Article Structure
The SSA-3368 form, also known as the Disability Report - Adult, is a crucial document for individuals seeking Social Security Disability Insurance (SSDI) benefits. This form plays a pivotal role in the assessment of a claim for disability, as the information provided directly influences the decision-making process regarding eligibility. Applicants are prompted to share comprehensive details about their medical conditions, work history, and daily activities. Sections of the form guide users to list all relevant health conditions, noting their severity, how these conditions prevent them from working, and when they began impacting their ability to perform job duties. Additionally, the SSA-3368 encourages clarity and completeness; it highlights the importance of filling out each section thoroughly and provides instructions on how to seek help if needed. Properly completing this form can expedite the review of claims, so taking the time to provide accurate information is beneficial. With support options available for those who may need assistance, the SSA-3368 ensures that all applicants have the opportunity to communicate their circumstances effectively.
Ssa 3368 Example
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Page 1 of 15 |
Social Security Administration |
OMB No. |
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.
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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.
Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 223(d), 1614(a), and 1631 of the Social Security Act, as amended, 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)
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
AFTER COMPLETING THIS REPORT, REMOVE THIS SHEET AND KEEP IT FOR YOUR RECORDS
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Page 3 of 15 |
DISABILITY REPORT
ADULT
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
1.D. Email Address
State/Province
ZIP/Postal Code Country (If not USA)
1.E. Daytime Phone Number, including area code, and the IDD and country codes if you live outside the |
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USA |
Phone number |
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
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1.G. Can you speak and understand English? |
Yes |
No |
If no, what language do you prefer?
If you cannot speak and understand English, we will provide an interpreter, free of charge.
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1.H. Can you read and understand English? |
Yes |
No |
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1.I. Can you write more than your name in English? |
Yes |
No |
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1.J. Have you used any other names on your medical or educational records? Examples are maiden name, |
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other married name, or nickname. |
Yes |
No |
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If yes, please list them here: |
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SECTION 2 - CONTACTS
Give the name of someone (other than your doctors) we can contact who knows about your medical
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conditions, and can help you with your claim. |
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2.A. Name (First, Middle Initial, Last) |
2.B. Relationship to you |
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2.C. Daytime Phone Number (as described in 1.E. above) |
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2.D. Mailing Address (Street or PO Box) Include apartment number or unit if applicable.
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City |
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State/Province |
ZIP/Postal Code |
Country (If not USA) |
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2.E. Can this person speak and understand English? |
Yes |
No |
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If no, what language is preferred? |
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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)
though you have never worked)? (month/day/year)
IF YOU HAVE STOPPED WORKING:
When do you believe your conditions(s) became severe enough to keep you from working (even (Go to Section 5 on page 5)
IF YOU HAVE NEVER WORKED: 4.B.
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)
4.A.
Do your conditions cause you pain or other symptoms?
SECTION 4 - WORK ACTIVITY
3.D.
pounds
OR
What is your weight without shoes?
3.C.
feet
inches
OR
What is your height without shoes?
3.B.
1.
2.
3.
4.
5.
3.A.
SECTION 3 - MEDICAL CONDITIONS
kilograms (if outside USA)
centimeters (if outside USA)
If you need more space, go to Section 11- Remarks on the last page
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.
2.I.
2.J. City
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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
Daytime Phone Number
Mailing Address (Street or PO Box) Include apartment number or unit if applicable.
State/Province
ZIP/Postal Code
Country (If not USA)
Yes |
No |
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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.)
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College: |
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2 |
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4 |
5 |
6 |
7 |
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9 10 11 12 GED |
1 2 3 4 or more |
Date completed: |
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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? |
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Yes |
No (Go to 5.C.) |
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Dates from: |
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Check the last grade you received special education.
Pre K K |
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9 10 11 12 |
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: |
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State/Province: |
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SECTION 5 - EDUCATION AND TRAINING (continued)
5.C. Have you completed any type of specialized job training, trade, or vocational school?
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Yes |
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No |
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If "Yes," what type? |
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Date completed: |
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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 |
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and simple notes? |
Yes |
No |
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5.F. In the language you identified in 5.D., can you write a simple message, such as a shopping list or short |
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and simple notes? |
Yes |
No |
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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.
