Form SSA-3368 Disability Report - Adult

Disability Report - Adult

SSA-3368-BK - Revised

Disability Report - Adult, (Fillable PDF)

OMB: 0960-0579

Document [pdf]

Download: pdf | pdf

Form SSA-3368-BK (11-2020) UF
Discontinue Prior Editions
Social Security Administration

Page 1 of 15
OMB No. 0960-0579

DISABILITY REPORT - ADULT
PLEASE READ THIS INFORMATION BEFORE COMPLETING THIS REPORT
The information you give us on this report will be used by the office that makes the disability decision on
your disability claim. Completing this report accurately and completely will help us expedite your claim.
Please complete as much of the report as you can.
IF YOU NEED HELP
You can get help from other people, such as a friend or family member. Please do not ask your healthcare
provider to complete this report. If you cannot complete the report, a Social Security Representative will
assist you. If you have an appointment, please have the completed report ready when we contact you. If we
ask you to do so, please mail the completed report to us ahead of time.
Note: If you are assisting someone else with this report, please answer the questions as if that person were
completing the report.
HOW TO COMPLETE THIS REPORT
•
•
•
•

•

•
•

Print or write clearly.
Include a ZIP or postal code with each address.
Provide complete phone numbers including area code. If a phone number is outside
the United States, also provide International Direct Dialing (IDD) code and country code.
If you cannot remember the names and addresses of your healthcare providers, you may
be able to get that information from the telephone book, Internet, medical bills,
prescriptions, or prescription medicine containers.
ANSWER EVERY QUESTION, unless the report indicates otherwise. If you do not know
an answer, or the answer is "none" or "does not apply," please write: "don't know," or
"none," or "does not apply."
Be sure to explain an answer if the question asks for an explanation, or if you want to give
additional information.
If you need more space to answer any question, please use Section 11 - Remarks on the
last page to finish your answer. Write the number of the question you are answering.

YOUR MEDICAL RECORDS
If you have any of your medical records, send or bring them to our office with this completed report. Please
tell us if you want to keep your records so we can return them to you. If you are having an interview in our
office, bring your medical records, your prescription medicine containers (if available), and the completed
report with you.
YOU DO NOT NEED TO ASK DOCTORS OR HOSPITALS FOR ANY MEDICAL RECORDS THAT YOU
DO NOT ALREADY HAVE. With your permission, we will request your records. The information that you
give us on this report tells us where to request your medical and other records.

Form SSA-3368-BK (11-2020) UF

Page 2 of 15

WHAT WE MEAN BY "DISABILITY"
“Disability” under Social Security is based on your inability to work. For purposes of this claim, we want you
to understand that “disability” means you are unable to work as defined by the Social Security Act. You will
be considered disabled if you are unable to do any kind of work for which you are suited and if your
disability is expected to last (or has lasted) for at least a year or is expected to result in death. So when we
ask “when did you become unable to work,” we are asking when you became disabled as defined by the
Social Security Act.
See Revised Privacy Act &
Privacy Act Statement
PRA Statements attached
Collection and Use of Personal Information
Sections 205(a), 223(d), 1614(a), and 1631 of the Social Security Act, as amended, allows us to collect this
information. Furnishing us this information is voluntary. However, failing to provide all or part of the
information may prevent an accurate and timely decision on any claim filed.
We will use the information to determine eligibility for benefits. We may also share your information for the
following purposes, called routine uses:
• To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social
Security Administration (SSA) in the efficient administration of its programs; and
• To applicants, claimants, prospective applicants or claimants, other than the data subject, their
authorized representatives or representative payees to the extent necessary to pursue Social
Security claims and to representative payees when the information pertains to individuals for whom
they serve as representative payees, for the purpose of assisting SSA in administering its
representative payment responsibilities under the Act and assisting the representative payees in
performing their duties as payees, including receiving and accounting for benefits for individuals for
whom they serve as payees.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For
example, where authorized, we may use and disclose this information in computer matching programs, in
which our records are compared with other records to establish or verify a person's eligibility for Federal
benefit programs and for repayment of incorrect or delinquent debts under these programs.
A list of additional routine uses is available in our Privacy Act Systems of Records Notice (SORN) 60-0089,
entitled Claims Folders System, as published in the Federal Register (FR) on April 1, 2003, at 68 FR 15784,
and 60-0320, entitled Electronic Disability Claim File, as published in the FR on December 22, 2003, at 68
FR 71210. Additional information, and a full listing of all of our SORNs, is available on our website at
www.ssa.gov/privacy.
Paperwork Reduction Act Statement
This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the
Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid
Office of Management and Budget control number. We estimate that it will take about 90 minutes to read
the instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM
TO YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your local Social Security office
through SSA's website at www.socialsecurity.gov. Offices are also listed under U. S. Government
agencies in your telephone directory or you may call Social Security at 1-800-772-1213 (TTY
1-800-325-0778). You may send comments regarding this burden estimate or any other aspect of this
collection, including suggestions for reducing this burden to: SSA, 6401 Security Blvd, Baltimore, MD
21235-6401. Send only comments relating to our time estimate to this address, not the
completed form.
AFTER COMPLETING THIS REPORT, REMOVE THIS SHEET AND KEEP IT FOR YOUR RECORDS

