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Social Security Online - Apply for Disability Benefits
noco t p i kS
Social Security Online
www.socialsecurity.gov
Apply for Disability Benefits
Home
Disability & SSI
Home
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Apply for Disability Benefits
To apply for disability benefits, begin by selecting the age
category of the disabled person:
Child (under age 18)
Adult (age 18 or over)
If your application has recently been denied, the Internet Appeal
is a starting point to request a review of our decision about your
eligibility for disability benefits.
If your application is denied for:
Medical reasons, you can complete and submit the required
Appeal Request and Appeal Disability Report online.
The disability report asks you for updated information about
your medical condition and any treatment, tests or doctor
visits since we made our decision.
Non-medical reasons, you should contact your local Social
Security Office to request the review. You also may call our
toll-free number, 1-800-772-1213, to request an appeal.
People who are deaf or hard of hearing can call our toll-free
TTY number, 1-800-325-0778.
Privacy Policy | Website Policies & Other Important Information | Site Map
Last reviewed or modified Wednesday Apr 01, 2009
https://www.socialsecurity.gov/applyfordisability/[6/29/2009 9:18:32 AM]
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Apply for Disability Benefits - Adult (Age 18 or Over)
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Apply for Disability Benefits
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Disability & SSI
Home
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Apply for Disability Benefits - Adult (Age 18 or Over)
Updated: July 2005
To apply for disability benefits for an adult, you will need to
complete an application for Social Security Benefits
AND an Adult Disability Report. The report collects
information about your disabling condition and how it affects
your ability to work. You can complete the forms online, or
you may call us to schedule an appointment and we will
help you in person or by phone.
How to apply
Please follow these steps:
Step 1. Review the Adult Disability Starter Kit. This kit
answers common questions about applying for benefits and
includes a worksheet that will help you gather the
information you need.
Step 2. Fill out the online application for Social Security
Benefits. (If you've never worked, skip this step and
contact us after you complete Step 3.)
Step 3. Fill out the online Adult Disability Report. At the
end of the report, we will ask you to sign a form that gives
your doctor permission to send us information about your
disability. We need this information so we can make a
decision on your claim.
NOTE: If you previously started an online application or
online disability report but did not finish it, you can:
Use your confirmation number to return to your online
application.
Use your re-entry number to return to your online
disability report.
Contacting Social Security
If you don’t want to do this online or need help, call us tollfree at 1-800-772-1213. If you are deaf or hard-of-hearing,
call our toll-free TTY number, 1-800-325-0778.
Representatives are available Monday through Friday
https://www.socialsecurity.gov/applyfordisability/adult.htm[6/29/2009 9:18:46 AM]
Apply for Disability Benefits - Adult (Age 18 or Over)
between 7 a.m. and 7 p.m.
[Top of page]
Privacy Policy | Website Policies & Other Important Information | Site Map
Last reviewed or modified Wednesday Apr 01, 2009
https://www.socialsecurity.gov/applyfordisability/adult.htm[6/29/2009 9:18:46 AM]
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Larger Text?
Adult Disability and Work History Report
oC
l a r t neCo t p i kS
Social Security Online
www.socialsecurity.gov
Adult Disability and Work History Report
Home
Questions?
How to Contact Us?
Search
Welcome!
If you are a professional, representative or organization assisting
adults age 18 or older in applying for disability benefits and are
familiar with the form SSA-3368-BK Disability Report - Adult, please
go to www.socialsecurity.gov/i3368pro. If you are an individual
applying for yourself or for another adult or are not familiar with the
SSA-3368-BK, continue reading this page.
This is a starting point to apply for disability benefits. Whether or not you
have already contacted Social Security, we need you to:
Give us information about your medical condition, medical records,
and your work and education history.
Complete a formal application for benefits.
You can apply online, apply in person or over the phone, or get more
information about disability and this application process
Applying Online
Using the online Adult Disability and Work History Report gives you:
Security and privacy for your information.
Step by step instructions and examples to help you complete the
report.
A process to collect information that applies to you, similar to the
interview process in a Social Security office.
The ability to work at your own pace, stopping when you want and
coming back to finish later.
Start the Report
Go Back to the Report I Already Started
Applying in Person or Over the Phone
If you prefer not to do this report on the Internet, you can use any of the
following ways to complete a Disability Report:
Call our toll-free number, 1-800-772-1213. Explain that you don't
want to use the online disability process but do want to set up an
appointment to apply for disability benefits. If you are deaf or hard of
hearing, call our toll-free "TTY" number, 1-800-325-0778.
https://secure.ssa.gov/apps6z/i3369/ee001-fe.jsp[6/29/2009 9:19:00 AM]
Adult Disability and Work History Report
Representatives are available Monday through Friday from 7 a.m. to
7 p.m.
Contact your local Social Security Office and explain that you do not
want to use the online disability process but would like to set up an
appointment to apply for disability benefits.
If you live outside the United States, see Service Around the World.
You can find more information on how to apply for disability benefits and
the claims process.
More Information About Disability and the Application Process
Social Security's Definition of Disability
How the Disability Application Process Works
Information about Social Security's Disability Programs
Internet Security Policy
Social Security's Accessibility Policy
Privacy Policy | Website Policies & Other Important Information | Site Map
https://secure.ssa.gov/apps6z/i3369/ee001-fe.jsp[6/29/2009 9:19:00 AM]
Internet Adult Disability Report
Skip to Central Content
Adult Disability & Work History Report - PRO
Help/FAQ
Welcome!
This is the starting point for professionals, representatives,
and organizations assisting adults age 18 or older in applying
for disability benefits. If you are an individual applying for
yourself or for another person, please go to the public version
of the Adult Disability and Work History Report. If the claimant
has not completed a formal application for benefits, he or she
needs to do so as soon as possible to avoid losing benefits.
In this disability report, we will ask you for information about
the claimant's medical sources and treatments, and work and
education history. We use this information to get medical
records and other information that helps us make the correct
decision about the claimant's disability claim. Please give us
as much information on all these areas as you can. Missing
or incomplete information may delay the claim or require a
contact with you or the claimant.
Important Information
Click on the link "Proper Applicant" for important information
on protecting the claimant's filing date and who can file an
application on the claimant's behalf.
To complete this report you will need:
Internet access
A personal computer with a Web browser that supports
128-bit encryption
Adobe Reader – If you don't have Adobe Reader on
your computer you can download a free copy. Use this
link to get a free copy of the Adobe Reader.
Privacy Information
The Social Security Administration has access to the
information you provide on this report and is authorized to
keep even partially completed reports. This is for purposes of
helping you complete the application process or update
information. If you have decided you want to continue, you
can start the report for a claimant now, or, if you are
undecided, you may do so at a later time. For more
information about filing online or other services provided by
the Social Security Administration, please contact us.
For additional information on the Social Security
https://secure.ssa.gov/apps6z/i3368PRO/main.html[6/29/2009 9:19:11 AM]
You may start a new Adult Disability and Work
History Report or access a report that has not
been submitted.
Start a New Report
Go Back to a Report I Already Started
Related Links
Information About this Internet Report:
How the Online Disability Report Works
Instructions for Alternative Views and Navigation
Special Instructions for Blind Users
Applying In Person or Over the Phone
Disability Report Form Guide
Disability Information:
How the Disability Application Process Works
Social Security's Definition of Disability
Information about Social Security's Disability
Programs
Legal and Official Information:
Proper Applicant
Claimant's Right to Representation
Internet Security Policy
Paperwork Reduction Act
Internet Adult Disability Report
Administration’s privacy policy, see the "Privacy Policy" link in
the footer below.
Privacy Policy | Website Policies & Other Important Information | Site Map
(800) 772-1213 or TTY (800) 325-0778, 7am-7pm
https://secure.ssa.gov/apps6z/i3368PRO/main.html[6/29/2009 9:19:11 AM]
The Paperwork Reduction Act Statement
Skip to Central Content
Adult Disability & Work History Report - PRO
The Paperwork Reduction Act Statement
This information collection meets the clearance requirements of 44 U.S.C. § 3507, as amended by section 2 of the
Paperwork Reduction Act of 1995. You are not required to answer these questions unless we display a valid Office of
Management and Budget control number. We estimate that it will take you an average of 90 minutes to respond, but total
time required will depend upon the number of questions you need to answer.
You may send comments on our estimate of the time needed to complete the Adult Disability and Work History ReportPRO to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to
this address, not the completed form.
The OMB approval number for the Internet Adult Disability and Work History Report is 0960-0579; expiration date
2/28/2011.
Close this window to return to the report.
(800) 772-1213 or TTY (800) 325-0778, 7am-7pm
https://secure.ssa.gov/apps6z/i3368PRO/msg015.jsp[6/29/2009 9:27:20 AM]
EE002 Screening Page
Prepared by the Usability Center, updated 06/08/04
Branding, Global Navigation, Claimant Summary, Function Bar
Should You Use this Report?
Not everyone will be able to use the Adult Disability and Work History Report - PRO online. You must answer all of the following questions to help determine if
you should use this Internet Report. If you are helping another person fill out this report, answer all the questions as they apply to the person you are helping.
The OMB control number for this Internet Adult Disability and Work History Report is xxxx-xxx; expiration date xx/xx/xxxx.
About You/Your Organization
Which of the following best describes your
organization?
About the Claimant
Claimant's Social Security Number:
(without dashes or hyphens)
Claimant's Date of Birth:
Does the claimant live in the United States or
its territories or possessions?
Yes
Has the claimant previously been denied for
Social Security or SSI disability benefits?
Yes, more than 60 days ago
No
Yes, less than 60 days ago
No
Do the claimant's illnesses, injuries, or
conditions (referred to as "conditions" from
hereon) keep him/her from working or
seriously limit his/her ability to work?
Yes
No
Will the claimant be unable to work for at least
a year due to his/her condition?
Yes
No
Has the claimant been diagnosed with a
condition that is expected to end in death?
Yes
No
Continue >
Footer
i3368 Pro, Exit Entry Pages, version 1.9
EE003 Welcome Back
Prepared by the Usability Center, updated 06/08/04
Branding, Global Navigation, Claimant Summary, Function Bar
Welcome Back!
Please enter the claimant's Social Security and Reentry numbers to reenter the Disability Report you already started. If you have lost the Reentry Number, you
will not be able to continue with the Disability Report you already began. You may start a new online Disability Report up to 3 times. You can start a new report
or contact your local Social Security office and they will help you. However, Social Security cannot access the Reentry Number.
You will be taken back to where you left off (if you didn't complete the new report process or if there is an error) or to the Main area where you will have access
to all parts of the report.
Claimant's Social Security Number:
(without dashes or hyphens)
Reentry Number:
< Previous
Footer
i3368 Pro, Exit Entry Pages, version 1.9
Continue >
FC001 About Your Organization - New Report Process
Prepared by the Usability Center, updated 06/24/04
Branding, Global Navigation, Claimant Summary, Function Bar
About Your Organization
Give the name and information about the person in your organization that Social Security should contact for more information about this claim, if needed.
This page does not replace the form SSA-1696-U4 Appointment of Representative. If you are representing the claimant, you must still give us a
completed SSA-1696-U4.
Items marked with an asterisk (*) are required.
*Organization Name:
*Contact Name:
Ms.
(Title, First, Last)
Contact Instructions:
(300 characters maximum. About 6 lines.)
Count Characters
50 chars
*Organization Address:
*(Street Address Line 1)
(Street Address Line 2)
*(City, State, ZIP)
*Contact Phone Number:
(
)
-
Ext:
(optional)
Email Address:
Continue >
Footer
i3368 Pro, Exit Entry Pages, version 1.9
FC001 About Your Organization - From Global Navigation
Prepared by the Usability Center, updated 06/24/04
Branding, Global Navigation, Claimant Summary, Function Bar
About Your Organization
Give the name and information about the person in your organization that Social Security should contact for more information about this claim, if needed.
This page does not replace the form SSA-1696-U4 Appointment of Representative. If you are representing the claimant, you must still give us a
completed SSA-1696-U4.
Items marked with an asterisk (*) are required.
*Organization Name:
*Contact Name:
Ms.
(Title, First, Last)
Contact Instructions:
(300 characters maximum. About 6 lines.)
Count Characters
50 chars
*Organization Address:
*(Street Address Line 1)
(Street Address Line 2)
*(City, State, ZIP)
*Contact Phone Number:
(
)
-
Ext:
(optional)
Email Address:
Done
Footer
i3368 Pro, Exit Entry Pages, version 1.9
i3368 Pro, Exit Entry Pages, version 1.9
i3368 Pro, Exit Entry Pages, version 1.9
AB002 About the Claimant
Prepared by the Usability Center, updated 06/08/04
Branding, Global Navigation, Claimant Summary, Function Bar
About the Claimant: General Information
Items marked with an asterisk (*) are required.
Claimant's Contact Details
*Claimant's Name:
(First, Middle Initial, Last, Suffix)
*Claimant's Address:
*(Street Address Line 1)
(Street Address Line 2)
*(City, State, ZIP)
*Daytime Phone Number:
(
)
-
Ext:
(optional)
Claimant's phone number
Claimant's message number
Email Address:
Someone Else We Can Contact
*Is there someone else we can contact who
knows about the claimant's condition and can
help with his/her claim?
