Fillable 07.SSA- Forms- Package - Adult Checklist March25

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07.SSA- Forms- Package - Adult Checklist March25

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Checklist – Adult Disability Interview
You should have as much of the following information as possible ready for your
interview. Keep your appointment, even if you do not have all of the information.
We will help you get any missing information.
5
Check off the items below as you get them together for your interview.
The enclosed Worksheet
will help you collect the information
you need for your interview.
Medical Information:
Names, addresses and phone numbers of all doctors, hospitals and clinics.
Patient ID number(s)
Dates seen
Name(s) of medicine(s) you are taking
Medical records in your possession
An original or certified copy of your birth certificate. If you were born in
another country, we also need proof of U.S. citizenship or legal residency
.
If you were in the military service, the original or certified copy of your
military discharge papers (Form DD 214) for all periods of active duty.
If you worked, your W-2 Form from last year; or if you were self-employed,
your federal income tax return (IRS 1040 and Schedules C and SE).
Workers’ compensation information, including date of injury, claim number
and proof of payment amounts.
Social Security Number(s) for your spouse and minor children.
Your checking or savings account number, if you have one.
Name, address and phone number of a person we can contact if we are
unable to get in touch with you.
Kinds of jobs and dates you worked in the 15 years before you became unable
to work.
Form SSA-3381 (12-2009) Destroy prior editions
MEDICAL AND JOB WORKSHEET - ADULT
Please do not mail this worksheet to your local ofce.
Did you know that you can start the application process online?
Visit www.socialsecurity.gov/applyfordisability for more information!
Complete this worksheet to get ready for the appointment or when ling online. This worksheet
is not the application for Social Security disability benets. You should bring this worksheet to
your appointment or have it with you if your appointment is by telephone.
A. Medical Conditions
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.
CONDITIONS
1.
2.
3.
4.
5.
B. If you are not working, when did you stop working?
C. Height without shoes:_______feet_____inches Weight without shoes:_____pounds
D. Medical Sources
Please list any doctors, hospitals, clinics, therapists, or emergency rooms you have visited
because of your conditions.
OVER
NAME ADDRESS
PHONE NUMBER
(with area code)
DATE FIRST
SEEN OR
ADMISSION
DATE
DATE LAST
SEEN OR
DISCHARGE
DATE
E. Medicines
Please list any medicines you take and why you take them. If prescribed, please provide the
doctor’s name.
NAME OF MEDICINE WHY YOU TAKE IT PRESCRIBED BY
F. Medical Tests
Please list any medical tests you had or are going to have in the future.
NAME OF TEST PROVIDER WHO SENT YOU DATE(S)
G. Job History
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 rst.
JOB TITLE
(e.g., cook)
TYPE OF BUSINESS
(e.g., restaurant)
DATES WORKED
FROM
Mo/Yr
TO
Mo/Yr
HOURS
PER DAY
DAYS
PER WEEK
RATE OF PAY
Amount Frequency
Form SSA-3381 (12-2009) Destroy prior editions
We will help you get any missing information.
telephone. Do not delay ling your application, even if you do not have all of the information.
Bring this worksheet to your appointment or have it with you if your appointment is by
READ ALL OF THIS INFORMATION BEFORE
YOU BEGIN COMPLETING THIS FORM
WORK HISTORY REPORT-Form SSA-3369-BK
The information that you give us on this form will be used by the office that makes the disability
decision on your disability claim. You can help them by completing as much of the form as you
can.
Work History Report -- Form SSA-3369-BK
HOW TO COMPLETE THIS FORM
IF YOU NEED HELP
If you need help with this form, complete as much of it as you can. Then call the phone number
p
rovided on the letter sent with the form or the phone number of the person who asked you to
complete the form for help to finish it.
• Print or type.
• A reference to "you," "your," or "the Disabled Person," or "claimant" means
the person who is applying for disability benefits. If you are filling out the form for
someone else, provide information about him or her.
• ANSWER ALL OF THE QUESTIONS FOR EACH JOB YOU DESCRIBE. If you
do not know the 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
think you need to explain an answer.
• If more space is needed to answer any questions, use the "REMARKS" section on
Page 8, and show the number of the question being answered.
WHY THIS INFORMATION IS IMPORTANT
REMEMBER TO GIVE US THE NAME AND ADDRESS OF THE PERSON
COMPLETING THIS FO
R
MONPAGE8
The information we ask for on this form will help us understand how your illnesses, injuries, or
conditions might affect your ability to do work for which you are qualified. The information tells
us about the kinds of work you did, including the types of skills you needed and the physical and
mental requirements of each job. In Section 2, be sure to give us all of the different jobs you did
in the 15 years before you became unable to work because of your illnesses, injuries, or
con
d
itions. The
r
eisasepa
r
ate pa
g
eto
d
esc
r
i
b
e each
d
iffe
r
ent
j
o
b
.
Privacy Act and Paperwork Reduction Act Statements
The Social Security Administration is authorized to collect the information on this form under sections
205(a), 223(d) and 1631(e)(1) of the Social Security Act. The information on this form is needed by
Social Security to make a decision on the named claimant's claim. While giving us the information on this
form is voluntary, failure to provide all or part of the requested information could prevent an accurate or
timely decision on the named claimant's claim. Although the information you furnish is almost never used
for any purpose other than making a determination about the claimant's disability, such information may
be disclosed by the Social Security Administration as follows: (1) to enable a third party or agency to
assist Social Security in establishing rights to Social Security benefits and/or coverage; (2) to comply with
Federal Laws requiring the release of information from Social Security records (e.g., to the Government
Accountability Office and the Department of Veterans Affairs); and (3) to facilitate statistical research and
such activities necessary to assure the integrity and improvement of the Social Security programs (e.g., to
the Bureau of the Census and private concerns under contract to Social Security).