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Job Title |
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Dates Worked |
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Rate of |
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Frequency |
MM/YY |
MM/YY |
1.
2.
3.
4.
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.)
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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: |
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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 |
6.D. In this job, how many hours each day did you do each of the tasks listed: |
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Task |
Hours |
Task |
Hours |
Task |
Hours |
Walk |
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Stoop (Bend down & forward at waist.) |
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Handle large objects |
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Stand |
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Kneel (Bend legs to rest on knees.) |
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Write, type, or handle small objects |
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Sit |
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Crouch (Bend legs & back down & |
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forward.) |
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Climb |
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Crawl (Move on hands & knees.) |
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6.E. Lifting and carrying (Explain in the box below, what you lifted, how far you carried it, and how often |
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you did this in your job.) |
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6.F. |
Check heaviest weight lifted: |
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Less than 10 lbs. |
10 lbs. |
20 lbs. |
50 lbs. |
100 lbs. or more |
Other |
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6.G. Check weight frequently |
lifted: (by frequently, we mean from 1/3 to 2/3 of the workday.) |
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Less than 10 lbs. |
10 lbs. |
25 lbs. |
50 lbs. or more |
Other |
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6.H. Did you supervise other people in this job? |
Yes (Complete items below) |
No (if No, go to 6.I.) |
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How many people did you supervise? |
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Yes |
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No |
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Did you hire and fire employees? |
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What part of your time did you spend supervising people? |
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6.I. |
Were you a lead worker? |
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Yes |
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No |
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Page 8 of 15 |
SECTION 7 - MEDICINES
7.Are you taking any medicines (prescription or
Yes, (Give the information requested below. You may need to look at your medicine containers.) 
No, (Go to Section 8 - Medical Treatment)
Name of Medicine
If prescribed, give name of
doctor
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 |
No |
8.B. For any mental condition(s) (including emotional or learning problems)? |
Yes |
No |
If you answered "No" to both 8.A. and 8.B., go to Section 9 - Other Medical Information on page 14.
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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.
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8.C. Name of Facility or Office |
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Name of healthcare professional who treated you |
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ALL OF THE QUESTIONS ON THIS PAGE |
REFER TO THE HEALTH CARE PROVIDER ABOVE. |
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Phone |
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Patient ID# (if known) |
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Mailing Address |
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City |
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State/Province |
ZIP/Postal Code |
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Dates of Treatment |
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1. Office, Clinic, or Outpatient |
2. Emergency Room visits |
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3. Overnight hospital stays |
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visits |
List the most recent date first |
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List the most recent date first |
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First Visit |
A. |
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Last Visit |
B. |
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Next scheduled appointment (if any) |
C. |
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C. Date in |
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Date out |
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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.
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Kind of Test |
Dates of Tests |
Kind of Test |
Dates of Tests |
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EKG (heart test) |
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EEG (brain wave test) |
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Treadmill (exercise test) |
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HIV Test |
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Cardiac Catheterization |
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Blood Test (not HIV) |
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Biopsy (list body part) |
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Hearing Test |
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MRI/CT Scan (list body part) |
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Speech/Language Test |
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Vision Test |
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Other (please describe) |
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Breathing Test
If you do not have any more doctors or hospitals to describe, go to Section 9 on page 14.
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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.
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8.D. Name of Facility or Office |
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Name of healthcare professional who treated you |
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ALL OF THE QUESTIONS ON THIS PAGE |
REFER TO THE HEALTH CARE PROVIDER ABOVE. |
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Phone |
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Patient ID# (if known) |
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Mailing Address |
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Dates of Treatment |
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1. Office, Clinic, or Outpatient |
2. Emergency Room visits |
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3. Overnight hospital stays |
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visits |
List the most recent date first |
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List the most recent date first |
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First Visit |
A. |
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A. Date in |
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Date out |
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Last Visit |
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Date out |
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Next scheduled appointment (if any) |
C. |
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C. Date in |
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Date out |
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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.