Yes
No
Can the claimant:
*Speak and understand English?
Yes
No, he/she speaks the following languages:
*Read and understand English?
Yes
No
*Write more than his/her name in English?
Yes
No
*If the claimant cannot speak and understand
English, is there someone we may contact
who speaks English and will give the
claimant messages?
Yes
No
Yes
No
Claimant's English-Speaking Ability
Other Information
*Are there other name(s) that the claimant
may have used on his/her medical records?
If the claimant has a Medicaid card or medical
assistance card issued by a state
government, please provide us with the
number.
*What is the claimant's height without shoes?
*What is the claimant's weight without shoes?
Feet:
Inches:
lbs
< Previous
Footer
i3368 Pro, About Claimant Pages, version 2.5
Continue >
AB002 About the Claimant - Protected
Prepared by the Usability Center, updated 06/08/04
Branding, Global Navigation, Claimant Summary, Function Bar
About the Claimant: General Information
Items marked with an asterisk (*) are required.
Claimant's Contact Details
*Claimant's Name:
(First, Middle Initial, Last, Suffix)
*Claimant's Address:
*(Street Address Line 1)
(Street Address Line 2)
*(City, State, ZIP)
*Daytime Phone Number:
(
)
-
Ext:
(optional)
Claimant's phone number
Claimant's message number
Email Address:
Someone Else We Can Contact
*Is there someone else we can contact who
knows about the claimant's condition and can
help with his/her claim?
Yes
No
Claimant's English-Speaking Ability
Can the claimant:
*Speak and understand English?
Yes
No, he/she speaks the following languages:
*Read and understand English?
Yes
No
*Write more than his/her name in English?
Yes
Yes
No
No
*If the claimant cannot speak and understand
English, is there someone we may contact
who speaks English and will give the
claimant messages?
Other Information
*Are there other name(s) that the claimant
may have used on his/her medical records?
If the claimant has a Medicaid card or medical
assistance card issued by a state
government, please provide us with the
number.
*What is the claimant's height without shoes?
*What is the claimant's weight without shoes?
Yes
No
Feet:
Inches:
lbs
< Previous
Footer
i3368 Pro, About Claimant Pages, version 2.5
Continue >
i3368 Pro, About Claimant Pages, version 2.5
i3368 Pro, About Claimant Pages, version 2.5
AB004 Condition Description
Prepared by the Usability Center, updated 06/08/04
Branding, Global Navigation, Claimant Summary, Function Bar
Important: Describe John Doe's Conditions
Items marked with an asterisk (*) are required.
*Describe each of the claimant's listed conditions
that limit his/her ability to work.
(500 characters maximum. About 10 lines.)
Count Characters
278 chars
*Explain how the claimant's conditions limit his/her
ability to do basic work activities such as sitting,
lifting and carrying things, standing, walking,
concentrating, or remembering instructions.
(500 characters maximum. About 10 lines.)
Count Characters
50 chars
*Explain how the following limit the claimant's
ability to work or do his/her daily activities:
Pain
Fatigue
Feeling depressed
Any other symptoms
(500 characters maximum. About 10 lines.)
Count Characters
0 chars
< Previous
Footer
i3368 Pro, About Claimant Pages, version 2.5
Continue >
AB005a Work Situation Description ("No, has never worked")
Prepared by the Usability Center, updated 06/08/04
Branding, Global Navigation, Claimant Summary, Function Bar
Important: Date Claimant Became Unable to Work
Items marked with an asterisk (*) are required.
*When does the claimant say his/her condition
became severe enough to keep him/her from
working (even though he/she has never worked)?
At birth
Encourage the claimant to select the closest date he/
she can remember.
< Previous
Footer
i3368 Pro, About Claimant Pages, version 2.5
Continue >
AB005b Work Situation Description ("Yes, currently working")
Prepared by the Usability Center, updated 04/06/04
Branding, Global Navigation, Claimant Summary, Function Bar
Important: Date Claimant Became Unable to Work
Items marked with an asterisk (*) are required.
*When did the claimant's condition first interfere
with his/her ability to work?
Encourage the claimant to select the closest date he/
she can remember.
*Has the claimant's condition caused him/her to
do any of these things?
Yes
No
If the claimant said "Yes", then tell us if the claimant's condition caused him/her to make any changes.
Please select all that apply.
Change job duties or found new ways to do the job
Change to a different employer
Work fewer hours
Take sick days or misses scheduled work time
Stop working for a period of time
Get extra help from employer, co-workers, or other employees
Make other changes to the work not listed above
*Explain in detail each type of change that was
selected above. (if applicable)
(1000 characters maximum. About 20 lines.)
Count Characters
50 chars
< Previous
Footer
i3368 Pro, About Claimant Pages, version 2.5
Continue >
AB005c Work Situation Description ("Yes, but stopped because of other reasons", "Yes but
stopped both due to his/her condition and other reasons")
Prepared by the Usability Center, updated 06/08/04
Branding, Global Navigation, Claimant Summary, Function Bar
Important: Date Claimant Became Unable to Work
Items marked with an asterisk (*) are required.
*When did the claimant become unable to work
because of his/her condition?
Encourage the claimant to select the closest date he/
she can remember.
*When did the claimant most recently stop
working?
Encourage the claimant to select the closest date he/
she can remember.
*Please explain why the claimant stopped working.
(900 characters maximum. About 20 lines.)
Count Characters
50 chars
*Did the claimant work at any time after the
condition first bothered him/her?
Yes
No
If the claimant said "Yes", then tell us if the claimant's condition caused him/her to make any changes.
Please select all that apply.
Change job duties or find new ways to do the job
Change to a different employer
Work fewer hours
Take sick days or missed scheduled work time
Stop working for a period of time
Get extra help from employer, co-workers, or other employees
Make other changes to the work not listed above
Did not make other changes to his/her work
*Explain in detail each type of change that was
selected above. (if applicable)
(1000 characters maximum. About 20 lines.)
Count Characters
50 chars
< Previous
Footer
i3368 Pro, About Claimant Pages, version 2.5
Continue >
AB005d Work Situation Description ("Yes, but stopped because of his/her condition")
Prepared by the Usability Center, updated 06/08/04
Branding, Global Navigation, Claimant Summary, Function Bar
Important: Date Claimant Became Unable to Work
Items marked with an asterisk (*) are required.
*When did the claimant become unable to work
because of his/her condition?
Encourage the claimant to select the closest date he/
she can remember.
*When did the claimant most recently stop
working?
Encourage the claimant to select the closest date he/
she can remember.
*Did the claimant work at any time after the
condition first bothered him/her?
Yes
No
If the claimant said "Yes", then tell us if the claimant's condition caused him/her to make any changes.
Please select all that apply.
Change job duties or find new ways to do the job
Change to a different employer
Work fewer hours
Take sick days or missed scheduled work time
Stop working for a period of time
Get extra help from employer, co-workers, or other employees
Make other changes to the work not listed above
Did not make other changes to his/her work
*Explain in detail each type of change that was
selected above.
(1000 characters maximum or 20 lines)
Count Characters
50 chars
< Previous
Footer
i3368 Pro, About Claimant Pages, version 2.5
Continue >
AB001 Claimant's Info (Claimant Tab: New report view, responded no and didn't answer non-*s) Prepared by the Usability Center, updated 06/08/04
Branding, Global Navigation, Claimant Summary, Function Bar
Claimant's Info
Doctors
Hospitals
Medications
Medical Tests
Jobs
Other Records
About John Doe: General Information
Edit
[Claimant's Name]
[Street Address Line 1], [City, State, ZIP]
Height: x ft x inches Weight: xxx lbs
You said the claimant:
Speaks and understands English.
Reads and understands English.
Is able to write more than his/her name in English.
Edit
The claimant does not have other names on his/her medical records other than [Claimant's Name].
Edit
There is no contact who knows about the claimant's condition and can help with his/her claim.
Edit
There is no contact who speaks English and will give the claimant messages.
About John Doe: Medical, Work, and Education History
Claimant's Condition
Edit
The following conditions first started to bother the claimant on [first bothered date]:
[Display first 100 characters of the condition listing]
Edit
The claimant's condition does not cause pain or other symptoms.
Edit
The claimants has not gone to a doctor, hospital, clinic or anyone else for mental or emotional problems that limit his/her daily
activities.
Description of Condition
Edit
Conditions that limit the claimant's ability to work:
[Display first 100 characters of text area]
Conditions that limit the claimant's basic work activities:
[Display first 100 characters of text area]
Pain, fatigue, feeling depressed and any other symptoms that limit the claimant's ability to work or do daily activities in the following manner:
[Display first 100 characters of text area]
Work History
Edit
The claimant has never worked.
Edit
The claimant became unable to work because of his/her condition on mm/dd/yyyy.
Education and Special Job Training
Edit
Years of school completed: [level completed 6.0], Approximate date completed: no date entered.
Edit
The claimant did not attend special education classes or received other education services.
Edit
The claimant did not complete any special job training, trade or vocational school.
Edit
The claimant did not receive vocational rehabilitation services or participated in a Ticket Program.
Footer
i3368 Pro, About Claimant Pages, version 2.5
Prepared by the Usability Center, updated 06/08/04
AB001 Claimant's Info (Claimant Tab: New report view, full details entered)
Branding, Global Navigation, Claimant Summary, Function Bar
Claimant's Info
Doctors
Hospitals
Medications
Medical Tests
Jobs
Other Records
About John Doe: General Information
Edit
[Claimant's Name]
[Street Address Line 1], [City, State, ZIP]
Height: x ft x inches Weight: xxx lbs
You said the claimant:
Speaks and understands English.
Reads and understands English.
Is able to write more than his/her name in English.
Edit
The claimant has other names on his/her medical records other than [Claimant's Name].
[ otherFirstName Other MiddleInitial otherLastName, otherSuffix]
[ otherFirstName Other MiddleInitial otherLastName, otherSuffix]
[ otherFirstName Other MiddleInitial otherLastName, otherSuffix]
[ otherFirstName Other MiddleInitial otherLastName, otherSuffix]
Edit
There is a person who knows about the claimant's condition and can help with his/her claim.
Edit
There is a person who speaks English and will give the claimant messages.
[ Contact Name]
[Street Address Line 1], [City, State, ZIP]
[ Contact Name]
[Street Address Line 1], [City, State, ZIP]
About John Doe: Medical, Work, and Education History
Claimant's Condition
Edit
The following conditions first started to bother the claimant on [first bothered date]:
[Display first 100 characters of the condition listing]
Edit
The claimant's condition causes pain or other symptoms.
Edit
The claimant went to a doctor, hospital, clinic or anyone else for mental or emotional problems that limit his/her daily activities.
Description of Condition
Edit
Conditions that limit the claimant's ability to work:
[Display first 100 characters of text area]
Conditions that limit the claimant's basic work activities:
[Display first 100 characters of text area]
Pain, fatigue, feeling depressed and any other symptoms that limit the claimant's ability to work or do daily activities in the following manner:
[Display first 100 characters of text area]
Work History
Edit
Edit
The claimant stopped work because of his/her condition.
The claimant became unable to work because of his/her condition on: [alleged onset].
The claimant most recently stopped working on: [date stopped work].
The claimant stopped working because:
[Display first 100 characters of text area]
The claimant worked after the condition first bothered him/her and this caused him/her to:
Change job duties or find new ways to do the job
Work fewer hours
Take sick days or miss scheduled work time
Explanation for changes:
[Display first 100 characters of text area]
Education and Special Job Training
Edit
Years of school completed: [level completed 6.0], Approximate date completed: [completion date 6.0].
Edit
The claimant attended special education classes or received other education services.
[Street Address Line 1], [City, State, ZIP]
School Information: [School Name]
Edit
The claimant completed special job training, trade or vocational school.
Program Information: [Display first 100 characters of 'Type of Program' text area]
Edit
The claimant received vocational rehabilitation services or participated in a Ticket Program at the following place.
[Agency Name]
[Street Address Line 1], [City, State, ZIP]
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i3368 Pro, About Claimant Pages, version 2.5
AB006 Close personal contact
Prepared by the Usability Center, updated 06/16/04
Branding, Global Navigation, Claimant Summary, Function Bar
Someone Else We Can Contact About Claimant's Conditions
Jump to:
Go
You said that there is someone else we can contact who knows about the claimant's conditions and can help with his/her claim. If this is not true, please
Change the Answer.
Items marked with an asterisk (*) are required.
*Contact Person's Name:
(First, Middle Initial, Lastm Suffix)
*Relationship to Claimant:
If other, please indicate:
*Contact's Address:
Same as John Doe's address
Same as 's address
Other address (provide below)
(Street Address Line 1)
(Street Address Line 2)
(City, State, ZIP)
*Daytime Phone Number:
Same as John Doe's phone number
Same as 's phone number
Other phone number (provide below)
(
)
Ext:
(optional)
< Previous
Footer
i3368 Pro, About Claimant Pages, version 2.5
Continue >
AB007 English-Speaking Contact
Prepared by the Usability Center, updated 06/16/04
Branding, Global Navigation, Claimant Summary, Function Bar
Someone We Can Contact Who Speaks and Understands English
Jump to:
Go
You said that there is someone else who speaks and understands English and can deliver messages to the claimant. If this is not true, please Change the Answer.
