TN 25 (03-10)

A. Introduction

The following instructions are for completing the preprinted paper Form SSA-3368 (Disability Report – Adult). The Disability Determination Services (DDS) uses the information on the 3368 to develop medical and other evidence, to establish the correct onset date. The 3368 is also used to assess the alleged disability in conjunction with nonmedical factors, such as education and work history.

B. When to obtain a Form SSA-3368

Obtain Form SSA-3368 in:

• Title II disability or blindness claims for Disability Insurance Benefits (DIB), Disabled Widow(er)’s Benefits (DWB), Childhood Disability Benefits (CDB), and Disabled Minor Child (DMC) claims.

• Title XVI disability or blindness claims for an adult, that is, an individual who is age 18 or over (unless the claimant will be denied for nonmedical reasons).

NOTE: Use all of the claimant’s own words whenever possible to record the information.

C. Completing the sections of Form SSA-3368

1. Section 1 -- Information about the Disabled Person

Enter identifying information about the claimant:

1. Name (first, middle initial, last);

2. Social Security Number;

3. Mailing address (include apartment, unit, or lot numbers, if applicable);

4. Email address (do not share Personally Identifiable Information (PII) when corresponding by email);

5. Daytime phone number;

   IMPORTANT: Check the box if the claimant does not have a phone, or cannot provide a number where we can leave a message.

6. Alternate phone number, another telephone number where the claimant can be reached;

7. Ability to speak and understand English. If the claimant is unable to speak and understand English, find out the preferred language;

8. Ability to read and understand English;

9. Ability to write more than his or her name in English; and

10. Any other names or aliases on the claimant’s medical or educational records, such as maiden name, other married name, initials (for example, T. Joseph for Thomas Joseph, or E.J. for Erwin Joseph, or nickname (for example, Becky for Rebecca, or Bob for Robert).

2. Section 2 -- Contacts

Enter the name of someone other than the claimant’s doctors, such as a friend or relative to contact who knows about the claimant’s physical or mental condition(s), and can help him or her throughout the claim process. Document the following information:

1. The name of the contact person;

2. The relationship of the contact person to the claimant;

3. The contact person’s daytime telephone number;

4. The contact person’s mailing address (include apartment, unit, or lot numbers);

5. The contact person’s preferred language if he or she does not speak and understand English. The DDS can arrange for an interpreter in the preferred language;

6. Identity of the person who is completing the report:

   • If the person completing the report is applying for disability, go to Section 3 – Medical Conditions;

   • If the person completing the report is the same person listed in 2.A., go to Section 3 – Medical Conditions;

   • If someone else is completing the report, complete the rest of Section 2;

7. The name of the person completing the form, if someone other than the claimant or the person listed in 2.A.;

8. The relationship of the person in 2.G. to the person applying for benefits;

9. The daytime telephone number of the person in 2.G.; and

10. The mailing address of the person in 2.G.

3. Section 3 -- Medical Conditions

Enter information about the claimant's condition(s) that restricts his or her ability to work.

1. List all of the physical or mental conditions (including emotional or learning problems) that limit the claimant’s ability to work. List each condition separately, using the claimant’s own words whenever possible.

   NOTE: If the claimant has CANCER, please include the type and stage.

2. Indicate the claimant’s height in feet and inches without shoes. If outside of the USA, you may obtain the height in centimeters.

3. Indicate the claimant’s weight in pounds without shoes. If outside of the USA, you may obtain the weight in kilograms.

4. Answer yes or no to the question that asks if the claimant’s conditions cause him or her pain or other symptoms.

4. Section 4 -- Work Activity

Use the claimant's allegations, and obtain the claimant's own perception of when he or she became unable to work because of his or her physical or mental condition(s). Obtain the date the condition became severe enough to prevent the claimant from working. We refer to this as the alleged onset date (AOD).

1. Find out if the claimant is currently working. If he or she answers:

   • “No, I have never worked,” go to question 4.B.; or

   • “No, I have stopped working,” go to question 4.C.; or

   • “Yes, I am currently working,” go to question 4.F.

   NOTE: If there are other non-medical factors that affect onset, address those on the SSA-3367 or Electronic Disability Collect System (EDCS) 3367 in the potential onset date (POD) block. For more detailed instructions, see DI 11005.045 and DI 81010.025.

2. IF YOU HAVE NEVER WORKED: If the claimant has never worked, obtain the month/day/year when he or she believes the condition(s) became severe enough to keep him or her from working, even though the claimant has never worked. This is the AOD for a claimant who has never worked. In EDCS, the AOD propagates from Modernized Claim System/Modernized Supplemental Security Claims System (MCS/MSSICS). Then go to Section 5.