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Kind of Test |
Dates of Tests |
Kind of Test |
Dates of Tests |
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EKG (heart test) |
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EEG (brain wave test) |
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Treadmill (exercise test) |
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HIV Test |
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Cardiac Catheterization |
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Blood Test (not HIV) |
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Biopsy (list body part) |
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Hearing Test |
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MRI/CT Scan (list body part) |
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Speech/Language Test |
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Vision Test |
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Other (please describe) |
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Breathing Test
If you do not have any more doctors or hospitals to describe, go to Section 9 on page 14.
Form Characteristics
| Fact Name | Description |
|---|---|
| Form Purpose | The SSA-3368 form is used to report information about an adult's disability when applying for Social Security benefits. |
| Use of Information | The information provided on the form aids the Social Security Administration in making disability determinations. |
| Completion Assistance | Individuals can receive help from family or friends, but healthcare providers should not fill out the form. |
| Reporting Requirements | Users must answer every question. If unsure, they can write "don’t know," "none," or "does not apply." |
| Privacy Considerations | Personal information collected is governed by laws including Sections 205, 223, 1614, and 1631 of the Social Security Act. |
| Estimated Time | Completing the report typically takes about 90 minutes according to the SSA. |
| Submission Instructions | The completed form should be sent or brought to a local Social Security office. Location can be found on the SSA website. |
| Legal Compliance | The information collection complies with the Paperwork Reduction Act (44 U.S.C. § 3507). |
Guidelines on Utilizing Ssa 3368
Filling out the SSA-3368 form is a crucial step in seeking disability benefits. This detailed report allows you to share essential information about your medical conditions, work history, and educational background. To avoid delays and ensure your claim is processed efficiently, it is important to complete the form accurately. Here’s how to do it:
- Begin by writing or printing clearly in the Information about the Disabled Person section. Enter your full name, Social Security Number, and mailing address, including ZIP code.
- Provide your daytime phone number, and if applicable, an alternate phone number. Indicate if you do not have a phone where messages can be left.
- Indicate your ability to speak, read, and write in English. If applicable, note any languages you prefer.
- List any other names you have used on medical or educational records.
- In the Contacts section, provide information about someone who can assist with your claim, including their name, relationship to you, and contact details.
- If you stopped working, answer questions regarding when you stopped and the reasons, being specific about your conditions and work activities.
- Detail your medical conditions in the Medical Conditions section. Make sure to list each condition separately, clearly indicating how they affect your ability to work.
- In the Work Activity section, answer whether you are currently working and provide details on any changes made due to your conditions.
- Share your educational background in the Education and Training section. Include the highest grade completed and specify if you received special education support.
- If you need additional space to elaborate on your answers, utilize Section 11 - Remarks on the last page of the form, and refer to the question numbers.
- Review the completed form for accuracy and clarity before submitting it.
- Send or bring the completed form to your local Social Security office, ensuring that you have included any relevant medical records you possess.
Once you have submitted the form, the Social Security Administration will use the provided information to evaluate your claim. This process can take time, so remain patient and follow up as necessary.
What You Should Know About This Form
What is Form SSA-3368?
Form SSA-3368 is officially known as the Disability Report - Adult. This form is used by individuals who are applying for Social Security Disability Insurance (SSDI) benefits. The purpose of this form is to provide the Social Security Administration (SSA) with detailed information about the applicant's medical conditions, work history, and limitations that prevent them from maintaining employment. Completing the form accurately helps expedite the processing of the disability claim.
How should I complete Form SSA-3368?
When filling out Form SSA-3368, it is essential to write clearly and provide complete information. This includes including your full addresses, phone numbers, and medical provider details. Answer every question as fully as possible. If you don’t know an answer, use terms like "don’t know" or "none." Additional details can be added in the remarks section at the end of the form if you feel an answer requires more explanation. It's also beneficial to gather your medical records and bring them along when attending any SSA interviews.
Who can help me complete Form SSA-3368?
If you encounter difficulties while completing the report, you can seek assistance from family or friends. It’s important not to ask your healthcare provider to fill out this form. If necessary, you may request help from a Social Security representative, who can guide you through the completion process. If you are helping someone else with the form, ensure you respond as if you were that individual.