Items marked with an asterisk (*) are required.
*Contact Person's Name:
(First, Middle Initial, Last, Suffix)
*Relationship to Claimant:
If other, please indicate:
*Contact's Address:
Same as John Doe's address
Same as 's address
Other address (provide below)
(Street Address Line 1)
(Street Address Line 2)
(City, State, ZIP)
*Daytime Phone Number:
Same as John Doe's phone number
Same as 's phone number
Other phone number (provide below)
(
)
-
Ext:
(optional)
< Previous
Footer
i3368 Pro, About Claimant Pages, version 2.5
Continue >
AB008 Other Names
Prepared by the Usability Center, updated 06/24/04
Branding, Global Navigation, Claimant Summary, Function Bar
Other Names Used on Medical Records
Jump to:
Go
You indicated that the claimant's medical records may be listed under another name (maiden name, previous married name(s), nickname, etc.). If this is not
true, please Change the Answer.
Items marked with an asterisk (*) are required.
*Claimant's Other Names
(First, Middle Initial, Last)
Provide at least one.
< Previous
Footer
i3368 Pro, About Claimant Pages, version 2.5
Continue >
AB009 Special Education Classes
Prepared by the Usability Center, updated 06/16/04
Branding, Global Navigation, Claimant Summary, Function Bar
Special Education Classes
Jump to:
Go
You said the claimant attended special education classes or received other education services, if this is not true, please Change the Answer.
Name of School:
Address:
(Street Address Line 1)
(Street Address Line 2)
(Street Address Line 3)
(City, State, ZIP)
Phone Number:
(
)
Dates Attended
From:
-
Ext:
(optional)
To:
Type of Program:
Tell us what kind of services the claimant received,
how often, and where he/she received these
services.
(1000 character maximum. About 20 lines.)
Count Characters
50 chars
The claimant had special education classes at more than one school
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i3368 Pro, About Claimant Pages, version 2.5
Continue >
Prepared by the Usability Center, updated 06/08/04
AB010 Special Job Training, Trade of Vocational School
Branding, Global Navigation, Claimant Summary, Function Bar
Special Job Training, Trade or Vocational School
Jump to:
Go
The claimant completed special job training, trade or vocational school, if this is not true, please Change the Answer.
Type of Program:
Tell us what kind of services the claimant received,
how often, and where the claimant received these
services.
(1000 character maximum. About 20 lines.)
Count Characters
50 chars
Approximate Date Completed:
< Previous
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i3368 Pro, About Claimant Pages, version 2.5
Continue >
Prepared by the Usability Center, updated 06/08/04
AB011 Other Medical Source Details: Vocational Rehabilitation
Branding, Global Navigation, Claimant Summary, Function Bar
Provide Vocational Rehabilitation Agency Details
Jump to:
Go
The claimant received vocational rehabilitation services or participated in a Ticket Program at the following place, if this is not true, please Change the Answer.
Items marked with an asterisk (*) are required.
*Organization Name:
Counselor's Name:
(First, Last)
*Address:
*(Street Address Line 1)
(Street Address Line 2)
(Street Address Line 3)
*(City, State, ZIP)
*Phone Number:
(
)
-
Ext:
(optional)
Appointment Dates
When did the claimant first go?
When did the claimant last go?
Types of Services or Tests Performed:
(1000 character maximum. About 20 lines of typing)
Count Characters
50 chars
The claimant had vocational rehabilitation services at another agency
< Previous
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i3368 Pro, About Claimant Pages, version 2.5
Continue >
DC001 Doctors Tab - Answered Yes, no details
Prepared by the Usability Center, updated 05/12/04
Branding, Global Navigation, Claimant Summary, Function Bar
Claimant's Info
Doctors
Hospitals
Medications
Medical Tests
Jobs
Other Records
Doctors (up to 15)
*Has the claimant gone to a doctor for his/her condition (s)?
Yes
No
If you answer "yes" and later need to change this to
"no", you must first delete all doctor information that
you may have entered.
Include physicians, psychologists, optometrists, nurse practioners, therapists, chiropractors, acupuncturists, etc.
You can prompt the claimant to check current medicine containers for doctors' names.
Do not include staff doctors at the hospital.
To edit doctor details, select the doctor's name below.
! You must provide details for at least one doctor.
Add a Doctor
i3368 Pro Doctors, version 1.6
DC001 Doctors Tab - Protected
Prepared by the Usability Center, updated 05/10/04
Branding, Global Navigation, Claimant Summary, Function Bar
Claimant's Info
Doctors
Hospitals
Medications
Medical Tests
Jobs
Other Records
Doctors (up to 15)
*Has the claimant gone to a doctor for his/her condition (s)?
Yes
No
If you answer "yes" and later need to change this to
"no", you must first delete all doctor information that
you may have entered.
Include physicians, psychologists, optometrists, nurse practioners, therapists, chiropractors, acupuncturists, etc.
You can prompt the claimant to check current medicine containers for doctors' names.
Do not include staff doctors at the hospital.
To edit doctor details, select the doctor's name below.
Dr. Jane Doe
Dr. Jane Doe
Dr. Jane Doe
Dr. Jane Doe
Dr. Jane Doe
Dr. Jane Doe
Add a Doctor
i3368 Pro Doctors, version 1.6
HP001 Hospitals Tab
Prepared by the Usability Center, updated 05/12/04
Branding, Global Navigation, Claimant Summary, Function Bar
Claimant's Info
Doctors
Hospitals
Medications
Medical Tests
Jobs
Other Records
Hospitals (up to 12)
*Has the claimant gone to a hospital for his/her condition (s)?
Yes
No
If you answer "yes" and later need to change this to "no", you
must first delete all hospital information that you may have
entered.
Include places other than doctors' offices where the claimant went for treatments, tests, surgery, or emergency room visits.
To edit hospital details, select the hospital name below.
! You must provide details for at least one hospital.
Add a Hospital
i3368 Pro Hospitals, version 2.0
HP001 Hospitals Tab
Prepared by the Usability Center, updated 05/07/04
Branding, Global Navigation, Claimant Summary, Function Bar
Claimant's Info
Doctors
Hospitals
Medications
Medical Tests
Jobs
Other Records
Hospitals (up to 12)
*Has the claimant gone to a hospital for his/her condition (s)?
Yes
No
If you answer "yes" and later need to change this to
"no", you must first delete all hospital information that
you may have entered.
Include places other than doctors' offices where the claimant went for treatments, tests, surgery, or emergency room visits.
To edit hospital details, select the hospital name below.
Johns Hopkins Hospital
Johns Hopkins Hospital
Union Memorial
Union Memorial
Johns Hopkins Hospital
Johns Hopkins Hospital
Add a Hospital
i3368 Pro Hospitals, version 2.0
HP002 Hospital Details - Upon review/return
Prepared by the Usability Center, updated 06/16/04
Branding, Global Navigation, Claimant Summary, Function Bar
Provide Hospital Details
Jump to:
Go
Items marked with an asterisk (*) are required.
*Hospital/Clinic Name:
*Address:
*(Street Address Line 1)
(Street Address Line 2)
(Street Address Line 3)
*(City, State, ZIP)
*Phone Number:
(
)
-
Ext:
(optional)
Hospital/Clinic #:
*Did the claimant have any inpatient stays at
this hospital or clinic?
We will only collect details for up to 3 stays.
*Did the claimant have any outpatient visits at
this hospital or clinic?
*Did the claimant have any emergency room
visits at this hospital or clinic?
We will only collect details for up to 2 visits.
Unknown
Edit Inpatient Stay 1
Edit Inpatient Stay 2
Edit Inpatient Stay 3
Had 3 inpatient stays
Has more than 3 inpatient stays at this hospital
Edit Outpatient visit details
Had outpatient visits
Edit Emergency Room Visit 1
Edit Emergency Room Visit 2
Had 2 emergency room visits
Has more than 2 emergency room visits at this hospital
Next Appointment:
(if not scheduled, enter "None")
If you want to delete this hospital, you must first delete
the inpatient, outpatient or emergency room pages for
this hospital that follow this page.
Continue >
Back to Hospital Tab
Footer
i3368 Pro Hospitals, version 2.0
HP003 Inpatient Details
Prepared by the Usability Center, 06/08/04
Branding, Global Navigation, Claimant Summary, Function Bar
: Inpatient Stay x of x
Jump to:
Go
When was the claimant admitted?
When was the claimant released?
Why was the claimant admitted to the hospital/
clinic?
(160 characters max. About 4 lines.)
Count Characters
50 chars
What treatment did the claimant receive?
(160 characters max. About 4 lines.)
Count Characters
50 chars
If the claimant saw the same doctor regularly
during this inpatient stay, please give us the
doctor's name.
Other: (Title, First Name, Last Name)
Dr.
Delete this Visit
< Previous
Continue >
Back to Hospital Details
Footer
i3368 Pro Hospitals, version 2.0
HP004 Outpatient Visits
Prepared by the Usability Center, 06/08/04
Branding, Global Navigation, Claimant Summary, Function Bar
: Outpatient Visits
Jump to:
Go
First outpatient visit:
Most recent outpatient visit:
Why did the claimant go for outpatient visits?
(1000 characters max. About 20 lines.)
Count Characters
50 chars
What treatments did the claimant receive?
(160 characters max. About 4 lines.)
Count Characters
50 chars
If the claimant saw the same doctor regularly
during those visits, please give us the doctor's
name.
Other: (Title, First Name, Last Name)
Dr.
Delete this Visit
< Previous
Continue >
Back to Hospital Details
Footer
i3368 Pro Hospitals, version 2.0
HP005 Emergency Room Details
Prepared by the Usability Center, updated 06/08/04
Branding, Global Navigation, Claimant Summary, Function Bar
: ER Visit x of x
Jump to:
Go
When did this visit to the emergency room take
place?
Why did the claimant go to the emergency
room?
(160 characters max. About 4 lines.)
Count Characters
50 chars
What treatments did the claimant receive?
(160 characters max. About 4 lines.)
Count Characters
50 chars
Delete this Visit
< Previous
Continue >
Back to Hospital Details
Footer
i3368 Pro Hospitals, version 2.0
MD001 Medications Tab - Answered Yes, no details
Prepared by the Usability Center, updated 06/10/04
Branding, Global Navigation, Claimant Summary, Function Bar
Claimant's Info
Doctors
Hospitals
Medications
Medical Tests
Jobs
Other Records
Medications
*Does the claimant currently take any prescription or over-the-counter
medicines for his/her condition (s)?
Yes
No
If you answer "yes" and later need to change this to
"no", you must first delete all medication information
that you may have entered.
List all prescription and non-prescription (over-the-counter) medicines that the claimant currently takes for his/her condition.
If possible, encourage the claimant to provide the exact name listed on his/her medicine container.
To edit medicine details, select the medicine name below.
Prescription Medicines (up to 20 medicines)
! You must provide details for at least one medicine.
Add Prescription Medicine
Over-the-Counter Medicines (up to 10 medicines)
! You must provide details for at least one medicine.
Add Over-the-Counter Medicine
Footer
i3368 Pro, Medications, version 2.0
MD001 Medications Tab
Prepared by the Usability Center, updated 06/08/04
Branding, Global Navigation, Claimant Summary, Function Bar
Claimant's Info
Doctors
Hospitals
Medications
Medical Tests
Jobs
Other Records
Medications
*Does the claimant currently take any prescription or over-the-counter
medicines for his/her condition (s)?
Yes
No
If you answer "yes" and later need to change this to
"no", you must first delete all medication information
that you may have entered.
List all prescription and non-prescription (over-the-counter) medicines that the claimant currently takes for his/her condition.
If possible, encourage the claimant to provide the exact name listed on his/her medicine container.
To edit medicine details, select the medicine name below.
Prescription Medicines (up to 20 medicines)
Midrin
Benzphetamine
Taxol
Fexofenadine
Wellbutrin
Chlorpromazine
Add Prescription Medicine
Over-the-Counter Medicines (up to 10 medicines)
Advil
St. Johns Wort
Ephedra
Prilosec OTC
Claritin
Stress B Complex
Add Over-the-Counter Medicine
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i3368 Pro, Medications, version 2.0
MD002a Prescription Medicine Details
Prepared by the Usability Center, updated 06/24/04
Branding, Global Navigation, Claimant Summary, Function Bar
Provide Prescription Medicine Details
Jump to:
Go
Items marked with an asterisk (*) are required.
*Prescription Medicine Name:
Who prescribed this medicine?
Other: (Title, First Name, Last Name)
Dr.
Reason for medicine:
(400 character maximum. About 8 lines.)
Count Characters
50 chars
Side effects experienced:
(1000 character maximum. About 20 lines.)
Count Characters
50 chars
Delete this Medicine
Done
Footer
i3368 Pro, Medications, version 2.0
MD002b Over-the-Counter Medicine Details
Prepared by the Usability Center, updated 06/08/04
Branding, Global Navigation, Claimant Summary, Function Bar
Provide Over-the-Counter Medicine Details
Jump to:
Go
Items marked with an asterisk (*) are required.
*Over-the-Counter Medicine Name:
Which doctor, if any, told the claimant to
take this medication?