3. IF YOU HAVE STOPPED WORKING: If the claimant has stopped working, obtain the month/day/year when he or she stopped working. Generally, this is the AOD for a claimant who has stopped working. Check the appropriate box for why the claimant stopped working:

   • Because of my condition(s), or

   • Because of other reasons. If so, enter the claimant’s explanation in the space provided to state why he or she stopped working. For example, the claimant may indicate because “the plant closed.” However, if the claimant states, “I was fired,” “quit,” or “laid off,” collect the reasons why. Even though the claimant stopped working for other reasons, obtain the month/day/year when the claimant believes his or her condition(s) became severe enough to keep him or her from working.

4. Ask whether the claimant’s condition(s) caused him or her to make changes in his or her work activity prior to the date he or she stopped working. For example, job duties, hours worked, or rate of pay. If the claimant answers:

   • “No,” go to Section 5 – Education and Training; or

   • “Yes,” collect the month/day/year the claimant made the changes in his or her work activity. Then go to 4.E.

     NOTE: The date collected in item 4.D. may or may not be the same as the dates in item 4.C.

5. Since the date in 4.D., ask if the claimant had gross earnings greater than the substantial gainful activity (SGA) amount (see DI 10501.015) in any month since he or she made changes in work activity. Consider impairment-related work expenses (IRWE) see DI 10520.001. Do not count sick leave, vacation, or disability pay. Obtain a “No” or “Yes” answer from the claimant and go to Section 5 -- Education and Training.

6. IF YOU ARE CURRENTLY WORKING: Find out whether the claimant’s condition(s) caused him or her to make changes in his or her work activity. For example, changes in job duties or hours worked. If the claimant answers:

   • “No,” collect the month/day/year when his or her condition(s) first started bothering him or her; or

   • “Yes,” collect the month/day/year when the claimant made changes.

     This is the AOD for a claimant who is currently working. In EDCS, the AOD propagates from MCS/MSSICS if the claimant alleges no changes in work activity.

     NOTE: AODs will not propagate from the mainframe for MCS Exclusion cases.

7. If the claimant had gross earnings greater than the SGA amount (see DI 10501.015) in any month since his or her condition(s) first bothered him or her, check the “Yes” box, otherwise, check the “No” box.

   NOTE: Consider impairment-related work expenses (IRWE) see DI 10520.001. Do not count sick leave, vacation, or disability pay. See DI 10505.035, Documenting Employment Cases Using the SSA-821-BK (Work Activity Report-Employee) and the SSA-823 (Report of SGA Determination-For SSA Use Only) and DI 10510.025, Documenting Self-Employment Cases Using the SSA-820-BK (Work Activity Report-Self-Employment) and the SSA-823 (Report of SGA Determination — For SSA Use Only) for more information about completing work activity reports. “

5. Section 5 -- Education and Training

1. Circle the highest grade of school completed by the claimant. For example, circle “0” if the claimant completed less than a first grade education, or circle “9” if that is the last grade completed by the claimant.

2. Enter details about any special education classes the claimant attended such as the name of the school, city, state/province, country (if not USA), and the “from/to” dates he or she attended the special education classes.

3. Ask the claimant if he or she has completed any type of specialized job training, trade, or vocational school. If the claimant answers “No,” check the “No” box and go to Section 6. If “Yes,” check the “Yes” box and collect what type of training/schooling and the date completed. List additional education or training under Section 11 – Remarks.

6. Section 6 -- Job History

For the evaluation and development of employment and documenting employment cases, see DI 10505.001 through DI 10505.035.

1. List the jobs (up to 5) that the claimant has had in the 15 years before he or she became unable to work because of the physical or mental conditions. List the most recent job first and do not exclude jobs from the list just because earnings are under SGA. Consider listing jobs other than the most recent if the claimant requests a specific job be added. For example, the claimant may have worked more than 5 jobs in the past 3 years, but had a steady job for the previous 10 years.

   If the claimant did not work at all in the 15 years before he or she became unable to work, check the box and go to Section 7 – Medicines.

   List for each job:

   • Job title: Enter the type of job performed, not the name of the employer. For example, if the claimant was a “waiter” at three different restaurants from 2005 to 2009, you only need one entry in Section 6.A if the job duties and physical and mental requirements were the same.

   • Type of business: For example, enter “restaurant.”

   • Dates worked: Enter the first day the waiter (job title) began working at a restaurant (type of business) in the “From” (month/year) area and the last day the waiter worked at a restaurant in the “To” (month/year) area.

   • Hours per day: Enter hours worked per day.

   • Days per week: Enter the number of days per week worked.

   • Rate of pay: Enter the rate of pay. For example, a cook earned “$12.00 hourly”; collect the $12.00 in the “Amount” field and hourly in the “Frequency” field.

