivalent education to read, “Reason(s) for special education”.

Modify: Date Completed (or scheduled to be completed)

Modify the question to read as follows:

“Have you received any type of training (specialized job, trade, or vocational training)?”

If yes, add sections to provide: Name of Training Facility, Phone Number, Mailing Address, City, STATE/Province, ZIP/Postal Code, Country (if not USA)

Keep text box for Type of Program

Modify section title to “Literacy Information”

Modify the beginning of the language questions as follows:

WRITING- “In the language you identified above, can you write…”

Modify the beginning of the language question as follows:

READING- “In the language you identified above, can you read …”

i3368 Job History / Section 4- Work Activity (Question 4.E) Currently Working

Modify Job Listing instructions to: “List the jobs (up to 5) that you had in the past 5 years. 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”

Add question: “Did you have a job in the last 5 years?

YES NO

If yes, modify Job Listing instructions to say, “Select the number of jobs you have had in the past 5 years”.

Modify the question to read as follows: “Since Sep 10, 2011, have you had earnings greater than $___ before tax in any month…?”

i3368 Job History / Paper-Section 6-Work History

Modify the questions to read as follows:

“For this job, describe in detail the tasks that you did in a typical workday. Examples of tasks include stocking shelves, greeting customers, scheduling appointments, and maintaining records.” Add a text box for explanation.

“If any 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.” Add a text box for description.

“If any tasks listed above involved supervising others, describe who and what you supervised and what supervisory duties you had. Examples of supervisory duties include performance management, making schedules, or maintaining time records.” Add a text box for explanation.

“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.” Add a text box for explanation.

“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.” Add a text box for explanation.

After question, “Tell us about the work-related skills…” add question:

Add this question, “Did your job require you to interact with coworkers, the general public, or anyone else?” YES NO

If they select yes, add a textbox with the following instructions:

“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 for 4 hours per day.”

Modify the instructions to read: “Tell us how much time you spent performing 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. The example below shows an 8-hour workday with 2 hours standing and/or walking and 6 hours sitting (8 hours total).” For each activity add a text box for “Hours/Minutes” to indicate time for each activity.

*The paper form includes an “Example” text box that shows how many hours/minutes for each activity. Standing and walking- 2 hours; stooping- 6 minutes. Work with Systems to determine how to include this on i3368.

Combine “Standing and/or Walking”

“Sitting”

Stooping (i.e., bending down and 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, turning pages, or buttoning a shirt); add radio buttons to select One Hand or Both Hands

Using hands to seize, hold, grasp, or turn (e.g., holding a large envelope, a small box, a hammer, or water bottle); add radio buttons to select One Hand or Both Hands

Reaching at or below the shoulder; add radio buttons to select One Arm or Both Arms

Reaching overhead (above the shoulder); add radio buttons to select One Arm or Both Arms

Climbing stairs or ramps

Climbing ladders, ropes, or scaffolds

Modify these instructions: “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.”

Modify the question to “Select the heaviest weight lifted” Add “Less than 1 lb.” to the list of options in the drop down.

Modify the question to “Select the weight frequently lifted (i.e., 1/3 to 2/3 of the workday)”. Add “Less than 1 lb.” to the list of options in the drop down.

After last heaviest weight question, add this question: “Did your job expose you to any of the following? Check all that apply.”

Add radio buttons to select the following options:

“ 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 of the options are checked, add a text box with instructions that say, “Tell us about the exposure(s) and how often you were exposed.”

Remove the questions- “Did you supervise other people in this job?” and “Were you a lead worker?”

Add the following question and a textbox for explanation:

“Explain how your medical conditions affect your ability to do this job.”

Stopped Working / Work History

Modify Job Listing instructions to: “List the jobs (up to 5) that you had in the past 5 years. 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”

Add question: “Did you have a job in the last 5 years?

YES NO

If yes, modify Job Listing instructions to say, “Select the number of jobs you have had in the past 5 years”.

Modify the question to read as follows: “Since Sep 10, 2011, have you had earnings greater than $___ before tax in any month…?”

Dates Worked

From: MM/YYYY

To: MM/YYYY

Modify the Job Details section questions to read as follows:

“For this job, describe in detail the tasks you did in a typical workday. Examples of tasks include stocking shelves, greeting customers, scheduling appointments, and maintaining records.” Add a text box for explanation.

“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.” Add a text box for explanation.

“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.” Add a text box for explanation.

“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, telephones, forklift, air compressor, and meat slicer.” Add a text box for explanation.

“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 amount providers should be paid.” Add a text box for explanation.

Add this question, “Did your job require you to interact with coworkers, the general public, or anyone else?” YES NO

If they select yes, add a textbox with the following instructions:

“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 for 4 hours per day.”

Modify the instructions to read: “Tell us how much time you spent performing 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.” For each activity add a text box or radio buttons to select Hours/Minutes to indicate time for each activity.

*The paper form includes an “Example” text box that shows how many hours/minutes for each activity. Standing and walking- 2 hours; stooping- 6 minutes. Work with Systems to determine how to include this on i3368.

Combine “Standing and/or Walking”

“Sitting”

Stooping (i.e., bending down and 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 hands to seize, hold, grasp, or turn (e.g., holding a large envelope, a small box, a hammer, or water bottle); add radio buttons to select One Hand or Both Hands

Modify these instructions: “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.”