Other: (Title, First Name, Last Name)
Dr.
Reason for medicine:
(400 character maximum. About 8 lines.)
Count Characters
50 chars
Side effects experienced:
(1000 character maximum. About 20 lines.)
Count Characters
50 chars
Delete this Medicine
Done
Footer
i3368 Pro, Medications, version 2.0
MD002a variation - User answers "No" or has not answered Doctor pathing question
Prepared by the Usability Center, updated 06/24/04
Branding, Global Navigation, Claimant Summary, Function Bar
Provide Prescription Medicine Details
Jump to:
Go
Items marked with an asterisk (*) are required.
*Prescription Medicine Name:
Who prescribed this medicine?
You must first tell us the claimant had doctors before you can answer this question.
Reason for medicine:
(400 character maximum. About 8 lines.)
Count Characters
50 chars
Side effects experienced:
(1000 character maximum. About 20 lines.)
Count Characters
50 chars
Delete this Medicine
Done
Footer
i3368 Pro, Medications, version 2.0
TS001 Medical Tests Tab - Answered yes, no details
Prepared by the Usability Center, updated 06/08/04
Branding, Global Navigation, Claimant Summary, Function Bar
Claimant's Info
Doctors
Hospitals
Medications
Medical Tests
Jobs
Other Records
Medical Tests (up to 18 tests)
*Has the claimant had or scheduled any medical tests for his/her
condition(s)?
Yes
No
If you answer "yes" and later need to change this to
"no", you must first delete all medical test information
that you may have entered.
List all tests that the claimant has had or expects to have.
Include a specific test only once, we will let you select how many times the test was performed.
To edit test details, select the test name below.
! You must provide details for at least one medical test.
Add Test
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i3368 Pro Medical Tests, version 1.9
TS001 Medical Tests Tab
Prepared by the Usability Center, updated 06/08/04
Branding, Global Navigation, Claimant Summary, Function Bar
Claimant's Info
Doctors
Hospitals
Medications
Medical Tests
Jobs
Other Records
Medical Tests (up to 18 tests)
*Has the claimant had or scheduled any medical tests for his/her
condition(s)?
Yes
No
If you answer "yes" and later need to change this to
"no", you must first delete all medical test information
that you may have entered.
List all tests that the claimant has had or expects to have.
Include a specific test only once, we will let you select how many times the test was performed.
To edit test details, select the test name below.
Blood Test
Biopsy
EEG (Brain Wave Test)
EMG entire body
MRI/CT Scan
Psychological evaluation
Add Test
Footer
i3368 Pro Medical Tests, version 1.9
TS001 Medical Tests Tab - With 'has more...' checkbox when all 'other' tests maxed out
Prepared by the Usability Center, updated 06/24/04
Branding, Global Navigation, Claimant Summary, Function Bar
Claimant's Info
Doctors
Hospitals
Medications
Medical Tests
Jobs
Other Records
Medical Tests (up to 18 tests)
*Has the claimant had or scheduled any medical tests for his/her
condition(s)?
Yes
No
If you answer "yes" and later need to change this to
"no", you must first delete all medical test information
that you may have entered.
List all tests that the claimant has had or expects to have.
Include a specific test only once, we will let you select how many times the test was performed.
To edit test details, select the test name below.
Blood Test
Biopsy
EEG (Brain Wave Test)
EMG entire body
MRI/CT Scan
Psychological evaluation
Add Test
The claimant has more "Other Tests" than those listed. List any additional "Other Tests" in the Remarks section of this report.
Footer
i3368 Pro Medical Tests, version 1.9
TS002a Medical Test Details - Test with body part question
Prepared by the Usability Center, updated 06/08/04
Branding, Global Navigation, Claimant Summary, Function Bar
Provide Details About
Jump to:
Go
Items marked with an asterisk (*) are required.
*Test Name:
Part of body covered by test:
Most recent date test was done or is expected to
be done:
Where was or where will this test be done?
Unknown
Who sent you or will send you for this test?
Unknown
Other: (Title, First Name, Last Name)
Ms.
How many times has this test been done?
Delete this Test
Done
Footer
i3368 Pro Medical Tests, version 1.9
TS002a Medical Test Details - Test with body part question and no doctor drop-down
Prepared by the Usability Center, updated 07/06/04
Branding, Global Navigation, Claimant Summary, Function Bar
Provide Details About
Jump to:
Go
Items marked with an asterisk (*) are required.
*Test Name:
Part of body covered by test:
Most recent date test was done or is expected to
be done:
Where was or where will this test be done?
Who sent you or will send you for this test?
Unknown
You must first tell us the claimant had doctors before you can answer this question.
How many times has this test been done?
Delete this Test
Done
Footer
i3368 Pro Medical Tests, version 1.9
TS002b Medical Test Details - Predefined
Prepared by the Usability Center, updated 07/06/04
Branding, Global Navigation, Claimant Summary, Function Bar
Provide Test Details
Jump to:
Go
Items marked with an asterisk (*) are required.
*Test Name:
Most recent date test was done or is expected to
be done:
Where was or where will this test be done?
Unknown
Who sent you or will send you for this test?
Unknown
Other: (Title, First Name, Last Name)
Ms.
How many times has this test been done?
Delete this Test
Done
Footer
i3368 Pro Medical Tests, version 1.9
TS002a Medical Test Details - User-defined with body part question
Prepared by the Usability Center, updated 07/06/04
Branding, Global Navigation, Claimant Summary, Function Bar
Provide Test Details
Jump to:
Go
Items marked with an asterisk (*) are required.
*Test Name:
Part of body covered by test:
Most recent date test was done or is expected to
be done:
Where was or where will this test be done?
Unknown
Who sent you or will send you for this test?
Unknown
Other: (Title, First Name, Last Name)
Ms.
How many times has this test been done?
Delete this Test
Done
Footer
i3368 Pro Medical Tests, version 1.9
JB001 Jobs Tab - Never Worked
Prepared by the Usability Center, updated 06/08/04
Branding, Global Navigation, Claimant Summary, Function Bar
Claimant's Info
Doctors
Hospitals
Medications
Medical Tests
Jobs
The claimant has never worked. If this is not true, please Change the Answer.
Footer
i3368 Pro, Job Pages, version 1.6
Jobs
Other Records
JB001 Jobs Tab - Currently Working/Stopped Work + None Entered + No Job Selected
Prepared by the Usability Center, updated 06/08/04
Branding, Global Navigation, Claimant Summary, Function Bar
Claimant's Info
Doctors
Hospitals
Medications
Medical Tests
Jobs
John Doe's Jobs (up to 18 jobs)
The claimant has worked, but stopped due to his/her condition. If this is not true, please Change the Answer.
List all the jobs the claimant had in the 15 years before he/she became unable to work because of his/her condition(s).
Start with the most recent job and go backward to the earliest job.
To edit job details, select the job title below.
! You must provide details for at least one job.
Add a Job
Footer
i3368 Pro, Job Pages, version 1.6
Other Records
JB001 Jobs Tab - Currently working, stopped work + 1 job + no 3369 comments
Prepared by the Usability Center, updated 06/08/04
Branding, Global Navigation, Claimant Summary, Function Bar
Claimant's Info
Doctors
Hospitals
Medications
Medical Tests
Jobs
Other Records
John Doe's Jobs (up to 18 jobs)
The claimant has worked, but stopped due to his/her condition. If this is not true, please Change the Answer.
List all the jobs the claimant had in the 15 years before he/she became unable to work because of his/her condition(s).
Start with the most recent job and go backward to the earliest job.
To edit job details, select the job title below.
Chiropractor, June 1982 to December '95
Add a Job
Longest Job
Select Longest Job
The following is the claimant's longest job: Chiropractor, June 1982 to December '95
Footer
i3368 Pro, Job Pages, version 1.6
JB001 Jobs Tab - Currently Working, Stopped Work + Details + Comments
Prepared by the Usability Center, updated 05/07/04
Branding, Global Navigation, Claimant Summary, Function Bar
Claimant's Info
Doctors
Hospitals
Medications
Medical Tests
Jobs
John Doe's Jobs (up to 18 jobs)
The claimant has worked, but stopped due to his/her condition. If this is not true, please Change the Answer.
List all the jobs the claimant had in the 15 years before he/she became unable to work because of his/her condition(s).
Start with the most recent job and go backward to the earliest job.
To edit job details, select the job title below.
Physical Therapist, October 1999 to June 2002
Chiropractor, June 1982 to December '95
Physical Therapist, October 1999 to June 2002
Chiropractor, June 1982 to June '95
Physical Therapist, October 1999 to June 2002
Chiropractor, June 1982 to December '95
Add a Job
John Doe's Longest Job and Work-Related Comments
Select Longest Job
Add Work Comments
i3368 Pro, Job Pages, version 1.6
The following is the claimant's longest job: Chiropractor, June 1982 to December '95
[Display first 100 characters of comments...]
Other Records
JB002 Job Details
Prepared by the Usability Center, updated 06/08/04
Branding, Global Navigation, Claimant Summary, Function Bar
Information about the Claimant's Job
Jump to:
Go
Items marked with an asterisk (*) are required.
Job Details
*Occupation/Job Title:
*Type of Business:
*Dates Worked:
From:
Hours Worked:
Average Hours per Day:
Pay Rate:
$
To:
.
Average Days per Week:
per
Job Skills and Work
Did the claimant:
Serve as a lead worker?
Yes
No
Use machines, tools or equipment?
Yes
No
Use technical knowledge or skills?
Yes
No
Do any writing, complete reports, or perform
any duties like this?
Yes
No
Yes
No
Describe the claimant's duties.
What were his/her main responsibilities?
What did he/she do during a normal workday?
Include specific tools and skills that were used
(1000 character maximum. About 20 lines of typing)
Count Characters
50 chars
Supervisory Activities
Did the claimant supervise other people?
If the claimant said "Yes", then provide us with details of the claimant's supervisory activities.
Number of people supervised:
Yes
No
Responsible for hiring/firing?
Time spent supervising:
Almost all day (about 2/3 of the work day)
Physical Activities
During a normal workday on this job, how much time does the claimant spend on each of these activities:
Walking
Standing
Sitting
Climbing
Kneeling
(Bending legs and resting on knees)
Crawling
(Moving on hands and knees)
Stooping
(Bending legs and back, down and forward)
Crouching
(Bending legs and back, down and forward)
Using fingers
(Writing, typing, or handling small objects)
Using hands
(Handling, grabbing, or grasping big objects)
Reaching
(Extending hands and arms in any direction)
Please describe how the claimant lifted and
carried things on the job.
What did he/she lift?
How far did he/she carry it?
How often did he/she do this?
Count Characters
50 chars
How heavy were the items the claimant
frequently lifted(1/3 to 2/3 of the work day) on
this job?
Less than 10 lbs. (Gallon of milk = 8 lbs.)
10 lbs.
25 lbs.
50 lbs. or more
Other:
What was the heaviest weight the claimant lifted
on this job?
Less than 10 lbs. (Gallon of milk = 8 lbs.)
10 lbs.
20 lbs.
50 lbs.
100 lbs or more
Other:
Done
Delete this Job
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i3368 Pro, Job Pages, version 1.6
Prepared by the Usability Center, updated 06/08/04
JB003 Select Longest Job - Not Selected
Branding, Global Navigation, Claimant Summary, Function Bar
Jump to:
Select Longest Job
Go
Items marked with an asterisk (*) are required.
*Select the one job the claimant did for the
longest period of time.
Done
i3368 PRO Footer
JB003 Select Longest Job - Job Selected
Branding, Global Navigation, Claimant Summary, Function Bar
Jump to:
Select Longest Job
Go
Items marked with an asterisk (*) are required.
*Select the one job the claimant did for the
longest period of time.
Physical Therapist (October 1999 to Summer 2002)
Done
i3368 Pro, Job Pages, version 1.6
Footer
Prepared by the Usability Center, updated 05/07/04
JB004 Work-Related Comments (Remarks for the 3369)
Branding, Global Navigation, Claimant Summary, Function Bar
Work-Related Comments
Jump to:
Go
Do you have any additional comments or
information about the claimant's work
that you think we should know about
when reviewing his/her case?
If so, please enter them here. If the claimant had
more jobs than you listed earlier, please include them
here also.
(2000 character maximum. About 40 lines of typing.)
Count Characters
50 chars
Done
i3368 Pro, Job Pages, version 1.6
CHGxxx Change Answer - Work Status
Prepared by the Usability Center, updated 06/08/04
Branding, Global Navigation, Claimant Summary, Function Bar
Change Work Status
*Has the claimant ever worked?
Yes, but stopped because of his/her condition
Yes, but stopped because of other reasons (not due to his/her condition)
Yes, but stopped due to his/her condition and other reasons
Yes, currently working
No, has never worked
Done
Footer
i3368 Pro, Job Pages, version 1.6
OS001 Other Medical Records Tab - Answered Yes, no details
Prepared by the Usability Center, updated 06/08/04
Branding, Global Navigation, Claimant Summary, Function Bar
Claimant's Info
Doctors
Hospitals
Medications
Medical Tests
Jobs
Other Records
Other Medical Records (up to 6 different places)
*Does the claimant have other places that might have medical records or
condition information?