We may also use the information you give us when we match records by computer. Matching programs
compare our records with those of other Federal, State, or local government agencies. Many agencies
may use matching programs to find or prove that a person qualifies for benefits paid by the Federal
government. The law allows us to do this even if you do not agree to it. Explanations about these and
other reasons why information you provide us may be used or given out are available in Social Security
offices.
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 1 hour to read the instructions, gather the facts, and answer the questions. SEND
OR BRING THE COMPLETED FORM TO THE STATE AGENCY THAT REQUESTED IT. If
you have questions about how to complete the form, contact the State Agency that requested it. If
you need the address or phone number for your State Agency, you can get it by calling Social
Security at 1-800-772-1213 (TTY 1-800-325-0778). You may send comments on our time estimate
above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401. Send only
comments relating to our
time estimate to this address, not the completed form.
PLEASE REMOVE THIS SHEET BEFORE RETURNING
THE COMPLETED FORM.
Dates Worked
Work History Report - Form SSA-3369-BK
Form Approved
OMB No. 0960-0578
SOCIAL SECURITY ADMINISTRATION
WORK HISTORY REPORT
PAGE 1
Form
SSA-3369-BK (2-2008) ef (04-2008) Use 12-2003 and 1-2005 Editions Until Supply Is Exhausted
( ) -
B. SOCIAL SECURITY NUMBER
- -
SECTION 1 - INFORMATION ABOUT THE DISABLED PERSON
C. DAYTIME TELEPHONE NUMBER (If you have no number where you can be reached, give us a
da
y
t
i
me number where we can
l
ea
v
eamessa
g
efor
y
ou.
)
A
rea
C
ode Phone
N
u
mber
List all the jobs that you have had in the 15 years before you became unable to work because
of your illnesses, injuries, or conditions.
ToFrom
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Message NumberYour Number None
SECTION 2 - INFORMATION ABOUT YOUR WOR
K
For SSA Use Only
Do not write in this box.
Job Title Type of Business
A. Name (First, Middle Initial, Last)
Less than 10 lbs 10 lbs 20 lbs 50 lbs 100 lbs. or more Other
Stoop?
NOYES
Give us more information about Job No. 1 listed on Page 1. Estimate hours and pay, if
you need to.
PAGE 2
Hours per day
Rate of Pay
$
Days per week
JOB TITLE NO. 1
In this job, did you: Use machines, tools or equipment?
Use technical knowledge or skills?
Do any writing, complete reports, or
perform duties like this?
Per (Check One)
Describe this job. What did you do all day? (If you need more space, write in the"Remarks" section.)
In this job, how many total hours each day did you:
Lifting and Carrying (Explain what you lifted, how far you carried it, and how often you did this.)
Check the heaviest weight lifted:
Were you a lead worker?
How many people did you supervise?
Did you hire and fire employees?
What part of your time was spent supervising people?
Did you supervise other people in this job?
Check weight you frequently lifted: (By frequently, we mean from 1/3 to 2/3 of the workday.)
NOYES
NOYES
NOYES
Less than 10 lbs 10 lbs 25 lbs 50 lbs. or more Other
YES NO
YES NO
(Complete the next 3
items.
)
(Skiptothelast
question on this
page.)
Walk?
Stand?
Sit?
Climb?
Kneel?
Crouch?
Crawl?
Handle, grab or grasp big objects?
Reach?
Write, type or handle small objects?
Year
Month
Week
Day
Hour
Form SS
A
-3369-BK (2-2008) ef (04-2008)
(Bend down and forward at waist)
(Bend legs to rest on knees)
(Bend legs & back down & forward)
(Move on hands & knees)
Rate of Pay
$
Give us more information about Job No. 2 listed on Page 1. Estimate hours and pay, if
you need to.
PAGE 3
Hours per day Days per week
JOB TITLE NO. 2
In this job, did you: Use machines, tools or equipment?
Use technical knowledge or skills?
Do any writing, complete reports, or
perform duties like this?
Per (Check One)
Describe this job. What did you do all day? (If you need more space, write in the"Remarks" section.)
In this job, how many total hours each day did you:
Lifting and Carrying
(Explain what you lifted, how far you carried it, and how often you did this.)
Check the heaviest weight lifted:
Were you a lead worker?
How many people did you supervise?
Did you hire and fire employees?
What part of your time was spent supervising people?
Did you supervise other people in this job?
Check weight you frequently lifted: (By frequently, we mean from 1/3 to 2/3 of the workday.)
Week
Month
YearHour
Day
NOYES
NOYES
Less than 10 lbs 10 lbs 20 lbs 50 lbs 100 lbs. or more Other
Less than 10 lbs 10 lbs 25 lbs 50 lbs. or more Other
NOYES
YES NO
YES NO
(Complete the next 3
items.
)
(Skiptothelast
question on this
page.)
NOYES
Form SS
A
-3369-BK (2-2008) ef (04-2008)
Stoop?
Walk?
Stand?
Sit?
Climb?
Kneel?
Crouch?
Crawl?
Handle, grab or grasp big objects?
Reach?
Write, type or handle small objects?
(Bend down and forward at waist)
(Bend legs to rest on knees)
(Bend legs & back down & forward)
(Move on hands & knees)
Give us more information about Job No. 3 listed on Page 1. Estimate hours and pay, if
you need to.
PAGE 4
Hours per day
Rate of Pay
$
Days per week
JOB TITLE NO. 3
In this job, did you: Use machines, tools or equipment?
Use technical knowledge or skills?
Do any writing, complete reports, or
perform duties like this?
Describe this job. What did you do all day? (If you need more space, write in the"Remarks" section.)
In this job, how many total hours each day did you:
Lifting and Carrying
(Explain what you lifted, how far you carried it, and how often you did this.)
Check the heaviest weight lifted:
Were you a lead worker?
How many people did you supervise?
Did you hire and fire employees?
What part of your time was spent supervising people?
Did you supervise other people in this job?
Check weight you frequently lifted: (By frequently, we mean from 1/3 to 2/3 of the workday.)