Form SSA-3368-BK (11-2020) UF

DISABILITY REPORT
ADULT

Page 3 of 15

For SSA Use Only- Do not write in this box.
Related SSN
Number Holder

Anyone who makes or causes to be made a false statement or representation of material fact for use in
determining a payment under the Social Security Act, or knowingly conceals or fails to disclose an event
with an intent to affect an initial or continued right to payment, commits a crime punishable under Federal
law by fine, imprisonment, or both, and may be subject to administrative sanctions.
If you are filling out this report for someone else, please provide information about him or her. When a
question refers to "you" or "your," it refers to the person who is applying for disability benefits.
SECTION 1 - INFORMATION ABOUT THE DISABLED PERSON
1.A. Name (First, Middle Initial, Last)
1.B. Social Security Number
1.C. Mailing Address (Street or PO Box) Include apartment number or unit (if applicable).
City

State/Province

ZIP/Postal Code Country (If not USA)

1.D. Email Address
1.E. Daytime Phone Number, including area code, and the IDD and country codes if you live outside the
Phone number
USA
Check this box if you do not have a phone or a number where we can leave a message.
1.F. Alternate Phone Number - another number where we may reach you, if any.
Alternate phone number
1.G. Can you speak and understand English?

Yes

If no, what language do you prefer?
If you cannot speak and understand English, we will provide an interpreter, free of charge.
1.H. Can you read and understand English?
No
Yes
1.I. Can you write more than your name in English?
Yes
No
1.J. Have you used any other names on your medical or educational records? Examples are maiden name,
other married name, or nickname.
Yes
No
If yes, please list them here:
SECTION 2 - CONTACTS
Give the name of someone (other than your doctors) we can contact who knows about your medical
conditions, and can help you with your claim.
2.A. Name (First, Middle Initial, Last)
2.B. Relationship to you
2.C. Daytime Phone Number (as described in 1.E. above)
2.D. Mailing Address (Street or PO Box) Include apartment number or unit if applicable.
City

State/Province

2.E. Can this person speak and understand English?
If no, what language is preferred?

ZIP/Postal Code Country (If not USA)
Yes

Form SSA-3368-BK (11-2020) UF

Page 4 of 15

SECTION 2 - CONTACTS (continued)
2.F. Who is completing this report?
The person who is applying for disability. (Go to Section 3 - Medical Conditions)
The person listed in 2.A. (Go to Section 3 - Medical Conditions)
Someone else (Complete the rest of Section 2 below)
2.G. Name (First, Middle Initial, Last)
2.H. Relationship to Person Applying
2.I. Daytime Phone Number
2.J. Mailing Address (Street or PO Box) Include apartment number or unit if applicable.
City

State/Province

ZIP/Postal Code Country (If not USA)

SECTION 3 - MEDICAL CONDITIONS
3.A. List all of the physical or mental conditions (including emotional or learning problems) that limit your
ability to work. If you have cancer, please include the stage and type. List each condition separately.
1.
2.
3.
4.
5.