If the claimant has relevant medical records in other places, list them here.
Do not repeat any places that you have already told us about.
We will collect details for only one organization type.
To edit organization details, select the organization or agency name below.
! You must provide details for at least one place.
Add Place
Footer
i3368 Pro Other Records, version 1.5
Yes
No
If you answer "yes" and later need to change this to
"no", you must first delete all medical test information
that you may have entered.
OS001 Other Medical Records Tab
Prepared by the Usability Center, updated 06/08/04
Branding, Global Navigation, Claimant Summary, Function Bar
Claimant's Info
Doctors
Hospitals
Medications
Medical Tests
Jobs
Other Records
Other Medical Records (up to 6 different places)
*Does the claimant have other places that might have medical records or
condition information?
If the claimant has relevant medical records in other places, list them here.
Do not repeat any places that you have already told us about.
We will collect details for only one organization type.
To edit organization details, select the organization or agency name below.
ABC Legal Services
Maryland Welfare Agency
Leavenworth
ABC Legal Services
Maryland Welfare Agency
Leavenworth
Add Place
Footer
i3368 Pro Other Records, version 1.5
Yes
No
If you answer "yes" and later need to change this to
"no", you must first delete all medical test information
that you may have entered.
Prepared by the Usability Center, updated 06/16/04
OS002 Other Medical Source Details: Workers Compensation
Branding, Global Navigation, Claimant Summary, Function Bar
Medical Records at a Workers' Compensation Office
Jump to:
Go
Items marked with an asterisk (*) are required.
*Workers' Compensation Office:
Contact Name:
(First, Last)
*Address:
*(Street Address Line 1)
(Street Address Line 2)
(Street Address Line 3)
*(City, State, ZIP)
*Phone Number:
(
)
-
Ext:
Claim Number:
Application Dates
Date Claimant Applied:
Date of Most Recent Decision:
Next Scheduled Appointment:
(if not scheduled, enter "None")
Reason for Claim:
(1000 character maximum. About 20 lines.)
Count Characters
50 chars
The claimant has medical records at another Workers Compensation office.
Delete this Place
Done
Footer
i3368 Pro Other Records, version 1.5
OS003 Other Medical Source Details: Welfare
Prepared by the Usability Center, updated 06/16/04
Branding, Global Navigation, Claimant Summary, Function Bar
Medical Records at a Welfare Agency
Jump to:
Go
Items marked with an asterisk (*) are required.
*Name of Welfare Agency:
Name of Social Worker:
(First, Last)
*Address:
*(Street Address Line 1)
(Street Address Line 2)
(Street Address Line 3)
*(City, State, ZIP)
*Phone Number:
(
)
-
Ext:
Case Number:
Appointment Dates
When did the claimant first go?
When did the claimant last go?
Next Scheduled Appointment:
(if not scheduled, enter "None")
Reason for Visits or Services:
(1000 character maximum. About 20 lines.)
Count Characters
50 chars
The claimant has medical records at another welfare agency.
Delete this Place
Done
Footer
i3368 Pro Other Records, version 1.5
Prepared by the Usability Center, updated 06/16/04
OS004 Other Medical Source Details: Prison/Jail
Branding, Global Navigation, Claimant Summary, Function Bar
Medical Records at a Prison/Jail
Jump to:
Go
Items marked with an asterisk (*) are required.
*Name of Prison or Jail:
Contact Name:
(First, Last)
*Address:
*(Street Address Line 1)
(Street Address Line 2)
(Street Address Line 3)
*(City, State, ZIP)
*Phone Number:
(
)
-
Ext:
Inmate Number:
Dates of Visits to Prison Doctor
First Visit:
Last Visit:
Next Scheduled Appointment:
(if not scheduled, enter "None")
Reason for Medical Visits:
(1000 character maximum. About 20 lines.)
Count Characters
50 chars
The claimant has medical records at another prison/jail.
Done
Delete this Place
Footer
i3368 Pro Other Records, version 1.5
OS005 Other Medical Source Details: Insurance Company
Prepared by the Usability Center, updated 06/16/04
Branding, Global Navigation, Claimant Summary, Function Bar
Jump to:
Medical Records at Insurance Company
Go
Items marked with an asterisk (*) are required.
*Insurance Company Name:
Contact Name:
(First, Last)
*Address:
*(Street Address Line 1)
(Street Address Line 2)
(Street Address Line 3)
*(City, State, ZIP)
*Phone Number:
(
)
-
Ext:
Identification/Patient Number:
Dates of Contact
First Contact:
Most Recent Contact:
Next Scheduled Appointment:
(if not scheduled, enter "None")
Reason for Visits or Services:
(1000 character maximum. About 20 lines.)
Count Characters
50 chars
The claimant has medical records at another insurance company.
Delete this Place
Done
Footer
i3368 Pro Other Records, version 1.5
OS006 Other Medical Source Details: Attorney/Law Firm
Prepared by the Usability Center, updated 06/16/04
Branding, Global Navigation, Claimant Summary, Function Bar
Medical Records with Attorney or Law Firm
Jump to:
Go
Items marked with an asterisk (*) are required.
*Name of Law Firm:
Name of Attorney/Lawyer:
(First, Last)
*Address:
*(Street Address Line 1)
(Street Address Line 2)
(Street Address Line 3)
*(City, State, ZIP)
*Phone Number:
(
)
-
Ext:
Case Number:
Visits to Attorney/Law Firm
When did the claimant first go?
When did the claimant last go?
Next Scheduled Appointment:
(if not scheduled, enter "None")
Reason for Visits or Services:
(1000 character maximum. About 20 lines.)
Count Characters
50 chars
The claimant has medical records with another attorney/law firm.
Delete this Place
Done
Footer
i3368 Pro Other Records, version 1.5
Prepared by the Usability Center, updated 06/16/04
OS007 Other Medical Source Details: Another Place
Branding, Global Navigation, Claimant Summary, Function Bar
Medical Records at Another Place
Jump to:
Go
Items marked with an asterisk (*) are required.
*Name of Place:
Contact Name:
(First, Last)
*Address:
*(Street Address Line 1)
(Street Address Line 2)
(Street Address Line 3)
*(City, State, ZIP)
*Phone Number:
(
)
-
Ext:
Case Number:
Dates of Visits
When did the claimant first go?
When did the claimant last go?
Next Scheduled Appointment:
(if not scheduled, enter "None")
Reason for Visits:
(1000 character maximum. About 20 lines.)
Count Characters
50 chars
The claimant has medical records at other places.
Delete this Place
Done
Footer
i3368 Pro Other Records, version 1.5
RS001 Review and Send: Report Submission Checkpoint - Send button inactive
Prepared by the Usability Center, updated 06/08/04
Branding, Global Navigation, Claimant Summary, Function Bar
Review and Send: Report Submission Checkpoint
You are ready to send this report electronically to Social Security. If you were not able to complete all parts of the report, don't worry. We will contact you or
the claimant, if we need any more information. If the claimant wants to make changes after sending this report, he/she or an authorized representative can
contact Social Security.
! = Please check these screens
= You have viewed these screens, no problems
1) Review, Print, Save, Confirm Information
!
Fix Errors/Confirm Information
Add Remarks
Print/Save for Your Records
Print XX Medical Release Forms (SSA-827)
!
Print Cover Sheet
2) Ready to Submit?
You must resolve all errors and print the Cover Sheet before you can submit this report.
Important: After you send this report, you will not be able to come back to it online.
Back to Claimant's Info
Footer
i3368 Pro, Review and Send Pages, version 2.1
Send Now
RS001 Review and Send: Report Submission Checkpoint - Send button active
Prepared by the Usability Center, updated 06/08/04
Branding, Global Navigation, Claimant Summary, Function Bar
Review and Send: Report Submission Checkpoint
You are ready to send this report electronically to Social Security. If you were not able to complete all parts of the report, don't worry. We will contact you or
the claimant, if we need any more information. If the claimant wants to make changes after sending this report, he/she or an authorized representative can
contact Social Security.
! = Please check these screens
= You have viewed these screens, no problems
1) Review, Print, Save, Confirm Information
Confirm Information
Add Remarks
Print/Save for Your Records
Print XX Medical Release Forms (SSA-827)
Print Cover Sheet
2) Ready to Submit?
You must resolve all errors and print the Cover Sheet before you can submit this report.
Important: After you send this report, you will not be able to come back to it online.
Back to Claimant's Info
Send Now
Footer
i3368 Pro, Review and Send Pages, version 2.1
RS002 Check Errors - From Global Nav
Prepared by the Usability Center, updated 06/09/04
Branding, Global Navigation, Claimant Summary, Function Bar
Fix Errors and Confirm Information
Back
! Errors: Before you can submit this form to Social Security, you must correct the following errors and/or omissions.
Edit
You must provide details for at least one doctor.
Edit
You must provide details for at least one hospital.
Edit
You must provide details for at least one medication.
Edit
You must provide details for at least one medical test.
Edit
You must provide details for at least one place.
Edit
You must provide details for at least one job.
Claimant's Info
Edit
About John Doe: General Information (claimant's contact info, English-speaking ability, height, weight, etc.)
Edit
About John Doe: Medical, Work, and Education History (condition listing, date condition first bothered, treatments received, etc.)
Edit
Describe John Doe's Conditions (detailed condition description)
Edit
Date Claimant Became Unable to Work (work history info)
Edit
Other Names Used on Medical Records
Edit
English-speaking Contact
Edit
Someone Else We Can Contact About Claimant's Conditions
Edit
Special Education Class Details
Edit
Special Job Training, Trade or Vocational School Details
Edit
Vocational Rehabilitation or Ticket-to-Work Program Details
Doctors
No details entered.
Hospitals
No details entered.
Medication
No details entered.
Medical Tests
No details entered.
Other Places with Medical Records
No details entered.
Jobs
No details entered.
Back
Footer
i3368 Pro, Review and Send Pages, version 2.1
RS002 Fix Errors/Confirm Information - Longest job not selected
Prepared by the Usability Center, updated 06/09/04
Branding, Global Navigation, Claimant Summary, Function Bar
Fix Errors and Confirm Information
Back to Checkpoint
Next Step >
! Errors: Before you can submit this form to Social Security, you must correct the following errors and/or omissions.
Edit
You did not select the longest job.
Claimant's Info
Edit
About John Doe: General Information (claimant's contact info, English-speaking ability, height, weight, etc.)
Edit
About John Doe: Medical, Work, and Education History (condition listing, date condition first bothered, treatments received, etc.)
Edit
Describe John Doe's Conditions (detailed condition description)
Edit
Date Claimant Became Unable to Work (work history info)
Edit
Other Names Used on Medical Records
Edit
English-speaking Contact
Edit
Someone Else We Can Contact About Claimant's Conditions
Edit
Special Education Class Details
Edit
Special Job Training, Trade or Vocational School Details
Edit
Vocational Rehabilitation or Ticket-to-Work Program Details
Doctors
Edit
Dr. John Doe
Edit
Dr. John Again
Edit
Dr. Jane Doe
Edit
Dr. Jane Again
Edit
Dr. Jane Gain
Hospitals
Edit
Johns Hopkins Hospital
Edit
Johns Hopkins Again
Edit
Union Memorial
Edit
Union Memorial Again
Medication
Edit
Prozac
Edit
Stronger Prozac
Edit
Stress B Complex
Edit
Lithium
Medical Tests
Edit
Finger Test
Edit
Toe Test
Edit
Biopsy
Edit
Enter Details
Other Places with Medical Records
Edit
ABC Legal Services
Edit
Maryland Welfare Agency
Edit
Leavenworth Prison
Edit
Acme Insurance Co.
Jobs
Edit
Backseat Driver
Edit
Armchair Commando
Edit
Mondaymorning Quarterback
Edit
Dream Job
Back to Checkpoint
i3368 Pro, Review and Send Pages, version 2.1
Footer
Next Step >
RS002 Confirm Information - Populated, No problems
Prepared by the Usability Center, updated 06/09/04
Branding, Global Navigation, Claimant Summary, Function Bar
Confirm Information
Back to Checkpoint
Next Step >
Claimant's Info
Edit
About John Doe: General Information (claimant's contact info, English-speaking ability, height, weight, etc.)
Edit
About John Doe: Medical, Work, and Education History (condition listing, date condition first bothered, treatments received, etc.)
Edit
Describe John Doe's Conditions (detailed condition description)
Edit
Date Claimant Became Unable to Work (work history info)
Edit
Other Names Used on Medical Records
Edit
English-speaking Contact
Edit
Someone Else We Can Contact About Claimant's Conditions
Edit
Special Education Class Details
Edit
Special Job Training, Trade or Vocational School Details
Edit
Vocational Rehabilitation or Ticket-to-Work Program Details
Doctors
Edit
Dr. John Doe
Edit
Dr. John Again
Edit
Dr. Jane Doe
Edit
Dr. Jane Again
Edit
Dr. Jane Gain
Hospitals
Edit
Johns Hopkins Hospital
Edit
Johns Hopkins Again
Edit
Union Memorial
Edit
Union Memorial Again
Medication
Edit
Prozac
Edit
Stronger Prozac
Edit
Stress B Complex
Edit
Lithium
Medical Tests
Edit
Finger Test
Edit
Toe Test
Edit
Biopsy
Edit
Enter Details
Other Places with Medical Records
Edit
ABC Legal Services
Edit
Maryland Welfare Agency
Edit
Leavenworth Prison
Edit
Acme Insurance Co.