Week
Month
YearHour
Day
NOYES
NOYES
NOYES
Less than 10 lbs 10 lbs 20 lbs 50 lbs 100 lbs. or more Other
Less than 10 lbs 10 lbs 25 lbs 50 lbs. or more Other
NOYES
YES NO
YES NO
P
e
r
(
C
h
e
c
k
O
n
e
)
(Complete the next 3
items.)
(Skiptothelast
question on this
page.)
Form SS
A
-3369-BK (2-2008) ef (04-2008)
Stoop?
Walk?
Stand?
Sit?
Climb?
Kneel?
Crouch?
Crawl?
Handle, grab or grasp big objects?
Reach?
Write, type or handle small objects?
(Bend down and forward at waist)
(Bend legs to rest on knees)
(Bend legs & back down & forward)
(Move on hands & knees)
Lifting and Carrying (Explain what you lifted, how far you carried it, and how often you did this.)
Give us more information about Job No. 4 listed on Page 1. Estimate hours and pay, if
you need to.
PAGE 5
Hours per day
Rate of Pay
$
Days per week
JOB TITLE NO. 4
In this job, did you: Use machines, tools or equipment?
Use technical knowledge or skills?
Do any writing, complete reports, or
perform duties like this?
Per (Check One)
Describe this job. What did you do all day? (If you need more space, write in the"Remarks" section.)
In this job, how many total hours each day did you:
Check the heaviest weight lifted:
Were you a lead worker?
How many people did you supervise?
Did you hire and fire employees?
What part of your time was spent supervising people?
Did you supervise other people in this job?
Check weight you frequently lifted: (By frequently, we mean from 1/3 to 2/3 of the workday.)
Week
Month
YearHour
Day
NOYES
NOYES
NOYES
Less than 10 lbs 10 lbs 20 lbs 50 lbs 100 lbs. or more Other
Less than 10 lbs 10 lbs 25 lbs 50 lbs. or more Other
NOYES
YES NO
YES NO
(Complete the next 3
items.
)
(Skiptothelast
question on this
page.)
Form SS
A
-3369-BK (2-2008) ef (04-2008)
Stoop?
Walk?
Stand?
Sit?
Climb?
Kneel?
Crouch?
Crawl?
Handle, grab or grasp big objects?
Reach?
Write, type or handle small objects?
(Bend down and forward at waist)
(Bend legs to rest on knees)
(Bend legs & back down & forward)
(Move on hands & knees)
Give us more information about Job No. 5 listed on Page 1. Estimate hours and pay, if
you need to.
PAGE 6
Hours per day
Rate of Pay
$
Days per week
JOB TITLE NO. 5
In this job, did you: Use machines, tools or equipment?
Use technical knowledge or skills?
Do any writing, complete reports, or
perform duties like this?
Per (Check One)
Describe this job. What did you do all day? (If you need more space, write in the"Remarks" section.)
In this job, how many total hours each day did you:
Lifting and Carrying
(Explain what you lifted, how far you carried it, and how often you did this.)
Check the heaviest weight lifted:
Were you a lead worker?
How many people did you supervise?
Did you hire and fire employees?
What part of your time was spent supervising people?
Did you supervise other people in this job?
Check weight you frequently lifted: (By frequently, we mean from 1/3 to 2/3 of the workday.)
Week
Month
YearHour
Day
NOYES
NOYES
NOYES
Less than 10 lbs 10 lbs 20 lbs 50 lbs 100 lbs. or more Other
Less than 10 lbs 10 lbs 25 lbs 50 lbs. or more Other
NOYES
YES NO
YES
NO
(Complete the next 3
items.
)
(Skiptothelast
question on this
page.)
Form SS
A
-3369-BK (2-2008) ef (04-2008)
Stoop?
Walk?
Stand?
Sit?
Climb?
Kneel?
Crouch?
Crawl?
Handle, grab or grasp big objects?
Reach?
Write, type or handle small objects?
(Bend down and forward at waist)
(Bend legs to rest on knees)
(Bend legs & back down & forward)
(Move on hands & knees)
Rate of Pay
$
PAGE 7
Give us more information about Job No. 6 listed on Page 1. Estimate hours and pay, if
you need to.
Hours per day Days per week
JOB TITLE NO. 6
In this job, did you: Use machines, tools or equipment?
Use technical knowledge or skills?
Do any writing, complete reports, or
perform duties like this?
Per (Check One)
Describe this job. What did you do all day? (If you need more space, write in the"Remarks" section.)
In this job, how many total hours each day did you:
Lifting and Carrying
(Explain what you lifted, how far you carried it, and how often you did this.)
Check the heaviest weight lifted:
Were you a lead worker?
How many people did you supervise?
Did you hire and fire employees?
What part of your time was spent supervising people?
Did you supervise other people in this job?
Check weight you frequently lifted: (By frequently, we mean from 1/3 to 2/3 of the workday.)
Week
Month
YearHour
Day
NOYES
NOYES
NOYES
Less than 10 lbs 10 lbs 20 lbs 50 lbs 100 lbs. or more Other
Less than 10 lbs 10 lbs 25 lbs 50 lbs. or more Other
NOYES
YES NO
YES NO
(Complete the next 3
items.
)
(Skiptothelast
question on this
page.)
Form SS
A
-3369-BK (2-2008) ef (04-2008)
Stoop?
Walk?
Stand?
Sit?
Climb?
Kneel?
Crouch?
Crawl?
Handle, grab or grasp big objects?
Reach?
Write, type or handle small objects?
(Bend down and forward at waist)
(Bend legs to rest on knees)
(Bend legs & back down & forward)
(Move on hands & knees)
ZIP Code
-
SECTION 3 - REMARKS
Form SS
A
-3369-BK (2-2008) ef (04-2008)
Use this section to add any information you did not have space for in other parts of the form. Show the page number of the
part you are continuing.
BE SURE TO COMPLETE THE BOTTOM OF THIS PAGE.