If you need more space, go to Section 11- Remarks on the last page
3.B. What is your height without shoes?
OR
feet
inches
centimeters (if outside USA)
3.C. What is your weight without shoes?

OR
pounds

kilograms (if outside USA)

Yes
No
3.D. Do your conditions cause you pain or other symptoms?
SECTION 4 - WORK ACTIVITY
4.A. Are you currently working?
No, I have never worked (Go to question 4.B. below)
No, I have stopped working (Go to question 4.C. below)
Yes, I am currently working (Go to question 4.F. on page 5)
IF YOU HAVE NEVER WORKED:
4.B. When do you believe your conditions(s) became severe enough to keep you from working (even
(Go to Section 5 on page 5)
though you have never worked)? (month/day/year)
IF YOU HAVE STOPPED WORKING:
4.C. When did you stop working? (month/day/year)
Why did you stop working?
Because of my condition(s).
Because of other reasons. Please explain why you stopped working (for example: laid off, early
retirement, seasonal work ended, business closed).
Even though you stopped working for other reasons, when do you believe your conditions(s) became
severe enough to keep you from working? (month/day/year)
4.D. Did your condition(s) cause you to make changes in your work activity? (for example: job duties,
hours, or rate of pay)
No (Go to Section 5 - Education and Training on page 5)
Yes, When did you make changes? (month/day/year)

Form SSA-3368-BK (11-2020) UF

Page 5 of 15

SECTION 4 - WORK ACTIVITY (continued)
4.E. Since the date in 4.D. above, have you had gross earnings greater than $1,180 in any month? Do not
count sick leave, vacation, or disability pay. (We may contact you for more information.)
No (Go to Section 5)
Yes (Go to Section 5)
IF YOU ARE CURRENTLY WORKING:
4.F. Has your condition(s) caused you to make changes in your work activity? (for example: job duties or
hours)
No When did your condition(s) first start bothering you? (month/day/year)
Yes When did you make changes? (month/day/year)
4.G. Since your condition(s) first bothered you, have you had gross earnings greater than $1,180 in any
month? Do not count sick leave, vacation, or disability pay. (We may contact you for more information.)
No
Yes
SECTION 5 - EDUCATION AND TRAINING
5.A. Check the highest grade of school completed. (Select 12, if you have education equivalent to
high school from another country.)

GED

College:
1
2

4 or more

Date completed:
MM

YYYY

Name of school:
City:

State/Province:

Country (if not USA)

5.B. Did you receive special education, such as through an Individualized Education Plan (IEP)
or equivalent education?
Yes
No (Go to 5.C.)
/
/
to
Dates from:
YYYY
MM
YYYY
MM
Check the last grade you received special education.
Pre K

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

State/Province:

Country (if not USA)

Form SSA-3368-BK (11-2020) UF

Page 6 of 15

SECTION 5 - EDUCATION AND TRAINING (continued)
5.C. Have you completed any type of specialized job training, trade, or vocational school?
No

Yes
If "Yes," what type?

Date completed:

YYYY
MM
5.D. What written language do you use every day in most situations (at home, work, school, in community,
etc.)?
5.E. In the language you identified in 5.D., can you read a simple message, such as a shopping list or short
and simple notes?
No
Yes
5.F. In the language you identified in 5.D., can you write a simple message, such as a shopping list or short
and simple notes?
Yes
No
If you need to list other educations or training use Section 11 - Remarks on the last page.
SECTION 6 - JOB HISTORY
6.A. List the jobs (up to 5) that you have had in the 15 years before you became unable to work because
of your physical or mental conditions. List your most recent job first.
Check here and go to Section 7 - Medicines on page 8 if you did not work at all in the 15 years before
you became unable to work.