Jobs
Edit
Backseat Driver
Edit
Armchair Commando
Edit
Mondaymorning Quarterback
Edit
Dream Job
Edit
The following is the claimant's longest job: Chiropractor, June 1982 to December '95
Back to Checkpoint
Footer
i3368 Pro, Review and Send Pages, version 2.1
Next Step >
RS002 Fix Errors/Confirm Information - Answered Yes, No Details
Prepared by the Usability Center, updated 06/09/04
Branding, Global Navigation, Claimant Summary, Function Bar
Fix Errors and Confirm Information
Back to Checkpoint
Next Step >
! Errors: Before you can submit this form to Social Security, you must correct the following errors and/or omissions.
Edit
You must provide details for at least one doctor.
Edit
You must provide details for at least one hospital.
Edit
You must provide details for at least one medication.
Edit
You must provide details for at least one medical test.
Edit
You must provide details for at least one place.
Edit
You must provide details for at least one job.
Claimant's Info
Edit
About John Doe: General Information (claimant's contact info, English-speaking ability, height, weight, etc.)
Edit
About John Doe: Medical, Work, and Education History (condition listing, date condition first bothered, treatments received, etc.)
Edit
Describe John Doe's Conditions (detailed condition description)
Edit
Date Claimant Became Unable to Work (work history info)
Edit
Other Names Used on Medical Records
Edit
English-speaking Contact
Edit
Someone Else We Can Contact About Claimant's Conditions
Edit
Special Education Class Details
Edit
Special Job Training, Trade or Vocational School Details
Edit
Vocational Rehabilitation or Ticket-to-Work Program Details
Doctors
No details entered.
Hospitals
No details entered.
Medication
No details entered.
Medical Tests
No details entered.
Other Places with Medical Records
No details entered.
Jobs
No details entered.
Back to Checkpoint
Footer
i3368 Pro, Review and Send Pages, version 2.1
Next Step >
RS002 Fix Errors/Confirm Information - Answered No
Prepared by the Usability Center, updated 06/08/04
Branding, Global Navigation, Claimant Summary, Function Bar
Confirm Information
Back to Checkpoint
Next Step >
Claimant's Info
Edit
About John Doe: General Information (claimant's contact info, English-speaking ability, height, weight, etc.)
Edit
About John Doe: Medical, Work, and Education History (condition listing, date condition first bothered, treatments received, etc.)
Edit
Describe John Doe's Conditions (detailed condition description)
Edit
Date Claimant Became Unable to Work (work history info)
Doctors
Edit
The claimant did not go to any doctors for his/her condition.
Hospitals
Edit
The claimant did not go to any hospitals for his/her condition.
Medication
Edit
The claimant does not take any medications for his/her condition.
Medical Tests
Edit
The claimant does not have or has not scheduled any medical tests for his/her condition.
Other Places with Medical Records
Edit
The claimant does not have medical records at other places.
Jobs
Edit
They claimant has never worked.
Back to Checkpoint
Footer
i3368 Pro, Review and Send Pages, version 2.1
Next Step >
RS002 Fix Errors/Confirm Information - Did not answer questions on tabbed pages
Prepared by the Usability Center, updated 06/09/04
Branding, Global Navigation, Claimant Summary, Function Bar
Fix Errors and Confirm Information
Back to Checkpoint
Next Step >
! Errors: Before you can submit this form to Social Security, you must correct the following errors and/or omissions.
Edit
You did not tell us if the claimant went to a doctor.
Edit
You did not tell us if the claimant went to a hospital.
Edit
You did not tell us if the claimant takes any prescription or over-the-counter medications.
Edit
You did not tell us if the claimant had or has scheduled any medical tests.
Edit
You did not tell us if the claimant has medical records at other places.
Edit
You must provide details for at least one job.
Claimant's Info
Edit
About John Doe: General Information (claimant's contact info, English-speaking ability, height, weight, etc.)
Edit
About John Doe: Medical, Work, and Education History (condition listing, date condition first bothered, treatments received, etc.)
Edit
Describe John Doe's Conditions (detailed condition description)
Edit
Date Claimant Became Unable to Work (work history info)
Edit
Other Names Used on Medical Records
Edit
English-speaking Contact
Edit
Someone Else We Can Contact About Claimant's Conditions
Edit
Vocational Rehabilitation or Ticket-to-Work Program Details
Doctors
No details entered.
Hospitals
No details entered.
Medication
No details entered.
Medical Tests
No details entered.
Other Places with Medical Records
No details entered.
Jobs
No details entered.
Back to Checkpoint
Footer
i3368 Pro, Review and Send Pages, version 2.1
Next Step >
RS003 Additional Remarks
Prepared by the Usability Center, updated 06/08/04
Branding, Global Navigation, Claimant Summary, Function Bar
Additional Remarks About this Case
Does the claimant have any additional
comments or information we should
know when reviewing this case?
If so, please enter them here. If you checked a box
anywhere on this report to show that the claimant had
more information than the space allowed (for
example, "The claimant has more doctors than
listed"), you may give us that information here.
(3000 character maximum. About 60 lines of typing.)
Count Characters
50 chars
Back to Checkpoint
i3368 Pro, Review and Send Pages, version 2.1
Footer
Next Step >
RS004 Print/Save
i3368 Pro, Review and Send Pages, version 2.1
cont. RS004
i3368 Pro, Review and Send Pages, version 2.1
cont. RS004
i3368 Pro, Review and Send Pages, version 2.1
cont. RS004
i3368 Pro, Review and Send Pages, version 2.1
cont. RS004
i3368 Pro, Review and Send Pages, version 2.1
cont. RS004
i3368 Pro, Review and Send Pages, version 2.1
cont. RS004
i3368 Pro, Review and Send Pages, version 2.1
RS005 Print Medical Release Forms
Prepared by the Usability Center, updated 06/08/04
Branding, Global Navigation, Claimant Summary, Function Bar
Print Medical Release Forms
The law requires us to obtain signed medical release forms from the claimant so that we may get medical records from each of his/her doctors or hospitals. Send
the medical releases along with the Cover Sheet and any other attachments.
Print XX copies.
SSA-827 Medical Release Form (pdf)
Note: If you need assistance on how to complete the medical release form, we have provided some instructions.
When you select the link, the form will launch in a new browser window. You should close the window after you have printed the form in order to return to this
Adult Disability and Work History Report. This form is in Portable Document Format (PDF) and requires Adobe Acrobat Reader to open and print it. If you don't
have Adobe Acrobat Reader on your computer you can dowload it at http://access.adobe.com.
Back to Checkpoint
Footer
i3368 Pro, Review and Send Pages, version 2.1
Next Step >
RS006 Print Cover Sheet
Prepared by the Usability Center, updated 06/08/04
Branding, Global Navigation, Claimant Summary, Function Bar
Print Cover Sheet
You must print and send this page to the following Social Security office with the SSA-827s, any medical evidence the claimant has given you, and any other
documents on behalf of the claimant.
Mail To:
Social Security Office
6401 Security Blvd.
Baltimore, MD 21235-0001
Organization
3rd Party Organization
Ms. Contact Person
11155 Claimant's Info St.
Wayne, PA 22255
(212) 555-1212
Claimant
My organization is assisting the following claimant in completing his/her Adult Disability and Work History Report.
John Doe
xxx-xx-xxxx
111 Claimant's Info St.
Nowhere, NW 22222
(222) 555-1212 (message number)
Attachments
The following items are attached:
SSA-827 Medical Release Form (Please attach at least XX signed and dated copies)
Number Attached:
Medical Evidence
Other:
Alerts and Comments
TERI (Potential terminally ill claimant)
Additional Comments:
Back to Checkpoint
i3368 Pro, Review and Send Pages, version 2.1
Footer
RS007 Submission Successful
Prepared by the Usability Center, updated 06/08/04
Branding, Global Navigation, Claimant Summary, Function Bar
Thank You - Successful Submission!
We have received your submission of the Online Adult Disability and Work History Report for the following claimant:
Claimant's Name: John Doe
Claimant's SSN: 111-11-1111
Important--Next Steps:
Remember to send the following items to the claimant's local Social Security office at the address below.
Cover sheet
Signed and dated medical release forms
Copies of any claimant's medical evidence you may have
Claimant's Local Social Security Office:
SOCIAL SECURITY ADMINISTRATION
110 West Road
Suite 500 Corp Center
Towson, MD 21204
(410) 825-3336
What to expect:
It takes about 120 days to process an application for disability benefits, but every case is different. The claim may take more or less time to process.
While we are processing your application, we may need to do the following:
Contact you or the claimant for more information or to set up an interview
Send you or the claimant additional forms to fill out
Ask the claimant to see a doctor for a special exam if we need more medical evidence (we will pay for this) relating to his/her condition
Contact Social Security if the claimant:
Goes to a new doctor
Has a new medical test done
Has a change in his/her condition
Returns to work
Changes his/her address or phone number
Time Limit:
We need a formal application for disability benefits from the claimant before we can process this claim. This Adult Disability and Work History Report is NOT a formal
application, but it is a required part of the the claims process. The claimant may lose benefits if we do not receive the application by:
6 months from the date you started a report for the claimant for the first time for Social Security (SSA) disability benefits, or
60 days from the date you started a report for the claimant for the first time for Supplemental Security Income (SSI) disability benefits.
Since this Report applies to both types of applications, we cannot tell at this time which deadline applies to the claimant. Therefore, to fully protect all possible benefits, we
recommend that he/she submit a formal application no later than 60 days from the date you started a report for the first time.
Start a New Report
Exit
i3368 Pro, Review and Send Pages, version 2.1
Footer
New Message Page: Third Parties Only
Prepared by the Usability Center, updated 06/08/04
Header
This Report is Only for Professionals, Representatives and Organizations
This Adult Disability and Work History Report - PRO is only for use by professionals, representatives and organizations
assisting disabled adults age 18 or older. There is a different online Adult Disability and Work History Report for you to
use if you are an individual completing this report for yourself or for someone else.
If you are not sure which report to complete, or for further assistance:
Call our toll-free number, 1-800-772-1213. If you are deaf or hard of hearing, call our toll-free "TTY" number, 1800-325-0778. Representatives are available Monday through Friday from 7 a.m. to 7 p.m.
Visit your local Social Security office.
Go to the Adult Disability and Work History Report
i3368 Pro Message Pages, version 1.6
Back
New Message Page: Warning System Shutdown
Prepared by the Usability Center, updated 06/08/04
Header
Warning: System Will Shut Down
This Internet Disability Report is scheduled to shut down for the day within two hours.
The Disability Report is available during the following hours (Eastern Time):
Monday through Friday: 5:00 AM - 1:00 AM
Saturday: 5:00 AM - 11:00 PM
Sunday: 8:00 AM - 10:00 PM
Holidays: 5:00 AM - 11:00 PM
If you choose to start the report now and the system shuts down before you finish it, you will lose only the information on
the page you are working on at the time of the shutdown.
You may want to consider starting the report at another time to avoid losing any information. If you decide to start this
report later, you should write down this web site so that you can return to it: http:www.socialsecurity.gov/disabilityreportpro
Select the Exit button to leave this report. You will be taken to the Social Security home page.
Exit
i3368 Pro Message Pages, version 1.6
Continue with Report
New Message Page: Print/Save/View Guide (from RS004)
Prepared by the Usability Center, updated 06/08/04
Header
Print/Save/View Guide
To print this report:
Choose the Print button on your browser button bar or Choose Print from the File menu. Make sure the correct printer is
selected and choose OK.
To save this report:
Choose Save As from the File menu. We recommend that you save as an HTML file. Provide a file name and location, if
needed, and choose OK.
To view the saved page:
Open your browser. Choose Open from the File menu. Click Browse and locate the file name and location you used.
(When you reopen this HTML file, none of the buttons or links on the page will work.
Close this window to return to the report.
i3368 Pro Message Pages, version 1.6
New Message Page: Proper Applicant
Prepared by the Usability Center, updated 06/08/04
Header
Proper Applicant
The disability application process requires the completion of this report and a separate application for benefits. This report is not the
application for benefits. Although you may complete this report for the claimant, we can only accept an application filed by the
claimant or one of the specific individuals listed below under the heading, "Who May File an Application on the Claimant's Behalf."
Social Security Disability Benefits
If you are one of the individuals listed below under the heading, Who May File an Application On the Claimant's Behalf, we may use
the date you started completing this report as the claimant's application filing date if you file an application on the claimant's behalf
within 6 months after the date you started completing this report.
If you are not one of the individuals listed, we will contact the claimant to determine if he or she would like to file an application for
benefits.
Supplemental Security Income Disability Benefits
If you are one of the individuals listed under the heading, Who May File an Application on the Claimant's Behalf, we may use the
date you started this report as the claimant's application filing date, if you file an application on the claimant's behalf within 60 days
after the date you started completing this report.
If you are not one of the individuals listed under the heading, Who May File an Application on the Claimant's Behalf, we may use the
date you started completing this report as the claimant's application filing date if the claimant files an application within the time
period specified in our contact with him or her explaining the need to file.
