SSA-3368: Adult Disability Report

Adult Disability Report

The SSA-3368: Adult Disability Report provides information about the applicant and can be completed online after completing the Online Disability Benefit Application.

SOAR recommends that case managers use the paper form as a worksheet to gather information and then transfer the information to the online application when they are ready to submit the complete application packet. If you have all the information, it should only take about 20 minutes to complete.

In this article, we’ll discuss the SSA-3368 paper form to help you prepare to use this with applicants. 

View a sample completed SSA-3368 paper form.

Completing the SSA-3368

Section 1: Information about the Applicant

This section asks for identifying information and contact details for the applicant.

• Mailing address: For applicants experiencing or at risk of homelessness, provide an address where they are comfortable receiving mail. This may be the SOAR representative’s agency address.
• Contact number: For applicants who do not have a phone, they may provide the number of a friend or local shelter where they can be contacted. They can also provide the SOAR representative’s number.
• This section also asks about the applicant’s ability to speak, read, write, and understand English, and if they’ve previously used other names.

Section 2: Contacts

This section requests contact information for someone other than the applicant’s doctors, such as a friend or relative, who knows about the applicant’s physical or mental condition(s) and can help them throughout the claim process.

• The SOAR representative’s information should be documented here.
• If the applicant has someone other than the SOAR representative helping them with the application, you can enter multiple contacts.

Section 3: Medical Conditions

List all of the physical or mental conditions (including emotional or learning problems) that limit the applicant’s ability to work. Applicants may be approved on a combination of physical and mental health conditions, so it is important to be comprehensive in this section.

• List each condition separately and use the applicant’s own words whenever possible, particularly for health concerns not associated with a formal diagnosis (i.e.: headaches, back pain, stomach aches).
• Tip: If the applicant has cancer, include the type and stage, as the applicant may qualify for a Compassionate Allowance.
• This section also asks for the applicant’s height and weight.

Section 4: Work Activity

Questions in this section are broken down into three different parts, depending on whether the applicant has never worked, stopped working, or is continuing to work. Applicants only need to answer one of these sections, depending on their situation.

• Applicants who have never worked will need to provide the date their conditions became severe enough to keep them from working.
• For applicants who have stopped working, SSA will ask for the date they stopped working and whether it was due to their conditions or other reasons.
  • If applicants stopped working due to the symptoms of their mental or physical health conditions, they would answer, “Because of my condition(s).”
  • The option “Because of other reasons” includes being laid off, seasonal work, or a business closing. If this applies, SSA will ask the applicant when they believe their conditions became severe enough to prevent them from working.
  • SSA will also ask if the applicant had changes in their work activity prior to the date they stopped working. It is important for SSA to know if an applicant needed to change job duties or hours worked based on their conditions. For example, an applicant may be able to work 10 hours per week, but his employer allows extra breaks and a flexible schedule when the applicant experiences anxiety. Information about this employer accommodation is not available to SSA in an earnings record, so it is important to provide details on the SSA-3368.
• If the applicant is currently working, provide information about any changes in their work activity, (e.g., change in job duties or hours worked based on their conditions, as noted above)

Section 5: Education and Training

Provide information in this section about the highest grade the applicant completed and details about special education or specialized training.

• If the applicant is unsure about the dates of school or training, this can be estimated.
• Information about special education can be valuable to the disability determination. School records may contain evidence about an applicant’s Individualized Education Program (IEP), IQ testing, behavioral issues at school, and childhood diagnoses.
• Specialized training can include: military training, trade and vocational schools, and Job Corps. Provide details about this training, even if the program was started but not completed.
• This section will also ask about the applicant’s preferred language and whether they can read and write in that language. 

Section 6: Job History

If the applicant did not work at all in the 5 years before becoming unable to work, check “No” and go to Section 7 - Medicines. 

Otherwise, choose "Yes" and list any jobs (up to 5) the applicant had in the 5 years before they became unable to work that lasted 30 days or more. List the most recent job first and do not exclude jobs from the list just because earnings are minimal. 