Job Title

Type of
Business

Dates Worked

From
MM/YY

To
MM/YY

Hours
Per
Day

Days
Per
Week

Rate of Pay

Amount

Frequency

5.
Check the box below that applies to you.
I had only one job in the last 15 years before I became unable to work. Answer the question below.
I had more than one job in the last 15 years before I became unable to work. Do not answer the
question on this page; go to Section 7 - Medicines on page 8. (We may contact you for more
information.)

Form SSA-3368-BK (11-2020) UF

Page 7 of 15

SECTION 6 - JOB HISTORY (continued)
Do not complete this page if you had more than one job in the last 15 years before you became unable to
work.
6.B. Describe this job. What did you do all day?

(If you need more space, use Section 11 - Remarks on the last page.)
6.C. In this job, did you:
Use machines, tools or equipment?

Yes

Use technical knowledge or skills?

Yes

Do any writing, complete reports, or perform any duties like this?

Yes

6.D. In this job, how many hours each day did you do each of the tasks listed:
Task Hours
Task
Hours

Task

Hours

Walk

Stoop (Bend down & forward at waist.)

Handle large objects

Stand

Kneel (Bend legs to rest on knees.)

Write, type, or handle small objects

Sit

Crouch (Bend legs & back down &
forward.)

Reach

Climb

Crawl (Move on hands & knees.)

6.E. Lifting and carrying (Explain in the box below, what you lifted, how far you carried it, and how often
you did this in your job.)

6.F. Check heaviest weight lifted:
Less than 10 lbs.
10 lbs.
20 lbs.
50 lbs.
100 lbs. or more
Other
6.G. Check weight frequently lifted: (by frequently, we mean from 1/3 to 2/3 of the workday.)
Less than 10 lbs.
10 lbs.
25 lbs.
50 lbs. or more
Other
6.H. Did you supervise other people in this job?
Yes (Complete items below)

No (if No, go to 6.I.)

How many people did you supervise?
Did you hire and fire employees?

Yes

What part of your time did you spend supervising people?
6.I. Were you a lead worker?

Form SSA-3368-BK (11-2020) UF

Page 8 of 15

SECTION 7 - MEDICINES
7. Are you taking any medicines (prescription or non-prescription)?
Yes, (Give the information requested below. You may need to look at your medicine containers.)
No, (Go to Section 8 - Medical Treatment)
If prescribed, give name of
doctor

Name of Medicine

Reason for medicine

If you need to list other medicines, go to Section 11 - Remarks on the last page.
SECTION 8 - MEDICAL TREATMENT
Have you seen a doctor or other health care professional or received treatment at a hospital or clinic, or do
you have a future appointment scheduled?
8.A. For any physical condition(s)?

Yes

8.B. For any mental condition(s) (including emotional or learning problems)?

Yes

If you answered "No" to both 8.A. and 8.B., go to Section 9 - Other Medical Information on page 14.

Form SSA-3368-BK (11-2020) UF

Page 9 of 15

SECTION 8 - MEDICAL TREATMENT (continued)
Tell us who may have medical records about any of your physical and/or mental condition(s) (including
emotional or learning problems). This includes doctors' offices, hospitals (including emergency room
visits), clinics, and other health care facilities. Tell us about your next appointment, if you have one
scheduled.
Name of healthcare professional who treated you
8.C. Name of Facility or Office

ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROVIDER ABOVE.
Phone
Patient ID# (if known)
Mailing Address
City

State/Province

ZIP/Postal Code Country (if not USA)

Dates of Treatment
1. Office, Clinic, or Outpatient
visits

2. Emergency Room visits
List the most recent date first

3. Overnight hospital stays
List the most recent date first

First Visit

A. Date in

Date out

Last Visit

B. Date in

Date out

Next scheduled appointment (if any)

C. Date in

Date out

What medical conditions were treated or evaluated?

What treatment did you receive for the above conditions? (Do not describe medicines or tests in this
box.)