What do I need to know about providing medical information?
Your medical information is crucial for the SSA to assess your disability claim. You do not need to obtain any medical records before submitting Form SSA-3368. With your permission, the SSA will request necessary records from healthcare providers. It's advisable to send or bring any medical records you already have when submitting the form to speed up the review process.
What does the term “disability” mean in this context?
In terms of Social Security, "disability" refers to your inability to perform any work due to medical conditions. You are considered disabled if you cannot engage in any substantial gainful activity and if your condition is expected to last at least a year or is likely to result in death. When filling out the form, be precise about when your limitations began, as this will directly impact the evaluation of your case.
What should I do after completing the SSA-3368 form?
Once you have fully completed Form SSA-3368, you should send or deliver it to your local Social Security office. You can locate the nearest office through the SSA's website or your local directory. Make sure to keep a copy of the form for your records. If you have any comments regarding the time it took to complete the form, those can be sent separately to the SSA at the address specified in the instructions.
Common mistakes
Completing the SSA-3368 form can feel overwhelming, and many people make common mistakes that can hinder their disability claims. One common error occurs when individuals fail to provide complete information about their work history. It’s crucial to accurately report when you stopped working and the reasons for stopping. Whether it’s due to your medical conditions or other factors, being clear about your work status helps the Social Security Administration (SSA) assess your case.
Another frequent mistake is not answering every question. Some may think skipping questions won't hurt their application, but answering every item is essential. If you don’t know an answer, simply indicate that by writing “don’t know” or “none.” This straightforward approach can keep your application from being flagged for missing information.
Many applicants also struggle with providing accurate details about their medical conditions. Listing all physical and mental conditions that limit your ability to work is vital, but not everyone remembers to do this. Remember, the SSA wants a clear picture of your health challenges. If you have multiple conditions, list each one separately and provide explanations where needed.
It’s easy to underestimate the importance of clear communication. Legibility matters. Whether you are printing or writing, ensure your answers are easy to read. Illegible handwriting can lead to mistakes in processing your claim. Take your time to ensure each entry is clear and complete.
Some individuals fail to bring necessary documentation when reporting to an SSA office. If you have any medical records or prescription information, be sure to include them. These documents provide essential support for your claim and can expedite the process. If you want your records returned, make that request clear when you submit them.
Lastly, misunderstandings can arise regarding the definition of "disability." It’s important to remember that the SSA’s definition revolves around whether you can do any work, not just whether you can perform your previous job. Be sure to provide thoughtful responses about your ability to work generally, rather than just your prior roles. This distinction is crucial for a successful application.
Documents used along the form
When applying for Social Security disability benefits, the SSA-3368 form, also known as the Disability Report - Adult, is a crucial document. However, several other forms and documents typically accompany this report to help verify information and support the claim. Here are five such documents that you might consider preparing alongside the SSA-3368 form.
- SSA-3373 (Function Report): This form asks claimants to provide detailed information about their daily activities and how their disabilities impact their ability to perform everyday functions. This includes sections on personal care, chores, social activities, and any limitations faced in these areas.
- Medical Records: These consist of the documentation and notes from healthcare providers that reflect the medical history and ongoing treatment related to the claimant's disability. This information is vital in proving the existence and impact of the claimed condition.
- SSA-827 (Authorization to Disclose Information to the Social Security Administration): This authorization form allows the Social Security Administration to obtain medical records and other relevant information from healthcare providers. Claimants must complete this to ensure their medical information can be shared for processing their claim.
- Work History Report (SSA-3369): This form details the claimant's work history, including jobs held in the past, the nature of the work performed, and the duration of employment. It helps the SSA assess if the claimant can perform any past work despite their disability.
- Social Security Number verification: Providing proof of a claimant's Social Security number is essential in the application process. This could be a copy of the Social Security card or a document that includes the number, like a tax return or pay stub.
Collectively, these documents assist the Social Security Administration in accurately assessing disability claims. Ensuring all materials are complete and submitted can significantly expedite the decision-making process. Preparing these documents ahead of time can lead to a smoother filing experience for everyone involved.
