SSA-3368: Adult Disability Report
The SSA-3368: Adult Disability Report helps DDS to obtain a complete picture of the applicant’s medical history and treatment. Complete information is essential. Be sure to include all information available to you.
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.
Completing the SSA-3368
Section 1: Information about the Disabled Person
This section asks for identifying information and contact details for the applicant.
- Mailing address: For applicants experiencing 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. It is helpful to indicate who the phone number belongs to in this question.
- This section also asks about the applicant’s ability to read, write, and understand English, and if they’ve previously used other names.
Section 2: Contacts
This section asks about 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.
- Question 2f asks about who is completing the report. It is important to answer that the SOAR representative is completing the report, so that SSA and DDS know that the applicant needed assistance in gathering details and filling out the form.
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, and if the applicant’s conditions result in pain or other symptoms. Note that symptoms of mental illness are included in this question.
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.
- For applicants who stopped working, SSA will ask if they stopped because of 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, and 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.
- If the applicant is currently working, provide information about any changes in their work activity. 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.
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.
Section 6: Job History
List the jobs (up to 5) that the applicant has had in the 15 years before they became unable to work. List the most recent job first and do not exclude jobs from the list just because earnings are minimal. If the applicant did not work at all in the 15 years before they became unable to work, check the appropriate box and go to Section 7 – Medicines.
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 “Baker’s deli” 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 15 years, answer the rest of the questions in Section 6.
- If the applicant had more than one job in the last 15 years before he or she 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 the medical provider, including:
- Contact information: mailing address, fax and phone numbers, treating physician, and patient number
- Dates of inpatient, outpatient, and emergency room treatment
- Conditions evaluated: list all mental and physical health conditions evaluated or treated by the provider
- Type of treatment received, for example, “medication management,” “physical therapy,” or “inpatient psychiatric treatment.” Do not describe medications or tests in this box.
- Tests performed at the medical provider, such as X-ray, HIV test, or vision test
- If more than five doctors or hospitals have treated the applicant, use Section 11 – Remarks and give the same detailed information for each additional healthcare provider.
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
Use this section to collect any additional information or explanation the applicant did not give in other parts of this 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 the sections of this report to enter the requested information, use this area for additional information.
- Indicate in remarks which medical records you will be submitting with the application. For example, if you have copies of all medical records for the applicant, enter in remarks: “SOAR representative will be submitting records from all treatment providers in sections 8 and 9.”
If the applicant has not seen medical sources 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 in remarks: “No treating source for back pain."
- SSA Forms
- February, 2013