     NOTE: The field office (FO) may use the Detail Earnings Query (DEQY) and Summary Earnings Query (SEQY) to assist in completing this section. However, do not use them as substitutes for completion of the Job History section of the SSA-3368. Do not fax queries into the EF. DDSs are not required to obtain queries as part of their process.

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

     • If the claimant had only one job in the last 15 years, answer the rest of the questions in Section 6.

     • If the claimant 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 go to Section 7. Advise the claimant that we may contact him or her for more information, such as, completing the Form SSA-3369 (Work History Report).

       NOTE: If the FO is completing the SSA-3369 along with the SSA-3368 and sending it to the DDS, line through Section 6 of the SSA-3368, annotate “See SSA-3369,” and go to Section 7.

2. If the claimant had only one job, describe in detail the basic job duties performed. If the claimant is working or has worked under sheltered conditions (see DI 10505.025D.), include the information in this section. If you need more space, use Section 11 – Remarks.

3. Answer “Yes” or “No” to the following information about the claimant's job:

   • Use machines, tools, equipment;

   • Use technical knowledge or skills;

   • Do any writing, complete reports, or perform any duties like this.

     The answers to this descriptive data may provide a clearer picture of the nature and duties of the job performed.

4. The total number of hours per day the claimant performed each of the following tasks: walk, stand, sit, climb, stoop (bend down and forward at the waist), kneel (bend legs to rest on knees), crouch (bend legs and back down and forward), crawl (move on hands and knees), handle large objects, handle small objects, write/type, and reach.

   NOTE: The hours of each task when totaled may exceed the total hours worked in a day when the claimant can only give an estimate of a typical workday.

5. Obtain an explanation from the claimant of what he or she lifted and how far he or she carried it, and how often he or she did this on the job.

6. Indicate the heaviest weight lifted by checking: less than 10 pounds, 10 pounds, 20 pounds, 50 pounds, 100 pounds or more, or by entering another weight in the space for “Other” pounds (or kilograms, if outside the USA).

7. Indicate the weight frequently lifted by checking: less than 10 pounds, 10 pounds, 25 pounds, 50 pounds or more, or by entering another weight in the space for “Other” pounds (or kilograms, if outside the USA).

   NOTE: By frequently, we mean from 1/3 to 2/3 of the workday.

8. If the claimant did not supervise other people in this job, check, “No,” and go to 6.I., otherwise fill-in numbers for the following items:

   • How many people did the claimant supervise?

   • What part of the claimant’s time was spent supervising people?

   • Did the claimant hire and fire employees?

9. A lead worker is an employee who plans and coordinates work, and guides and trains others while doing the same kind of work. Answer “Yes” or “No” if the claimant was a lead worker.

7. Section 7 -- Medicines

List all brand name or generic medicines the claimant is taking, including those prescribed by a medical source(s), and any over-the-counter medicines, to treat the physical and mental conditions that the claimant alleges prevents him or her from working. If the claimant answers “Yes,” collect the following information:

• Name of medicine;

• If prescribed, give name of doctor; and

• Reason for medicine.

If possible, collect this information from the prescription(s) or prescription bottles. If the claimant does not know this information, enter the word “don’t know” in the “Name of Medicine” block and in the “Reason for medicine” block enter why the claimant takes the medicine, for example, anxiety attacks. (If you need more space to list additional medicines, go to Section 11 – Remarks).

8. Section 8 -- Medical Treatment

Include all medical sources that have examined or treated the claimant for the alleged physical or mental conditions, even if they are not recent. Medical sources should not be limited to any specific timeframes. The DDS uses judgment in developing medical sources based on a number of factors, such as, claim type, date last insured, and prescribed period.

Prison records are sometimes a source for medical records. The history in the medical evidence may indicate the circumstances under which an impairment(s) arose or aggravated the condition(s). To locate records, follow procedures in the Prisoner Update Processing System (PUPS) GN 02607.520 and Field Offices Identifying and Documenting Prisoner Status for Title II Disability Benefits DI 10105.094.

If the claimant received treatment at a hospital or clinic by a doctor or other health care professional, or if the claimant has a future appointment scheduled:

1. For any physical condition(s)? (Check “Yes” or “No.”)

2. For any mental condition(s) including emotional and learning problems? (Check “Yes” or “No.”)

   If the claimant answers “No” to both questions 8.A. and 8.B., go to Section 9 – Other Medical Information. If the claimant answers “Yes” to 8.A. or 8.B., obtain the source information for the claimant’s medical records about his or her condition(s) that limits his or her ability to work. This also includes doctors’ offices, hospitals (including emergency room visits), clinics, and other health care facilities.

3. Collect the following medical treating source information:

   • Name of facility or office

   • Name of health care professional who treated the claimant

   • Phone number

   • Patient identification (ID) number (if known). The patient ID number is essential to request medical evidence.

