Disability Report - Adult

State Disability Determination Services (DDS) use Form SSA-3368, Disability Report – Adult, and its electronic versions, to determine if an adult disability applicant’s impairment(s) is severe and, if so, how the impairment(s) affects the applicant’s ability to work. This determination dictates whether the DDS and SSA will find the applicant disabled. The information we collect on the SSA 3368 is used by the State Disability Determination Services (DDS) to obtain evidence and evaluate whether or not an individual is found disabled. The collection is mandatory for applicants filing to obtain Title II disability benefits or Title XVI Supplemental Security Income (SSI) payments. We collect this information from the individual one time. We collect the information via several modalities: the SSA-3368-BK PDF paper form, the EDCS SSA-3368 Intranet application, and the i3368 Internet application. The respondents complete the SSA-3368 by themselves with self help information available, or another may complete the paper form or electronic application on their behalf. The respondents generally do not need information from someone else to complete the application. The respondents are disability applicants or third parties assisting the applicants applying for Title II disability benefits or Title XVI SSI payments. We are submitting a non-substantive Change Request to revise the informational langauge on the save and exit screens for the Internet modallity, i3368.

The latest form for Disability Report - Adult expires 2026-11-30 and is listed under ICR 202501-0960-002.

View the official OMB control history on Reginfo.gov.

Disability Report - Adult, (Fillable PDF)

Federal Enterprise Architecture: Income Security - General Retirement and Disability

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