Climbing ladders, ropes, or scaffolds

Climbing stairs or ramps

Reaching overhead (above the shoulder); add radio buttons to select One Arm or Both Arms

Reaching at or below the shoulder; add radio buttons to select One Arm or Both Arms

Using fingers to touch, pick, or pinch (e.g., using a mouse, keyboard, turning pages, or buttoning a shirt); add radio buttons to select One Hand or Both Hands

After last heaviest weight question, add this question: “Did your job expose you to any of the following? Check all that apply.”

Add radio buttons to select the following options:

“ 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 of the options are checked, add a text box with instructions that say, “Tell us about the exposure(s) and how often you were exposed.”

Modify the question to “Select the heaviest weight lifted” Add “Less than 1 lb.” to the list of options in the drop down.

Modify the question to “Select the weight frequently lifted (i.e., 1/3 to 2/3 of the workday)”. Add “Less than 1 lb.” to the list of options in the drop down.

Remove the questions “Did you supervise other people in this job?” and “Were you a lead worker?”

Add this question and a textbox for explanation:

“Explain how your medical conditions affect their ability to do this job.”

Paper Section 7- Medicine/ i3368 Medicine

Modify instructions to ask this question say “Are you currently taking any prescription or non-prescription medicine(s)?”

Modify question to “Reason for Medicine (if known)”

Modify question to “If prescribed give Doctor’s Name (if known)”

The i3368 currently lists Doctors and Other Healthcare Professionals AND Hospital and Clinics separately. We would like to combine these two separate sections into one section titled “Medical Treatment” because the same information is asked for in both sections. Tests and Medical Sources should be listed separately. This section should mirror the revised SSA-3368. Maybe we can borrow the functionality from the i454.

Paper Section 8- Medical Treatment/ i3368 Doctors and Other Healthcare Professionals

Remove these instructions. Add this question:

“Have you seen or received treatment from a healthcare provider (doctor, hospital, clinic, psychiatrist, nurse practitioner, therapist, physical therapist, or other medical professional, or do you have a future appointment scheduled?”

Add this statement:

“You may find this information on medical bills, online medical chart, or the internet.”

This section should include text boxes for the following:

“Name of Facility or Office

Name of Health Care Provider that treated you

What medical conditions were treated or evaluated?

Phone Number

Street Address

City

STATE/Province

ZIP/Postal Code

Country (if not USA)”

Remove Patient ID Number, if known:

Modify section title to “Doctors, Therapists, Hospitals, Clinics”

Modify this question to read as follows:

“Has this doctor/healthcare professional ordered any medical tests for you? Include tests already performed and scheduled in the future.

In “Kind of Test”, add “Psychological/IQ test” to the list of tests.

As previously stated, Tests should be separate from Medical Sources.

Date First Seen (MM/YYYYY)

Date Last Seen (MM/YYYY)

Date Next Seen (MM/YYYY)

The i3368 currently lists Doctors and Other Healthcare Professionals AND Hospital and Clinics separately. We would like to combine these two separate sections into one section titled “Medical Treatment” because the same information is asked for in both sections. Tests and medical sources should be listed separately. This section should mirror the revised SSA-3368. Maybe we can borrow the functionality from the i454.

Hospitals and Clinics

Remove these instructions. Add this question:

“Have you seen or received treatment from a healthcare provider (doctor, hospital, clinic, psychiatrist, nurse practitioner, therapist, physical therapist, or other medical professional, or do you have a future appointment scheduled?”

Add this statement:

“You may find this information on medical bills, online medical chart, or the internet.”

scheduled. You may find this information on medical bills, online medical chart, or the internet.”

Modify this question to read as follows:

“Has this hospital/clinic ordered any medical tests for you? Include tests already performed and scheduled in the future.

In “Kind of Test”, add “Psychological/IQ test” to the list of tests.

As previously stated, Tests should be separate from Medical Sources.

Edit instructions:

“Did any of the providers listed above order any medical tests for you?” Include tests already performed and scheduled in the future.”

Medical Tests

In “Kind of Test”, add “Psychological/IQ test” to the list of tests.

Section 9- Other Medical Information/ Other Medical Records

Edit instructions as follows:

“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.”

Add radio buttons to select Yes or No.

Other Medical Record Details

IF yes,

Edit this section as follows:

“Name or Organization

Phone Number

Mailing Address

City

STATE/Province

ZIP/Postal Code

Country (if not USA)

Name of Contact Person

Claim Number (if any)

Date of First Contact

Date of Last Contact

Date of Next Contact (if any)

Reason(s) for Contacts”

Allow them to add multiple people or organizations with details.

Section 10- Support Services

This is a new section to add to the i3368 Work/Education Pages after the Education, Training, and Literacy Section.

Modify this section as follows:

“Date Report Completed (MM/DD/YYYY)”

“Who is completing this report?” Add radio buttons and the following options:

“John Doe

Contact Person

Additional Contact Person

Someone else”

If they select “Someone else” provide text boxes to complete the following information:

“NAME (First, Middle Initial, Last)

Relationship to John Doe

MAILING ADDRESS (Street or PO Box) Include the apartment, 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.”

Modify title of section to “Who Is Completing This Report”