   • Mailing address (complete street address), City, State/Province, ZIP/Postal Code, and Country (if not USA).

     NOTE: Use the telephone book or online directory to obtain or verify names, addresses, and telephone numbers for medical sources. Always include ZIP codes to eliminate DDS recontacts.

   • Dates of treatment (or approximate dates): Include the date of the next scheduled appointment to a doctor, hospital, or clinic. See, Special Documentation Requirements – Medical Sources of National Significance DI 11005.060.

     • Office, clinic, or outpatient visits (collect the dates of the first visit, last visit, and the next scheduled appointment, if any).

     • Emergency Room visits (list the most recent dates first).

     • Overnight hospital stays (list the most recent dates first, giving the “Date in” and “Date out” for each stay).

   Enter information in the appropriate boxes about:

   • What medical conditions were treated or evaluated?

     NOTE: If the claimant will be seeing a new medical source for the first time, also complete all of 8.C., including the scheduled appointment date and the condition to be treated or evaluated.

   • What treatment did you receive for the above conditions?

     EXAMPLE: “To get my blood pressure monitored.” (Do not describe medicines or tests in this box.)

Check the appropriate Kind of Test boxes for any tests the provider performed, to which the claimant was sent, or are scheduled for the claimant in the future. Collect the dates for past and future tests. If you need more space to list more tests, use Section 11 – Remarks.

NOTE: If no tests by this provider or at this facility, check the appropriate box provided above “Kind of Test.”

Additional medical sources may be entered in Section 8.D. through 8.G.

• If more than five doctors or hospitals have treated the claimant, use Section 11 – Remarks and give the same detailed information for each healthcare provider.

• If the claimant does not have any more doctors or hospitals to describe, go to Section 9 – Other Medical Information.

9. Section 9 -- Other Medical Information

Obtain from the claimant the name of anyone else who has medical information about the claimant’s physical or mental condition(s), including emotional and learning problems. If the claimant is scheduled to see anyone else, get this information. This may include sources such as workers’ compensation, vocational rehabilitation, insurance companies, prisons, attorneys, social service agencies, and welfare. If the claimant answers “Yes,” collect the following information:

• Name of organization

• Phone number

• Mailing address (complete street address), City, State/Province, ZIP/Postal code, and Country (if not USA)

• Name of contact person, claim or ID Number (if any), date of first contact, date of last contact, date of next contact (if any), and reasons for contacts.

  NOTE: If the claimant is unable to remember the exact dates, obtain approximate dates.

If you need to list other people or organizations, use Section 11 – Remarks.

10. Section 10 – Vocational Rehabilitation, Employment, or Other Support Services

Complete this section for Age 18 Redetermination claims. Indicate if the claimant has received services from Vocational Rehabilitation or any other organization(s) to help him or her get back to work.

1. Ask if the claimant has participated or is participating in:

   • An individual work plan with an employment network under the Ticket to Work Program;

   • An individualized plan for employment (IPE) with a vocational rehabilitation agency or any other organization;

   • A plan to achieve self support (PASS);

   • An 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 the claimant go to work.

     Check “Yes” if the claimant has participated or is participating in any of the above, and go to 10.B.

     Check “No” if the claimant has not participated, or is not participating, in any of the above, and go to Section 11.

2. If the claimant has received such services, collect the following information:

   • Name of organization or school;

   • Name of counselor, instructor, or job coach;

   • Phone number; and

   • Mailing address (complete street number and name), City, State/Province, ZIP/Postal code, and Country (if not USA).

3. Indicate the date when the claimant started participating in the plan or program.

4. Ask if the claimant is still participating in the plan or program. Check the appropriate box and fill-in the information:

   • Yes, I am scheduled to complete the plan or program on (date), or

   • No, I completed the plan or program on (date), or

   • No, I stopped participating in the plan or program before completing it because (give explanation).

5. List the types of services, tests, or evaluations that the claimant received. For example, intelligence or psychological testing, vision or hearing test, physical exam, work evaluations, or classes.

If you need to list another plan or program, use Section 11 – Remarks.

11. Section 11 – Remarks

Use this section to collect any additional information or explanation the claimant did not give in other parts of this report:

• If the claimant did not have enough space in the sections of this report to enter the requested information, use this area for additional information requested in those sections.

• Show the section(s) and item(s) of the question(s) to which the claimant is referring.

• If the claimant has not seen any of his or her medical sources for the conditions alleged in Section 3, annotate “No treating source for (alleged condition).” For example, if the claimant never sought treatment for eye floaters, enter in Remarks: “No treating source for eye floaters.”

12. Date Report Completed

Enter the date (month/day/year) the form was completed.