Tell us about any tests the provider performed or sent you to, or has scheduled you to take. Please give the
dates for past and future tests. If you need to list more tests, use Section 11 - Remarks on the last page.
Check this box if no test by this provider or at this facility.
Kind of Test
Dates of Tests
Kind of Test
Dates of Tests
EKG (heart test)

EEG (brain wave test)

Treadmill (exercise test)

HIV Test

Cardiac Catheterization

Blood Test (not HIV)

Biopsy (list body part)

X-Ray (list body part)

Hearing Test

MRI/CT Scan (list body part)

Speech/Language Test
Vision Test

Other (please describe)

Breathing Test

If you do not have any more doctors or hospitals to describe, go to Section 9 on page 14.

Form SSA-3368-BK (11-2020) UF

Page 10 of 15

SECTION 8 - MEDICAL TREATMENT (continued)
Tell us who may have medical records about any of your physical and/or mental condition(s) (including
emotional or learning problems). This includes doctors' offices, hospitals (including emergency room
visits), clinics, and other health care facilities. Tell us about your next appointment, if you have one
scheduled.
8.D. Name of Facility or Office
Name of healthcare professional who treated you

ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROVIDER ABOVE.
Phone
Patient ID# (if known)
Mailing Address
City

State/Province

ZIP/Postal Code Country (if not USA)

Dates of Treatment
1. Office, Clinic, or Outpatient
visits

2. Emergency Room visits
List the most recent date first

3. Overnight hospital stays
List the most recent date first

First Visit

A. Date in

Date out

Last Visit

B. Date in

Date out

Next scheduled appointment (if any)

C. Date in

Date out

What medical conditions were treated or evaluated?

What treatment did you receive for the above conditions? (Do not describe medicines or tests in this
box.)

EEG (brain wave test)

Treadmill (exercise test)

HIV Test

Cardiac Catheterization

Blood Test (not HIV)

Biopsy (list body part)

X-Ray (list body part)

Hearing Test

MRI/CT Scan (list body part)

Speech/Language Test
Vision Test

Other (please describe)

Breathing Test

If you do not have any more doctors or hospitals to describe, go to Section 9 on page 14.

Form SSA-3368-BK (11-2020) UF

Page 11 of 15

ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROVIDER ABOVE.
Phone
Patient ID# (if known)
Mailing Address
City

State/Province

ZIP/Postal Code Country (if not USA)

Dates of Treatment
1. Office, Clinic, or Outpatient
visits

2. Emergency Room visits
List the most recent date first

3. Overnight hospital stays
List the most recent date first

First Visit

A. Date in

Date out

Last Visit

B. Date in

Date out

Next scheduled appointment (if any)

C. Date in

Date out

What medical conditions were treated or evaluated?

What treatment did you receive for the above conditions? (Do not describe medicines or tests in this
box.)

EEG (brain wave test)

Treadmill (exercise test)

HIV Test

Cardiac Catheterization

Blood Test (not HIV)

Biopsy (list body part)

X-Ray (list body part)

Hearing Test

MRI/CT Scan (list body part)

Speech/Language Test
Vision Test

Other (please describe)

Breathing Test

If you do not have any more doctors or hospitals to describe, go to Section 9 on page 14.

Form SSA-3368-BK (11-2020) UF

Page 12 of 15

ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROVIDER ABOVE.
Phone
Patient ID# (if known)
Mailing Address
City

State/Province

ZIP/Postal Code Country (if not USA)

Dates of Treatment
1. Office, Clinic, or Outpatient
visits

2. Emergency Room visits
List the most recent date first

3. Overnight hospital stays
List the most recent date first

First Visit

A. Date in

Date out

Last Visit

B. Date in

Date out

Next scheduled appointment (if any)

C. Date in

Date out

What medical conditions were treated or evaluated?

What treatment did you receive for the above conditions? (Do not describe medicines or tests in this
box.)

EEG (brain wave test)

Treadmill (exercise test)

HIV Test

Cardiac Catheterization

Blood Test (not HIV)

Biopsy (list body part)

X-Ray (list body part)

Hearing Test

MRI/CT Scan (list body part)

Speech/Language Test
Vision Test

Other (please describe)

Breathing Test

If you do not have any more doctors or hospitals to describe, go to Section 9 on page 14.