Similar forms
- SSDI Application (Form SSA-16): Like the SSA-3368, the SSDI application seeks detailed information about an individual's work history, medical conditions, and how these conditions impair their ability to work, forming the basis for Social Security Disability Insurance eligibility.
- SSI Application (Form SSA-8000): The Supplemental Security Income (SSI) application requires similar personal and financial information, focusing on the applicant's income and resources, alongside detail about disabilities, echoing the SSA-3368’s intent to assess disability.
- Claim for Disability Insurance Benefits (Form SSA-827): This form grants the SSA permission to obtain medical records from healthcare providers. It complements the SSA-3368 by facilitating the information-gathering process crucial for evaluating a disability claim.
- Work History Report (Form SSA-3369): This document delves into an applicant's prior job experiences and skills. It is similar to the SSA-3368 in that it assesses the impact of medical conditions on past work performance.
- Adult Disability Report (Form SSA-3367): This form collects information on impairments, health care providers, and other factors influencing an applicant’s capability to work. Its focus aligns with the inquiries made in the SSA-3368.
- Disability Determination Explanation (DDE): Though not a form completed by the applicant, this internal SSA document explains the decision on a disability claim, often referencing information provided in SSA-3368 about the applicant's limitations.
- Appeal Request Form (Form SSA-561): If a disability claim is denied, applicants may submit this form to appeal the decision. It often requires a detailed account of the applicant's disabilities and limitations, paralleling the information collected in the SSA-3368.
Dos and Don'ts
When filling out the SSA 3368 form, there are some important dos and don'ts to keep in mind. Following these guidelines can help ensure that your application is processed smoothly and accurately.
- Do answer every question. If you don't know an answer, just write "don't know," "none," or "does not apply."
- Do provide complete phone numbers and addresses, including postal codes.
- Do explain your answers when required or if you have additional information to add.
- Do include your medical records if you have them; this can facilitate the process.
- Don't leave any questions unanswered, unless specified otherwise in the report.
- Don't ask your healthcare provider to fill out the report for you.
- Don't include incomplete or unclear information; it could delay your claim.
- Don't forget to keep a copy of the completed form for your records.
Misconceptions
- Misconception 1: The SSA-3368 form is only for individuals who have been disabled for a long time.
This form is for anyone applying for disability benefits based on their inability to work, regardless of how long they have been disabled.
- Misconception 2: You must have all your medical records before completing the SSA-3368.
You do not need to have all your medical records on hand. The Social Security Administration will request records with your permission.
- Misconception 3: Completing the SSA-3368 is optional.
Filling out the SSA-3368 is a necessary step in the disability application process. Incomplete applications may delay decisions.
- Misconception 4: You cannot ask for help when completing the form.
It is acceptable to seek assistance from friends or family members. However, do not ask healthcare providers to fill out the form.
- Misconception 5: The SSA-3368 form is too complicated to complete.
The form is designed to be clear and asks straightforward questions. Take your time to complete it accurately.
- Misconception 6: You can skip questions if you do not remember the answers.
You should answer every question to the best of your ability. If you don't know an answer, write "don't know" or "none."
- Misconception 7: Your disability must be permanent to qualify.
Temporary disabilities can also qualify for benefits if they are expected to last at least a year or lead to death.
- Misconception 8: You must be completely unable to work to receive benefits.
You may still qualify if you are unable to perform any type of work suitable for you due to your condition.
Key takeaways
When filling out the SSA-3368 form, ensure that the information provided is both accurate and complete. This can significantly impact the processing speed of your disability claim.
- Seek assistance from a friend or family member if needed, but do not ask your healthcare provider to complete the form.
- Print or write clearly, making sure to include necessary details like ZIP codes and complete phone numbers.
- Answer every question, even if that means indicating uncertainty with phrases like "don't know" or "none."
- Explain any answers when additional context is required or when you wish to provide more information.
- Keep any relevant medical records ready, as they may strengthen your application.
- Identify your medical conditions clearly, including specifics such as stages of cancer, if applicable.
- After completing the form, send or bring it to your local Social Security office for processing.
This form serves an essential role in determining your eligibility for disability benefits. Pay particular attention to the sections that outline your medical conditions and work history.
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