Who May File An Application on the Claimant's Behalf
A claimant 18 years old or over must file his or her own application. However, we may accept an application filed by you on the
claimant's behalf if you are the:
claimant's court-appointed legal representative or person responsible for the claimant's care because the claimant is
adjudged legally incompetent or is physically unable to file his or her own application, or
manager or principal officer of the institution where the claimant resides.
When dire circumstances exist, we may accept an application filed by someone other than the individuals listed above to prevent the
claimant from losing benefits. These situations are rare. If you believe dire circumstances are involved, you should contact us right
away to file an application on the claimant's behalf.
If you are one of the individuals listed above you will need to contact us to file the application.
To arrange for an application appointment, you can call our toll-free number, 1-800-772-1213. If you are deaf or hard of hearing, call
our toll-free "TTY" number, 1-800-325-0778. Representatives are available Monday through Friday from 7 a.m. to 7 p.m.
Close this window to return to the report.
i3368 Pro Message Pages, version 1.6
New Message Page: Applying in Person or Over the Phone
Prepared by the Usability Center, updated 06/08/04
Header
Applying in Person or Over the Phone
If you prefer not to fill out this report on the Internet, you can use any of the following ways to complete the Appeal
Disability Report:
Call our toll-free number, 1-800-772-1213. If you are deaf or hard of hearing, call our toll-free "TTY" number, 1-800325-0778. Representatives are available Monday through Friday from 7 a.m. to 7 p.m.
Visit your local Social Security office.
Print a paper SSA-3368 from the Internet. This form is in Portable Document Format (PDF) and requires Adobe
Acrobat Reader to open and print it. If you don't have Adobe Acrobat Reader on your computer you can download it
at http://access.adobe.com.
If you live outside the United States, see Service Around the World.
i3368 Pro Message Pages, version 1.6
Message Page: This Report Is Only for Claimants Age 18 or Older
Prepared by the Usability Center, updated 06/08/04
Header
This Report Is Only for Claimants Age 18 or Older
This Adult Disability and Work History Report is only for disabled adults age 18 or older. There are different disability
reports for children under age 18.
Please contact Social Security for assistance in applying for disability benefits for a child:
Call our toll-free number, 1-800-772-1213. If you are deaf or hard of hearing, call our toll-free "TTY" number, 1-800325-0778. Representatives are available Monday through Friday from 7 a.m. to 7 p.m.
Visit your local Social Security office.
Previous
i3368 Pro Message Pages, version 1.6
Message Page: Full Retirement Age Reached
Prepared by the Usability Center, updated 06/08/04
Header
Full Retirement Age Reached
Based on the date of birth you entered, the claimant has reached the "Full Retirement Age" for Social Security benefits on
Month Day, Year, which is X months ago. If a person becomes disabled after reaching "Full Retirement Age" a disability
application would not usually be taken. Instead, we would take an application for Social Security retirement benefits or
Supplemental Security Income payments for the aged.
There are some exceptions. If you want to know about these exceptions to see if they apply to the claimant or if you want to
apply for any other type of benefit for this claimant, please contact us:
Call our toll-free number, 1-800-772-1213. If you are deaf or hard of hearing, call our toll-free "TTY" number, 1-800325-0778. Representatives are available Monday through Friday from 7 a.m. to 7 p.m.
Visit your local Social Security office.
Previous
i3368 Pro Message Pages, version 1.6
Message Page: The Claimant Does Not Live in the United States
Prepared by the Usability Center, updated 06/08/04
Header
The Claimant Does Not Live in the United States
This Internet Adult Disability and Work History Report cannot be used for people who live outside of the United States. You
or the claimant may need to contact a Social Security representative to make other arrangements to apply for benefits.
To contact Social Security, see our Service Around the World web page.
Select the Exit button to leave this report. You will be taken to the Social Security home page.
Exit
i3368 Pro Message Pages, version 1.6
Prepared by the Usability Center, updated 06/08/04
Message Page: Check the Information You Entered
Header
Check the Information You Entered
The information you entered does not match our records.
If you typed the wrong information, you will need to correct it before continuing.
If the information is correct, please confirm it by reentering the same information.
To do either of the above, select the Previous button below.
If you prefer, you can contact Social Security to make other arrangements to complete a Disability Report for this claimant.
Be sure to tell the representative that you tried the Internet Disability Report and received this message.
To contact Social Security:
Call our toll-free number, 1-800-772-1213. If you are deaf or hard of hearing, call our toll-free "TTY" number, 1-800325-0778. Representatives are available Monday through Friday from 7 a.m. to 7 p.m.
Visit your local Social Security office.
Previous
i3368 Pro Message Pages, version 1.6
Message Page: Benefits Denied Fewer Than 60 Days Ago
Prepared by the Usability Center, updated 06/08/04
Header
Benefits Denied Fewer Than 60 Days Ago
Since the claimant's prior application was denied within the last 60 days, it may be better to appeal that decision rather than start a
new Disability Report.
The claimant has the right to file a new application at any time, but filing a new application is not the same as appealing a decision. If
the claimant disagrees with the decision made on his/her prior application and files a new application instead of appealing:
The claimant might lose some benefits, or not qualify for any benefits, and
We could deny the new application using the decision on the claimant's prior application, if the facts and issues are the same.
So, if the claimant disagrees with the decision made on his/her prior application, he/she should file an appeal within 60 days.
To appeal you or the claimant can:
Call our toll-free number, 1-800-772-1213. If you are deaf or hard of hearing, call our toll-free "TTY" number, 1-800-325-0778.
Representatives are available Monday through Friday from 7 a.m. to 7 p.m.
Visit your local Social Security office.
< Previous
i3368 Pro Message Pages, version 1.6
Message Page: The Claimant May Not Be Disabled Under Our Rules
Prepared by the Usability Center, updated 06/08/04
Header
The Claimant May Not Be Disabled Under Our Rules
We consider the claimant disabled under Social Security rules if, due to a medical or mental condition:
He/she cannot do work that he/she did before and we decide that he/she cannot adjust to other work because of his/
her condition(s), and
His/her disability is expected to last for at least one year or to result in death.
Unlike other programs, Social Security pays only for total disability. No benefits are payable for partial disability or for shortterm disability. Social Security program rules assume that working families have access to other resources to provide
support during periods of short-term disabilities, including workers' compensation, insurance, savings, and investments.
More Information
The above explanation of Social Security's definition of disability is written in easy-to-understand language. For more
details, read the official definition as written in the Social Security Act. Using this link opens a new window. To return to this
page, close the new window.
< Previous
i3368 Pro Message Pages, version 1.6
Continue with Report
Message Page: Prior Application Denied More Than 60 Days Ago
Prepared by the Usability Center, updated 06/08/04
Header
Prior Application Denied More Than 60 Days Ago
There are two things the claimant should consider before continuing:
1. If his/her prior application was denied more than 60 days ago:
He/she needs to fill out a new Adult Disability and Work History Report.
Please give us all the information requested even if he/she told us about it before. The forms the claimant
gave usbefore may have been sent to permanent storage. By giving all the information on this new report, he/
she can speed up the application.
2. If he/she did not appeal the denial within 60 days and had a good reason for not filing an appeal within 60 days:
It may be better for the claimant to file an appeal of the denial on the prior application.
Contact Social Security as explained below. The claimant will be asked to sign a statement about why he/she
is filing an appeal late.
To contact Social Security:
Call our toll-free number, 1-800-772-1213. If you are deaf or hard of hearing, call our toll-free "TTY" number, 1-800325-0778. Representatives are available Monday through Friday from 7 a.m. to 7 p.m.
Visit your local Social Security office.
< Previous
i3368 Pro Message Pages, version 1.6
Continue with Report
Message Page: Check the Social Security Number You Entered
Prepared by the Usability Center, updated 06/08/04
Header
Check the Social Security Number You Entered
Our system cannot accept an Internet Adult Disability and Work History Report on the Social Security Number you
entered:
743-17-0024
Please check this number:
If you typed the wrong number, you will need to correct it before continuing.
If this is the claimant's correct Social Security Number, contact Social Security to make other arrangements to
complete a Disability Report.
Be sure to tell the representative that you tried the Internet Disability Report and received this message.
To contact Social Security:
Call our toll-free number, 1-800-772-1213. If you are deaf or hard of hearing, call our toll-free "TTY" number, 1800-325-0778. Representatives are available Monday through Friday from 7 a.m. to 7 p.m.
Visit your local Social Security office.
Previous
i3368 Pro Message Pages, version 1.6
Message Page: Sign-In Problem
Prepared by the Usability Center, updated 06/08/04
Header
Sign-In Problem
We could not find a match for the Social Security Number and Reentry Number you entered.
Please check the numbers and sign in again. You can retry no more than 3 times for this claimant.
If you can't sign in after 3 tries, the prior record will be locked. You can start an Adult Disability and Work History Report over
again for this claimant or call us to help you file the claim. To ensure the claimant's privacy, we cannot access the Reentry
Number.
To contact Social Security:
Call our toll-free number, 1-800-772-1213. If you are deaf or hard of hearing, call our toll-free "TTY" number, 1-800-3250778. Representatives are available Monday through Friday from 7 a.m. to 7 p.m.
Visit your local Social Security Office.
Reentry Sign In
i3368 Pro Message Pages, version 1.6
Start a New Report
Message Page: There Is a Pending Report for This Social Security Number
Prepared by the Usability Center, updated 06/08/04
Header
There Is a Pending Report for this Social Security Number
Based on the Social Security Number you entered, it appears you or the claimant have already started to complete this
report. If the report was started at the web site http://www.socialsecurity.gov/adultdisabilityreport and you wish to continue
it, you must return to that web site and use the Reentry Number issued for that report. To continue with the report already
started through this web site, select the "Reentry Sign In" button below. If you or the claimant haven't already started an
Adult Disability and Work History Report, check the Social Security Number you entered and enter it again using the "Start
a New Report" button below.
If you have lost the claimant's Reentry Number, you can start over, but you will lose all of the information you entered
before. To ensure the claimant's privacy, we cannot access the Reentry Number.
If you decide to start over, select the "Start a New Report" button below. Starting a new report does NOT extend the time
the claimant has to complete a formal application for either Social Security (SS) or Supplemental Security Income (SSI)
benefits. The claimant may lose benefits if we do not receive a signed application within 6 months (SS benefits) or 60 days
(SSI benefits) from when you or the claimant first started completing an online disability report.
To contact Social Security:
Call our toll-free number, 1-800-772-1213. If you are deaf or hard of hearing, call our toll-free "TTY" number, 1-800325-0778. Representatives are available Monday through Friday from 7 a.m. to 7 p.m.
Visit your local Social Security office.
Reentry Sign In
Start a New Report
Previous
i3368 Pro Message Pages, version 1.6
Message Page: Disability Report Already Sent
Prepared by the Usability Center, updated 06/08/04
Header
The Claimant Has Already Sent an Adult Disability and Work History Report
An Adult Disability and Work History Report has already been electronically submitted to Social Security for this claimant. If
you or the claimant have new information, you must contact us. We cannot accept additional information over the Internet.
Please contact your local Social Security office to:
Tell us about any changes in the claimant's condition(s) or treatments,
Report a change of address or contact information
Report a return to work
Check on the status of the claim
If the claimant had a prior application that was denied more than 60 days ago and he or she wants to reapply, please
contact Social Security.
To contact Social Security:
Call our toll-free number, 1-800-772-1213. If you are deaf or hard of hearing, call our toll-free "TTY" number, 1-800325-0778. Representatives are available Monday through Friday from 7 a.m. to 7 p.m.
Visit your local Social Security office.
Select the Exit button to leave this report. You will be taken to the Social Security home page.
Exit
i3368 Pro Message Pages, version 1.6
Message Page: Special Message About Claimants Currently Working
Prepared by the Usability Center, updated 06/08/04
Header
Special Message About Claimants Currently Working
When we make a disability decision about a claimant who is still working, we need to consider many things about that
person's work situation.
Working While Disabled
1. The first thing we look at is the amount of money the claimant earns each month. This amount may change in
January of each year. Claimants who are working and earning more than the allowable monthly amount for a given year
would not meet Social Security's definition of being totally disabled unless some special situation applies. For claimants
who are legally blind, a higher earnings limit applies. Click here to view the allowable monthly amounts for this year.
Using this link opens a new window. To return to this page, close the new window.
2. Next we take into consideration any special work arrangements that allow the claimant to continue to work in
spite of his/her disability. These might include extra help, lower production quotas, time off and others.
3. We also look at special work expenses the claimant has because of his/her condition(s). For example, the
claimant may have bought a special computer or a specially-equipped van to drive to work.
Working After Recovery from Disability
In some situations it benefits the claimant to apply for Social Security disability if he/she was disabled and unable to work
for at least 12 months, but has now recovered and returned to work. If this applies to the claimant, we suggest that you or
the claimant contact Social Security to discuss the situation.
If the claimant has already contacted Social Security, or thinks he/she qualifies for benefits based on the information
above, you may continue with this report.
If you or the claimant want to discuss his/her case with a Social Security representative first, call our toll-free number, 1800-772-1213. For deaf or hard of hearing, call our toll-free "TTY" number, 1-800-325-0778. Representatives are
available Monday through Friday from 7 a.m. to 7 p.m.