Form SSA-3368-BK (11-2020) UF

Page 13 of 15

ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROVIDER ABOVE.
Phone
Patient ID# (if known)
Mailing Address
City

State/Province

ZIP/Postal Code Country (if not USA)

Dates of Treatment
1. Office, Clinic, or Outpatient
visits

2. Emergency Room visits
List the most recent date first

3. Overnight hospital stays
List the most recent date first

First Visit

A. Date in

Date out

Last Visit

B. Date in

Date out

Next scheduled appointment (if any)

C. Date in

Date out

What medical conditions were treated or evaluated?

What treatment did you receive for the above conditions? (Do not describe medicines or tests in this
box.)

EEG (brain wave test)

Treadmill (exercise test)

HIV Test

Cardiac Catheterization

Blood Test (not HIV)

Biopsy (list body part)

X-Ray (list body part)

Hearing Test

MRI/CT Scan (list body part)

Speech/Language Test
Vision Test

Other (please describe)

Breathing Test

If you do not have any more doctors or hospitals to describe, go to Section 9 on page 14.

Form SSA-3368-BK (11-2020) UF

Page 14 of 15

SECTION 9 - OTHER MEDICAL INFORMATION
9. Does anyone else have medical information about your physical and/or mental condition(s) (including
emotional and learning problems), or are you scheduled to see anyone else? (This may include places
such as workers' compensation, vocational rehabilitation, insurance companies who have paid you
disability benefits, prisons, attorneys, social service agencies and welfare.)
Yes (Please complete the information below)
No (If you are receiving Supplemental Security Income (SSI) and have been asked to complete this
report, go to Section 10 - Vocational Rehabilitation; if not, go to Section 11 - Remarks on the last page.)
Name of Organization
Phone Number
Mailing Address
City

State/Province

ZIP/Postal Code

Country (if not USA)

Claim or ID number (if any)

Name of Contact Person
Date of Last Contact

Date of First Contact

Date of Next Contact (if any)

Reasons for Contacts

If you need to list other people or organizations use Section 11 - Remarks on the last page and give
the same detailed information as above for each one you list.
COMPLETE THIS SECTION ONLY IF YOU ARE ALREADY RECEIVING SSI.
SECTION 10 - VOCATIONAL REHABILITATION, EMPLOYMENT, OR OTHER SUPPORT SERVICES
10.A. Have you participated, or are you participating in:
• An individual work plan with an employment network under the Ticket to Work Program;
• An individualized plan for employment with a vocational rehabilitation agency or any other organization;
• A Plan to Achieve Self-Support (PASS);
• Any Individualized Education Program (IEP) through a school (if a student age 18-21); or
• Any program providing vocational rehabilitation, employment services, or other support services to help
you go to work?
Yes (Complete the following information)
No (Go to Section 11 - Remarks)
10.B. Name of Organization or School
Name of Counselor, Instructor, or Job Coach

Phone Number

Mailing Address
City

State/Province

ZIP/Postal Code

10.C. When did you start participating in the plan or program?

Country (if not USA)

Form SSA-3368-BK (11-2020) UF

Page 15 of 15

SECTION 10 - VOCATIONAL REHABILITATION, EMPLOYMENT, OR OTHER SUPPORT SERVICES
(continued)
10.D. Are you still participating in the plan or program?
Yes, I am scheduled to complete the plan or program on:
No, I completed the plan or program on:
No, I stopped participating in the plan or program before completing it because:

10.E. List the types of service, tests, or evaluations that you received (for example: intelligence or
psychological testing, vision or hearing test, physical exam, work evaluation, or classes.

If you need to list another plan or program use Section 11 - Remarks and give the same detailed
information as above.
SECTION 11 - REMARKS
Please write any additional information you did not give in earlier parts of this report. If you did not have
enough space in the sections of this report to write the requested information, please use this space to tell
us the additional information requested in those sections. Be sure to show the section to which you are
referring.

Date Report Completed (MM/DD/YYYY)

File Type	application/pdf
File Title	SSA-3368-BK
Subject	Disability Report- Adult
Author	SSA
File Modified	2021-10-19
File Created	2020-11-04