Date
Email address
PAGE 8
Address
City
State
(Number and Street)
(optional)
Name of person completing this form if other than the disabled
p
e
r
son
(
P
l
ease
p
r
i
nt
)
We need your written authorization to help get the information required to process your claim, and to determine your capability o
f
managing benefits. Laws and regulations require that sources of personal information have a signed authorization before
releasing it to us. Also, laws require specific authorization for the release of information about certain conditions and from
educational sources.
You can provide this authorization by signing a form SSA-827. Federal law permits sources with information about you to
release that information if you sign a single authorization to release all your information from all your possible sources. We will
make copies of it for each source. A covered entity (that is, a source of medical information about you) may not condition
treatment, payment, enrollment, or eligibility for benefits on whether you sign this authorization form. A few States, and some
individual sources of information, require that the authorization specifically name the source that you authorize to release
personal information. In those cases, we may ask you to sign one authorization for each source and we may contact you again if
we need you to sign more authorizations.
You have the right to revoke this authorization at any time, except to the extent a source of information has already relied on it to
take an action. To revoke, send a written statement to any Social Security Office. If you do, also send a copy directly to any of
your sources that you no longer wish to disclose information about you; SSA can tell you if we identified any sources you didn't
tell us about. SSA may use information disclosed prior to revocation to decide your claim.
It is SSA's policy to provide service to people with limited English proficiency in their native language or preferred mode of
communication consistent with Executive Order 13166 (August 11, 2000) and the Individuals with Disabilities Education Act.
SSA makes every reasonable effort to ensure that the information in the SSA-827 is provided to you in your native or preferred
language.
Explanation of Form SSA-827,
"Authorization to Disclose Information to the Social Security Administration (SSA)"
Fo
r
m SS
A
-827 (6-2007) ef (06-2007) Page2of2
PAPERWORK REDUCTION ACT
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 10 minutes to read the instructions, gather the facts, and answer the questions. SEND
OR BRING IN THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is 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 on our time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD
21235-6401. Send only
comments relating to our time estimate to this address, not the completed form.
All personal information collected by SSA is protected by the Privacy Act of 1974. Once medical information is disclosed to
SSA, it is no longer protected by the health information privacy provisions of 45 CFR part 164 (mandated by the Health Insurance
Portability and Accountability Act (HIPAA)). SSA retains personal information in strict adherence to the retention schedules
established and maintained in conjunction with the National Archives and Records Administration. At the end of a record's useful
life cycle, it is destroyed in accordance with the privacy provisions, as specified in 36 CFR part 1228.
SSA is authorized to collect the information on form SSA-827 by sections 205(a), 223(d)(5)(A), 1614(a)(3)(H)(i), 1631(d)(1) and
1631 (e)(1)(A) of the Social Security Act. We use the information obtained with this form to determine your eligibility, or
continuing eligibility, for benefits, and your ability to manage any benefits received. This use usually includes review of the
information by the State agency processing your case and quality control people in SSA. In some cases, your information may
also be reviewed by SSA personnel that process your appeal of a decision, or by investigators to resolve allegations of fraud or
abuse, and may be used in any related administrative, civil, or criminal proceedings.
Signing this form is voluntary, but failing to sign it, or revoking it before we receive necessary information, could prevent an
accurate or timely decision on your claim, and could result in denial or loss of benefits. Although the information we obtain with
this form is almost never used for any purpose other than those stated above, the information may be disclosed by SSA without
your consent if authorized by Federal laws such as the Privacy Act and the Social Security Act. For example, SSA may disclose
information:
SSA will not redisclose without proper prior written consent information: (1) relating to alcohol and/or drug abuse as covered in
42 CFR part 2, or (2) from educational records for a minor obtained under 34 CFR part 99 (Family Educational Rights and
Privacy Act (FERPA)), or (3) regarding mental health, developmental disability, AIDS or HIV.
We may also use the information you give us when we match records by computer. Matching programs compare our records
with those of other Federal, State, or local government agencies. Many agencies may use matching programs to find or prove that
a person qualifies for benefits paid by the Federal government. The law allows us to do this even if you do not agree to it.
Explanations about possible reasons why information you provide us may be used or given out are available upon request from
any Social Security Office.
1. To enable a third party (e.g., consulting physicians) or other government agency to assist SSA to establish rights to
Social Security benefits and/or coverage;
2. Pursuant to law authorizing the release of information from Social Security records (e.g., to the Inspector General, to
Federal or State benefit agencies or auditors, or to the Department of Veterans Affairs(VA));
3. For statistical research and audit activities necessary to ensure the integrity and improvement of the Social Security
programs (e.g., to the Bureau of the Census and private concerns under contract with SSA).
IMPORTANT INFORMATION, INCLUDING NOTICE REQUIRED BY THE PRIVACY ACT
IF needed, second witness sign here (e.g., if signed with "X" above)
The Social Security Administration and to the State agency authorized to process my case (usually called "disability
determination services"), including contract copy services, and doctors or other professionals consulted during the
process. [Also, for international claims, to the U.S. Department of State Foreign Service Post.]
IF not signed by subject of disclosure, specify basis for authority to sign
(Parent/guardian/personal representative sign
here if two signatures required by State law)
Parent of minor Other personal representative (explain)Guardian
WITNESS I know the person signing this form or am satisfied of this person's identity:
--
Phone Number (or Address)
** PLEASE READ THE ENTIRE FORM, BOTH PAGES, BEFORE SIGNING BELOW **
AUTHORIZATION TO DISCLOSE INFORMATION TO
THE SOCIAL SECURITY ADMINISTRATION
(
SSA
)
Phone Numbe
r
(
with a
r
ea code
)
Date Signed
City
State ZIP
-
Form Approved
OMB No. 0960-0623
I voluntarily authorize and request disclosure (including paper, oral, and electronic interchange):
OF WHAT
All my medical records; also education records and other information related to my ability to
perform tasks. This includes specific permission to release:
1. All records and other information regarding my treatment, hospitalization, and outpatient care for my impairment(s)
including
, and not limited to:
-- Psychological, psychiatric or other mental impairment(s) (excludes "psychotherapy notes" as defined in 45 CFR 164.501)
-- Drug abuse, alcoholism, or other substance abuse
-- Sickle cell anemia
-- Records which may indicate the presence of a communicable or venereal disease which may include, but are not limited to,
diseases such as hepatitis, syphilis, gonorrhea and the human immunodeficiency virus, also known as Acquired Immune
Deficiency Syndrome (AIDS); and tests for HIV.