Continue with Report
i3368 Pro Message Pages, version 1.6
Message Page: Special Message About Claimants Who Never Worked
Prepared by the Usability Center, updated 06/08/04
Header
Special Message About Claimants Who Never Worked
For your information, there are four types of disability benefits available to people who have never worked. Each type is briefly
described below:
Supplemental Security Income (SSI) Payments
SSI provides money for such basic needs as food, clothing, and shelter for aged, blind, and disabled people who have little or
no income or resources.
Disabled widow or widower benefits
These benefits are payable to a disabled person whose deceased spouse paid into Social Security. In general, the claimant
must:
Be a widow or widower between age 50 and 65
Have become disabled before or within 7 years of the date the claimant's husband or wife died.
There are some exceptions to these rules.
Disabled adult child benefits
If the claimant is age 18 or older, he/she may be able to receive benefits on a parent's record if he/she:
Is not married
Became disabled before reaching age 22
Has a parent (either mother or father) who either:
is receiving Social Security benefits or
who worked and paid enough into Social Security before he or she died.
There are some exceptions to these rules.
Medicare
Social Security has a special program for people of all ages who have kidney problems requiring dialysis or a kidney
transplant.
For more information, visit the Social Security Administration Disability Programs web site. If you or the claimant have already
contacted Social Security, or if you think the claimant fits into one of the categories above, you may continue with this report.
If you want to discuss your case with a Social Security representative first, call our toll-free number, 1-800-772-1213. If you are
deaf or hard of hearing, call our toll-free "TTY" number, 1-800-325-0778. Representatives are available Monday through
Friday from 7 a.m. to 7 p.m.
Continue with Report
i3368 Pro Message Pages, version 1.6
Message Page: How the Online Adult Disability and Work History Report Works
Prepared by the Usability Center, updated 06/08/04
Header
How the Online Adult Disability and Work History Report Works
This report does not have to be completed all at once. After you provide us with your organization details, you will receive a
Reentry Number for the specific claimant. You will be able to stop working on the report whenever you want, and then use
the Reentry Number to return to the report.
We have Special Instructions for Blind Users. Otherwise the following are tips on how to use the online report:
When you start a new report, you will have to enter some basic information before we can provide you with access
to other parts of the report. During this stage, you can use the "Continue" button to move forward, or the "Previous"
button to move backward. Both these buttons are located at the bottom of the page.
If you Sign Out of the report before completing this basic information, we will return to you the place where you last
left off when you return to the report.
Once you have completed the basic information, you will have access to various sections of the report. To move
from section to section in the report, use the Tabs at the top of the page.
Additional buttons, other than "Done", may appear at the bottom of a page. These buttons allow you to take an
action such as deleting a page or moving back and forth through a series of related pages.
Do NOT use the "Back" button on your browser to move backward.
IMPORTANT: DO NOT USE THE ENTER KEY TO MOVE AROUND IN THE REPORT OR TO SELECT FROM
THE DROP DOWN LISTS.
Time Limits
There are time limits for your work on each page. You will receive a warning after 25 minutes, and you will be able to
extend your time on the page. After the third warning on a page, you must move to another page or your time will run out,
and your work on that page will be lost. If you have turned JavaScript off in your browser, you will not receive any warnings.
If you do not go to another page after 30 minutes, your disability report session will end, and your work on the last page will
be lost.
Need More Space
If you run out of space in giving an answer, you can provide it to us on the Remarks page in the Review and Send section
at the end of the report. If you have more information to give us than will fit on the report, including the Remarks section,
please write the information on a separate sheet of paper and send it to us at the address we will give you after you've
completed this online report.
Locked Entries and Changing Answers
On a tabbed page, if you answer the Yes/No question as "Yes" and then enter at least one page of detailed information,
the "Yes" answer will be locked. To subsequently change the "Yes" answer to "No", you must first delete the detailed
information.
Close this window to return to the report.
i3368 Pro Message Pages, version 1.6
Message Page: Special Instructions for Blind Users
Prepared by the Usability Center, updated 06/08/04
Header
Special Instructions for Users Who Are Blind
The following instructions are for users with screen readers, such as JAWS and Window-Eyes, and browser-based
readers, such as Home Page Reader.
Filling out these reports is best accomplished in a Forms or MSAA mode that allows the user to tab to controls and fill in
input boxes, radio buttons, check boxes, and list boxes. Instructional text usually occurs at the beginning of these screens
and can be accessed in non-MSAA or virtual-cursor mode. Tabindices have also been added to allow for tabbing through
text.
In addition, help text is available using the Help/FAQ link at the top of each page.
There is a time limit on all pages. Unless you have turned JavaScript off in your browser, you will receive a warning after 25
minutes on a page. The warning includes instructions for extending your time on the page for an additional 30 minutes.
After the third warning, you must move to another page, or your time will run out and your work on that page will be lost.
At the end of most screens, there is a continue button to allow the user to go to the next page and a prior page button to
return to the previous page. The hotkey ALT + C is associated with the Continue button and ALT + P for the prior page.
Press Alt + C or ALT + P and then press Enter to move forward or back.
Close this window to return to the report.
i3368 Pro Message Pages, version 1.6
Message Page: Your Session Has Expired
Prepared by the Usability Center, updated 06/08/04
Header
Your Session Has Expired
If you would like to continue completing the Adult Disability and Work History Report for this claimant, you may try again by
selecting the Return to Report button below.
Select the Exit button to leave this report. You will be taken to the Social Security home page.
Exit
i3368 Pro Message Pages, version 1.6
Return to Report
Message Page: Death or Celebrity Notice
Prepared by the Usability Center, updated 06/08/04
Header
We Cannot Process Your Request
We have not been able to match the information you entered with our records.
If the information that you provided is correct, then it may be necessary to correct your information with Social Security.
To resolve this problem, please call 1-800-772-1213 or contact your local Social Security office.
Select the Exit button to leave this report. You will be taken to the Social Security home page.
Exit
i3368 Pro Message Pages, version 1.6
Message Page: System Failure
Prepared by the Usability Center, updated 06/08/04
Header
We Cannot Process Your Request
If you still wish to complete the Adult Disability and Work History Report for this claimant, you may try again later, or call
1-800-772-1213 or contact your local Social Security office.
Select the Exit button to leave this report. You will be taken to the Social Security home page.
Exit
i3368 Pro Message Pages, version 1.6
Message Page: Off-Hours Message
Prepared by the Usability Center, updated 06/08/04
Header
We Cannot Process Your Request
Please try again during business hours.
This service is available during the following hours (Eastern Time):
Monday through Friday: 5:00 AM - 1:00 AM
Saturday: 5:00 AM - 11:00 PM
Sunday: 8:00 AM - 10:00 PM
Holidays: 5:00 AM - 11:00 PM
Select the Exit button to leave this report. You will be taken to the Social Security home page.
Exit
i3368 Pro Message Pages, version 1.6
Message Page: Limit on the Number of Restarts on a Partial Report
Prepared by the Usability Center, updated 06/08/04
Header
Limit on the Number of Restarts on a Partial Report
You have reached the limit on the number of requests to reenter the Adult Disability and Work History Report you already
started for this claimant. You can start a new Adult Disability and Work History Report for this claimant or call us to help you
complete this report.
To ensure the claimant's privacy, the prior Adult Disability and Work History Report is now locked. If you start a new Adult
Disability and Work History Report for this claimant, you will have to reenter any information that you already entered on
the prior one.
To contact Social Security to help file this claim:
Call our toll-free number, 1-800-772-1213. If you are deaf or hard of hearing, call our toll-free "TTY" number, 1-800325-0778. Representatives are available Monday through Friday from 7a.m. to 7p.m.
Visit your local Social Security office.
Start a New Report
i3368 Pro Message Pages, version 1.6
Exit
Message Page: Processing Alert
Prepared by the Usability Center, updated 06/08/04
Header
We Are Processing This Request
Please wait a moment before selecting the Continue button.
Continue
i3368 Pro Message Pages, version 1.6
Message Page: Limit Number of Restarts
Prepared by the Usability Center, updated 06/08/04
Header
Limit on the Number of New Reports Started
You have reached the limit on the number of requests you can make to start a new Adult Disability and Work History Report
for this Social Security Number.
Please contact Social Security to make other arrangements to complete a Disability Report for this claimant. Be sure to tell
the representative that you tried the Internet Disability Report and received this message.
To contact Social Security:
Call our toll-free number, 1-800-772-1213. If you are deaf or hard of hearing, call our toll-free "TTY" number, 1-800325-0778. Representatives are available Monday through Friday from 7a.m. to 7p.m.
Visit your local Social Security office.
Select the Exit button to leave this report. You will be taken to the Social Security home page.
Exit
i3368 Pro Message Pages, version 1.6
Message Page: Illness Expected to End in Death
Prepared by the Usability Center, updated 06/08/04
Header
Illness Expected to End in Death
You told us that the claimant has been diagnosed with an illness that is expected to end in death. Please contact the
claimant's local Social Security office. We may be able to speed processing of the claim. When you contact the office, tell
the representative that you are completing an Online Adult Disability and Work History Report for the claimant and received
this message.
If the claimant's illness is not expected to end in death, please use the Previous button below to go back and correct the
answer.
Previous
i3368 Pro Message Pages, version 1.6
Continue with Report
Message Page: How to Complete the Medical Release Form
Prepared by the Usability Center, updated 06/08/04
Header
How to Complete the Medical Release Form
1. Read the entire form, front and back. The information on the back explains more about how the form will be used and
explains the possible consequences of not signing the form. Additional instructions are also on the form. If you have any
questions, please contact us.
2. Be sure the name of the person whose records must be disclosed (the applicant or beneficiary) is written in the upper
right corner of the form, with his/her own Social Security Number. SSA will fill in the rest of that block if needed.
3. Do not fill in the large empty box in the middle of the form; SSA will use this space to help the source identify the
information we need.
4. Do not put a check in the empty block under "PURPOSE" unless SSA specifically asks you to.
5. INDIVIDUAL SIGN - Sign each form in this block.
An adult should sign his/her own form.
An individual can sign with an "X" if necessary.
If an individual has been declared legally incompetent, his/her legal guardian or legally recognized representative
should sign the form.
If the individual whose information is going to be disclosed is not the one signing the form, be sure to check the box
to the right that shows that person's authority to sign (parent, guardian, etc.) and then give proof of that legal
relationship to SSA. If the subject of disclosure is a minor, then a custodial parent, guardian or other legally
recognized representative should sign the form.
If the subject of the disclosure is age 12 or older but still considered to be a minor under State law, he or she should
sign the form and the parent, guardian or other legally recognized representative should sign in the "Parent/guardian
sign" area to the right.
6. ALWAYS enter the DATE the form is signed.
7. Enter the address and daytime phone number of the individual signing the form.
8. WITNESS SIGN - The signature of the individual signing the forms must be witnessed by at least one other individual.
Many sources will not honor our request unless it is witnessed.
The witness can be any competent adult (spouse, social worker, Social Security employee, etc.).
The witness should sign and provide his or her address information in case the source wants to confirm the
signature.
A second witness is usually only required if the subject of the disclosure signs with an "X".
Close this window to return to the report.
i3368 Pro Message Pages, version 1.6
Message Page: Limit on the Number of Tries to Start a Report
Prepared by the Usability Center, updated 06/08/04
Header
Limit on the Number of Tries to Start the Adult Disability and Work History Report
You have reached the limit on the number of tries to start a Adult Disability and Work History Report for this claimant.
Please contact Social Security to make other arrangements to complete this report.
To contact Social Security:
Call our toll-free number, 1-800-772-1213. If you are deaf or hard of hearing, call our toll-free "TTY" number, 1-800-325-0778. Representatives
are available Monday through Friday from 7a.m. to 7p.m.
Visit your local Social Security office.
Select the Exit button to leave this report. You will be taken to the Social Security home page.
Exit
i3368 Pro Message Pages, version 1.6
Message Page: We Cannot Match the Zip Code You Entered
Prepared by the Usability Center, updated 06/08/04
Header
We Cannot Match the Zip Code You Entered
We are unable to verify this ZIP code. Please check the number you entered and make sure it is correct. If the Post Office
recently gave this area a new ZIP code, it may not be on our records yet. In that case, use the prior ZIP code for this address.
Please contact Social Security to make other arrangements to complete a disability report if:
this is the claimant's correct ZIP code and not a new code recently given to the area by the Post Office, or
this is a new ZIP code recently given by the Post Office and you or the claimant don't know the prior ZIP code.
To contact Social Security:
Call our toll-free number, 1-800-772-1213. If you are deaf or hard of hearing, call our toll-free "TTY" number, 1-800325-0778. Representatives are available Monday through Friday from 7a.m. to 7p.m.
Visit a Social Security office. To find the local Social Security office, close this window and use the link given on the
previous page.
To reenter the ZIP code, close this window and type it in again.
Close this window to return to the report.
i3368 Pro Message Pages, version 1.6
File Type application/pdf File Title I3368-PRO SCREEN GUIDE Author Faye I. Lipsky File Modified 2009-06-29 File Created 2009-06-29