For each job listed, include:

• Job title: Enter the type of job performed, not the name of the employer. If the applicant does not remember their job title, add a generic title that describes the tasks performed. For example, enter “waiter,” “cashier,” or “manager.”
• Type of business: Enter the name or type of business. For example, enter “grocery store” or “restaurant.”
• Dates worked: Enter the first and last date of work for each job, in month/year format.
• Hours per day, days per week, and rate of pay: If the applicant does not have these details, write “unknown” and add a note in the remarks section that the applicant experienced difficulty recalling details of past employment.

Check the appropriate Job History box that applies to the claimant:

• If the applicant had only one job in the last 5 years, answer the rest of the questions in Section 6 about the tasks and physical/environmental requirements of the job, and how their medical conditions impact their ability to do this job.
• If the applicant had more than one job in the last 5 years before they became unable to work, do not answer the rest of the questions in Section 6 and go to Section 7. DDS may contact the applicant for more information about past employment, and may ask them to complete the SSA-3369: Work History Report.

Section 7: Medicines

List all brand name or generic medicines the applicant is taking to treat their physical and mental conditions, including those prescribed by a doctor and any over-the-counter medicines. Provide the name of the medicine, the prescribing physician, and the reason for the medicine, (i.e., depression, insomnia, or pain relief).

• If possible, collect this information from the prescription(s) or prescription bottles. If the applicant does not know this information, enter “don’t know” for “Name of Medicine,” and for “Reason for Medicine,” enter why the applicant takes the medicine, for example, anxiety attacks.
• If the applicant has been prescribed medication but is inconsistent in taking it due to symptoms of their illness, poor memory, or limited funds, add the medications to section 7 and provide details in the remarks section about the reasons the applicant is not consistently taking the medicine(s).
• Include information about the use of medical marijuana and the side effects of this treatment.

Section 8: Medical Treatment

Include all medical sources that have examined or treated the applicant for physical or mental conditions, even if they are not recent. Medical treatment sources can include hospitals, clinics, substance use treatment, and evaluation by other health professionals.

• Jails and prisons may also be a source of medical records. If the applicant underwent evaluations or treatment while incarcerated, you can add this information to either section 8 or 9.
• DDS needs to know as many details as possible about each medical provider, including:
  • Contact information: facility name, treating provider, phone number, and mailing address
  • First, Last (i.e., most recent), and Upcoming dates of treatment.
  • Conditions: list all mental and physical health conditions evaluated or treated by the provider
• If more than six doctors or hospitals have treated the applicant, use Section 11-Remarks and give the same detailed information for each additional healthcare provider.
• This section also asks about medical tests performed or scheduled, such as X-ray, HIV test, or vision test.
  • For each test, include provider/facility and date.

Section 9: Other Medical Information

Provide the name of anyone else who has medical information about the applicant’s physical or mental condition(s), including emotional and learning problems. This may include sources such as workers’ compensation, vocational rehabilitation, insurance companies, prisons, attorneys, and social service agencies.

Section 10: Vocational Rehabilitation, Employment, or Other Support Services

This section is only for individuals who are already receiving SSI. For example, individuals aged 18 who have been receiving SSI as children and are undergoing a redetermination to qualify for SSI as an adult. If this section applies, provide information about any vocational rehabilitation or supportive services the applicant has received.

Section 11: Remarks

Include any additional information not provided in other parts of the report.

• At the beginning of the remarks, add that this is a SOAR application.
• Document if the applicant is experiencing homelessness and if they had any difficulties completing the form.
• If the applicant did not have enough space in a section to enter all requested information, provide additional details here. Be sure to include the section and question number. 
• Indicate which medical records you will be submitting with the application. For example, if you have copies of all medical records for the applicant, enter, “SOAR representative will be submitting records from all treatment providers in sections 8 and 9.”
  • If the applicant has not received treatment for any of the conditions listed in Section 3, document “No treating source for (listed condition).” For example, if the applicant never sought treatment for back pain, enter “No treating source for back pain."

Section 12: Who is completing this report?

This question asks about who is completing the Disability Report. It is important to indicate that the SOAR representative is completing the report so that SSA and DDS know the applicant needed assistance in gathering details and filling out the form. How you answer depends on where you have included your name and contact information (e.g., 2A or 2F).