-- Gene-related impairments (including genetic test results)
2. Information about how my impairment(s) affects my ability to complete tasks and activities of daily living, and affects my ability to work.
3. Copies of educational tests or evaluations, including Individualized Educational Programs, triennial assessments, psychological and
speech evaluations, and any other records that can help evaluate function; also teachers' observations and evaluations.
4. In
f
ormation created within 12 months a
f
ter the date this authorization is signed, as well as past in
f
ormation.
TO WHOM
PURPOSE
EXPIRES WHEN This authorization is good for 12 months from the date signed (below my signature).
• All medical sources (hospitals, clinics, labs,
physicians, psychologists, etc.) including
mental health, correctional, addiction
treatment, and VA health care facilities
• All educational sources (schools, teachers,
records administrators, counselors, etc.)
• Social workers/rehabilitation counselors
• Consulting examiners used by SSA
•Employers
• Others who may know about my condition
(family, neighbors, friends, public officials)
Phone Number (or Address)
This general and special authorization to disclose was developed to comply with the provisions regarding disclosure of medical, educational, and
other information under P.L. 104-191 ("HIPAA"); 45 CFR parts 160 and 164; 42 U.S. Code section 290dd-2; 42 CFR part 2; 38 U.S. Code section
7332; 38 CFR 1.475; 20 U.S. Code section 1232g ("FERPA"); 34 CFR parts 99 and 300; and State law.
Fo
r
m SS
A
-827 (6-2007) ef (06-2007) Use 2-2003 and Late
r
Editions Until Suppl
y
is Exhausted
Page1of2
SIGN
SIGN
• I authorize the use of a copy (including electronic copy) of this form for the disclosure of the information described above.
• I understand that there are some circumstances in which this information may be redisclosed to other parties (see page 2 for details).
• I may write to SSA and my sources to revoke this authorization at any time (see page 2 for details).
• SSA will give me a copy of this form if I ask; I may ask the source to allow me to inspect or get a copy of material to be disclosed.
• Iha
v
e read both
p
a
g
es o
f
this
f
orm and a
g
ree to the disclosures abo
v
e
f
rom the t
y
p
es o
f
sources listed.
Street Address
Determining my eligibility for benefits, including looking at the combined effect of any impairments
that by themselves would not meet SSA's definition of disability; and whether I can manage such benefits.
Determining whether I am
capable of managing benefits ONLY (check only if this applies)
SSN
THIS BOX TO BE COMPLETED B
Y
SS
A
/
DDS (as needed) Additional info
r
mation to identif
y
the subject (e.g., other names used), the specific source, or the material to be disclosed:
FROM WHOM
WHOSE Records to be Disclosed
NAME (First, Middle, Last)
SIGN
INDIVIDUAL
authorizing disclosure
PLE
A
SE SIGN USING BLUE OR BL
A
C
K
IN
K
ONLY
Birthday
(
mm/
d
d
/
y
y
)
F
U
C
T
I
O
R
E
P
O
R
T
-
A
D
U
L
T
-
F
o
r
m
S
S
A
-
3
3
7
3
-
B
K
READ ALL OF THIS IFORMATIO BEFORE
YOU BEGI COMPLETIG THIS FORM
IF YOU EED HELP
If you need help with this form, complete as much of it as you can and call the phone number
provided on the letter sent with the form, or contact the person who asked you to complete the
form. If you need the address or phone number for the office that provided the form, you can get it
by calling Social Security at 1-800-772-1213.
REMEMBER TO GIVE US THE AME AD ADDRESS OF THE PERSO
C
O
M
P
L
E
T
I
G
T
H
I
S
F
O
R
M
O
P
A
G
E
8
The information that you give us on this form will be used by the office that makes the disability
decision on your disability claim. You can help them by completing as much of the form as you
can.
It is important that you tell us about your activities and abilities.
HOW TO COMPLETE THIS FORM
• Print or type.
• DO OT LEAVE ASWERS BLAK. If you do not know the answer or the answer
is "none" or "does not apply," please write "don't know" or "none" or "does not apply."
• Do not ask a doctor or hospital to complete this form.
• Be sure to explain an answer if the question asks for an explanation, or if you
think you need to explain an answer.
• If more space is needed to answer any questions, use the "REMARKS" section on
Page 8, and show the number of the question being answered.
Function Report - Adult - Form SSA-3373-BK
Privacy Act and Paperwork Reduction Act Statements
PLEASE REMOVE THIS SHEET BEFORE RETURIG
THE COMPLETED FORM.
Sections 205(a), 1631(d)(1) and 1631(e)(1) of the Social Security Act, as amended, authorize us to collect this
information. The information on this form is needed by Social Security to make a decision on the named
claimant's claim. While giving us the information on this form is voluntary, failure to provide all or part of the
requested information could prevent an accurate or timely decision on the named claimant's claim. We
generally use the information you supply for the purpose of making decisions regarding claims. However, we
may use it for the administration and integrity of Social Security programs. We may also disclose information
to another person or to another agency in accordance with approved routine uses, which include but are not
limited to the following: (1) to enable a third party or agency to assist Social Security in establishing rights to
Social Security benefits and/or coverage; (2) to comply with Federal laws requiring the release of information
from Social Security records (e.g., to the Government Accountability Office and the Department of Veterans
Affairs); (3) to make determinations for eligibility in similar health and income maintenance programs at the
Federal, State, and local level; and (4) to facilitate statistical research, audit, or investigative activities
necessary to assure the integrity of Social Security programs. We may also use the information you provide in
computer matching programs. Matching programs compare our records with records kept by other Federal,
State, or local government agencies. Information from these matching programs can be used to establish or
verify a person's eligibility for Federally-funded or administered benefit programs and for repayment of
payments or delinquent debts under these programs.
Additional information regarding this form, routine uses of information, and our programs and systems, is
available on-line at www.socialsecurity.gov or at any local Social Security office.
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 61 minutes to read the instructions, gather the facts, and answer the questions. SED OR BRIG
THE COMPLETED FORM TO THE OFFICE THAT REQUESTED IT. If you do not have that
address, you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). You may send comments
on our time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401. Send only comments
relating to our time estimate to this address, not the completed form.
-
-
2.
SOCIAL SECURITY NUMBER
F
U
N
C
T
I
O
N
R
E
P
O
R
T
-
A
D
U
L
T
S
O
C
I
A
L
S
E
C
U
R
I
T
Y
A
D
M
I
N
I
S
T
R
A
T
I
O
N
Form Approved
O
M
B
N
o
.
0
9
6
0
-
0
6
8
1
Page 1
Form SSA-3373-BK (12-2009) ef (04-2010) Destroy prior editions
For SSA Use Only
Do not write in this box.
Phone Number
Your Number
Message Number
None
(
)
-
1.
NAME OF DISABLED PERSON (First, Middle Initial, Last)
SECTION A - GENERAL INFORMATION
Related SSN
Number Holder
-
-
How your illnesses, injuries, or conditions limit your activities
4
.
a
.
Where do you live? (Check one.)
A
lone
Other
With Family With Friends
(What?)
(Describe relationship.)
b. With whom do you live? (Check one.)
SECTION B - INFORMATION ABOUT YOUR ILLNESSES, INJURIES, OR CONDITIONS
5. How do your illnesses, injuries, or conditions limit your ability to work?
3. YOUR DAYTIME TELEPHONE NUMBER (If there is no telephone number where you can be reached,
please give us a daytime number where we can leave a message for you.)
Area Code
House
Shelter
A
partment
Group Home
Boarding House
Other
Nursing Home
Form SSA-3373-BK (12-2009) ef (04-2010) Destroy prior editions
12. PERSONAL CARE (Check here
Dress
if
NO PROBLEM with personal care.)
a. Explain how your illnesses, injuries, or conditions affect your ability to:
Bathe
Care for hair
Shave
Feed self
Use the toilet
Other
S
E
C
T
I
O
N
C
-
I
N
F
O
R
M
A
T
I
O
N
A
B
O
U
T
D
A
I
L
Y
A
C
T
I
V
I
T
I
E
S
6. Describe what you do from the time you wake up until going to bed.
11. Do the illnesses, injuries, or conditions affect your sleep?
If "YES," how?
10. What were you able to do before your illnesses, injuries, or conditions that you can't do now?
NoYes
If "YES," who helps, and what do they do to help?
9. Does anyone help you care for other people or animals? Yes No
8. Do you take care of pets or other animals? Yes No
If "YES," what do you do for them?
If "YES," for whom do you care, and what do you do for them?
7. Do you take care of anyone else such as a wife/husband, children, grandchildren,
parents, friend, other?
Yes No
P
a
g
e
2
a. List household chores, both indoors and outdoors, that you are able to do. (For example,
cleaning, laundry, household repairs, ironing, mowing, etc.)
If "Yes," what kind of food do you prepare? (For example, sandwiches, frozen dinners, or complete
meals with several courses.)
If "YES," what type of help or reminders are needed?
b. Do you need any special reminders to take care of personal
needs and grooming?
Yes No
13. MEALS
c. Do you need help or reminders taking medicine? Yes No
If "YES," what kind of help do you need?
Yes Noa. Do you prepare your own meals?
b. How much time does it take you, and how often do you do each of these things?
How often do you prepare food or meals? (For example, daily, weekly, monthly.)
How long does it take you?
A
ny changes in cooking habits since the illness, injuries, or conditions began?
b. If "No," explain why you cannot or do not prepare meals.
14. HOUSE AND YARD WORK
c. Do you need help or encouragement doing these things?
If "YES," what help is needed?
Yes
No
Page 3
Form SSA-3373-BK (12-2009) ef (04-2010) Destroy prior editions
Page 4
d. If you don't do house or yard work, explain why not.
15. GETTING AROUND
a. How often do you go outside?
If you don't go out at all, explain why not.
b. When going out,
how
do you travel? (Check all that apply.)
Walk Drive a car
Ride a bicycle
Ride in a car
Use public transportation
Other
(Explain)
c. When going out, can you go out alone? Yes No
If "NO," explain why you can't go out alone.
d. Do you drive? Yes No
If you don't drive, explain why not.
16. SHOPPING
a. If you do any shopping, do you shop: (Check all that apply.)
In stores
By phone By mail By computer
b. Describe what you shop for.
c. How often do you shop and how long does it take?
a. Are you able to:
17. MONEY
Pay bills
Yes NoCount change Yes No
Yes No
Use a checkbook/money orders
Handle a savings account Yes No
Explain all "NO" answers.
Form SSA-3373-BK (12-2009) ef (04-2010) Destroy prior editions
Page 5
b. Has your ability to handle money changed since the illnesses,
injuries, or conditions began?
Yes No
If "YES," explain how the ability to handle money has changed.
18. HOBBIES AND INTERESTS
a. What are your hobbies and interests? (For example, reading, watching TV, sewing, playing sports,
etc.)
b. How often and how well do you do these things?
c. Describe any changes in these activities since the illnesses, injuries, or conditions began.
19. SOCIAL ACTIVITIES
a. Do you spend time with others? (In person, on the phone, on the computer, etc.) Yes No
If "YES," describe the kinds of things you do with others.
How often do you do these things?
List the places you go on a regular basis. (For example, church, community center, sports events,
social groups, etc.)
Do you need to be reminded to go places? Yes No
How often do you go and how much do you take part?
Do you need someone to accompany you? Yes No
b.
Form SSA-3373-BK (12-2009) ef (04-2010) Destroy prior editions
d. Describe any changes in social activities since the illnesses, injuries, or conditions began.
Page 6
If "YES," explain.
c. Do you have any problems getting along with family, friends, neighbors,
or others?
Yes No
SECTION D - INFORMATION ABOUT ABILITIES
20. a. Check any of the following items that your illnesses, injuries, or conditions affect:
Lifting
Squatting
Bending
Standing
Reaching
Walking
Sitting
Kneeling
Talking
Hearing
Understanding
Following Instructions
Using Hands
Getting Along With Others
Stair Climbing
Seeing
Memory
Completing Tasks
Concentration
Please explain how your illnesses, injuries, or conditions affect each of the items you checked. (For
example, you can only lift [how many pounds], or you can only walk [how far])
b. Are you:
c. How far can you walk before needing to stop and rest?
If you have to rest, how long before you can resume walking?
d. For how long can you pay attention?
e. Do you finish what you start?
(For example, a conversation,
chores, reading, watching a movie.)
Yes No
f. How well do you follow written instructions? (For example, a recipe.)
g. How well do you follow spoken instructions?
Form SSA-3373-BK (12-2009) ef (04-2010) Destroy prior editions
Right Handed?
Left Handed?
If "YES," please give name of employer.
Page 7
h. How well do you get along with authority figures? (For example, police, bosses, landlords or
teachers.)
i. Have you ever been fired or laid off from a job because of problems getting
along with other people?
Yes No
If "YES," please explain.
j
. How well do you handle stress?
k. How well do you handle changes in routine?
l. Have you noticed any unusual behavior or fears? Yes No
If "YES," please explain.
Which of these were prescribed by a doctor?
When do you need to use these aids?
Crutches Cane
Hearing Aid
Other
Wheelchair
A
rtificial Limb
A
rtificial Voice Box
Walker Brace/Splint Glasses/Contact Lenses
(Explain)
When was it prescribed?
21. Do you use any of the following? (Check all that apply.)
Form SSA-3373-BK (12-2009) ef (04-2010) Destroy prior editions
Page 8
City
Zip Cod
e
-
Stat
e
Address (Number and Street) Email address (optional)
Name of person completing this form (Please print)
Date (month, day, year)
Form SSA-3373-BK (12-2009) ef (04-2010) Destroy prior editions
Use this section for any added information you did not show in earlier parts of this form. When you
are done with this section (or if you didn't have anything to add), be sure to complete the fields at the
bottom of this page.
SECTION E - REMARKS
22. Do you currently take any medicines for your illnesses, injuries, or conditions?
NoYes
NoYes
I
f
"
Y
E
S
,
"
d
o
a
n
y
o
f
y
o
u
r
m
e
d
i
c
i
n
e
s
c
a
u
s
e
s
i
d
e
e
f
f
e
c
t
s
?
If "YES," please explain. (Do not list all of the medicines that you take. List only the medicines that
cause side effects.)
NAME OF MEDICINE SIDE EFFECTS YOU HAVE
DISABILITY REPORT - ADULT
SSA-3368-BK
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 health care 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 health care 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.
Y
OU 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 (01-2010) ef (04-2010) (Destroy Prior Editions)
Disabilit
y
Report -
A
dult - Form SS
A
-3368-BK
FORM SSA-3368-BK (01-2010) ef (04-2010)
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.
Youwillbeconsidereddisabledifyouareunabletodoanykindofworkforwhichyouaresuitedandif
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.
The Privacy Act
Sections 205(a), 223(d), and 1631(e) (1) of the Social Security Act, as amended, authorize us to
collect this information. The information you provide will be used to make a decision on the named
claimant's claim. While giving us the information on this report is voluntary, failure to provide all or
part of the requested information could prevent an accurate or timely decision on the named
claimant's claim. We generally use the information you supply for the purpose of making decisions
regarding claims. However, we may use it for the administration and integrity of Social Security
programs. We may also disclose information to another person or to another agency in
accordance with approved routine uses, which include but are not limited to the following: (1) to
enable a third party or agency to assist Social Security in establishing rights to Social Security
benefits and/or coverage; (2) to comply with Federal Laws requiring the release of information
about Social Security records (e.g., to the Government Accountability Office and the Department
of Veterans Affairs); (3) to make determinations for eligibility in similar health and income
maintenance programs at the Federal, State, and local level; and (4) to facilitate statistical
research, audit, or investigative activities necessary to assure the integrity of Social Security
programs.
We may also use the information you provide in computer matching programs. Matching programs
compare our records with records kept by other Federal, State, or local government agencies.
Information from these matching programs can be used to establish or verify a person's eligibility
for Federally-funded or administered benefit programs and for repayment of payments or
delinquent debts under these programs.
Additional information regarding this form, routine uses of information, and our programs and
systems, is available on-line at www.socialsecurity.gov or at any local Social Security office.
The Paperwork Reduction Act
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 60 minutes to read the instructions, gather the facts, and answer the questions.
SEND OR BRING THE COMPLETED FORM TO THE OFFICE THAT REQUESTED IT. If you do
not have that address, you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778).
You may send comments on our time estimate above to
: SSA, 6401 Security Boulevard,
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
2. E. Can this person speak and understand English?
1.E. Daytime Phone Number, including area code, and the IDD and country codes if you live outside the USA
or Canada.
Numbe
r
Holde
r
DISABILITY REPORT
ADULT
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.
ForSSAUseOnly-Donotwriteinthisbox.
Related SSN
1.F. Alternate Phone Number - another number where we may reach you, if any.
2.C. Daytime Phone Number (as described in 1.E. above)
1.G. Can you speak and understand English?
If no, what language do you prefer?
If you cannot speak and understand English, we will provide an interpreter, free of charge.
1.J. Have you used any other names on your medical or educational records? Examples are maiden name,
other married name, or nickname.
If no, what lan
g
ua
g
e is preferred?
1.D. Email Address
1.H. Can you read and understand English?
1.I. CanyouwritemorethanyournameinEnglish?
Country (If not USA)
State/Province
ZIP/Postal Code
City
A
lternate phone number
Phone number
YES NO
YES NO
NOYES
If
y
es, please list them here:
SECTION 1 - INFORM
A
TION
A
BOUT THE DIS
A
BLED PERSON
SECTION 2 - CONT
A
CTS
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.
1.B. Social Security Number
2.B. Relationship to you
1.A. Name (First, Middle Initial, Last)
2.A. Name
(
First, Middle Initial, Last
)
YES
NO
FORM SSA-3368-BK (01-2010) ef (04-2010) (Destroy Prior Editions)
PAGE 1
YES NO
Check this box if you do not have a phone or a number where we can leave a message
.
City
State/Province
ZIP/Postal Code
Country (If not USA)
1.C. Mailing Address (Street or P O Box) Include apartment number or unit if applicable.
2.D. Mailing Address (Street or P O Box) Include apartment number or unit if applicable.
SOCIAL SECURITY ADMINISTRATION
Form Approved
OMB No. 0960-0579
IF YOU HAVE NEVER WORKED:
4.B. When do you believe your condition(s) became severe enough to keep you from working (even though you
have never worked
)
?
(
month/da
y
/
y
ear
)
IF YOU HAVE STOPPED WORKING:
4.C. When did you stop working? (month/day/year)
Whydidyoustopworking?
2.J. Mailing Address (Street or P O Box) Include apartment number or unit if applicable.
3.B. What is your height without shoes?
3.C. What is your weight without shoes?
2.F. Who is completing this report?
4.A. Are you currently working?
2.I. Daytime Phone Number
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.
2.G. Name (First, Middle Initial, Last) 2.H. Relationship to Person Applying
City Country (If not USA)
State/Province
ZIP/Postal Code
1.
2.
3.
4.
5.
If
y
ou need mo
r
e space,
g
o to Section 11 - Rema
r
ks on the last pa
g
e
OR
feet inches centimeters (if outside USA)
pounds kilograms (if outside USA)
OR
3.D. Do your conditions cause you pain or other symptoms?
FORM SSA-3368-BK (01-2010) ef (04-2010)
No, I have stopped working
Yes, I am currently working
No, I have never worked
Because of my condition(s).
Because of other reasons.
No (Go to Section 5 - Education and Training on page 3)
Yes When did you make changes? (month/day/year)
PAGE 2
YES NO
SECTION 2 - CONTACTS (continued)
SECTION 3 - MEDICAL CONDITIONS
SECTION 4 - WORK
A
CTI
V
IT
Y
(
Go to Section 3 - Medical Conditions
)
(
Go to Section 3 - Medical Conditions
)
Even though you stopped working for other reasons, when do you believe your
condition(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:
j
ob duties, hours, or rate of pay)
retirement, seasonal work ended, business closed)
(GotoSection5onpage3)
(Go to question 4.B. below)
(Go to question 4.C. below)
(Go to question 4.F. on page 3)
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)
Please explain why you stopped working (for example: laid off, early
When did your condition(s) first start bothering you? (month/day/year)
When did you make changes? (month/day/year)
4.E. Since the date in 4.D. above, have you had gross earnings greater than $980 in any month? Do not count
sick leave, vacation, or disability pay. (We may contact you for more information.)
4.F. Has your condition(s) caused you to make changes in your work activity? (for example: job duties or hours)
IF YOU ARE CURRENTLY WORKING:
4.G. Since your condition(s) first bothered you, have you had gross earnings greater than $980 in any month?
Do not count sick leave, vacation, or disability pay. (We may contact you for more information.)
FORM SSA-3368-BK (01-2010) ef (04-2010)
SECTION 4 - WORK ACTIVITY (continued)
2.
3.
4.
5.
5.B. Did
y
ou attend special education classes?
Colle
g
e:
5.A. Check the hi
g
hest
g
r
ade of school completed.
YES NO
City State/Province
PAGE 3
YESNO
No (Go to Section 5) Yes (Go to Section 5)
SECTION 5 - EDUCATION AND TRAINING
1.
01 23 45678 9101112GED1234ormore
Country (If not USA)
y
Name of School
Dates attended special education classes: to
Date completed:
f
r
om
5.C. Have you completed any type of specialized job training, trade, or vocational school?
YES NO
If "Yes," what type?
Date completed:
If
y
ou need to list othe
r
education o
r
t
r
ainin
g
use Section 11 - Rema
r
ks on the last pa
g
e.
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 on page 5 if you did not work at all in the 15 years before you became unable to
work.
No
Yes
Type of
Business
Job Title
From
MM
/
YY
To
MM
/
YY
Hours
Per
Day
Rate of Pay
Dates Worked
Days
Per
Week
A
mount F
r
equency
(Goto5.C.)
NO
6.G. Check weight frequently lifted: (by frequently, we mean from 1/3 to 2/3 of the workday.)
YES
(Complete items below.)
6.F. Check heaviest weight lifted:
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.I. Were you a lead worker?
6.H. Did you supervise other people in this job?
Less than 10 lbs. 10 lbs. 25 lbs. 50 lbs. or more Other
Less than 10 lbs. 10 lbs. 20 lbs. 50 lbs. 100 lbs. or more Other
Use machines, tools or equipment?
Use technical knowledge or skills?
Do any writing, complete reports, or perform any duties like this?
FORM SSA-3368-BK (01-2010) ef (04-2010)
PAGE 4
Ihadonly one job in the last 15 years before I became unable to work. Answer the questions below.
Ihadmore than one job in the last 15 years before I became unable to work. Do not answer the
questions on this page; go to Section 7 on page 5. (We may contact you for more information.)
6.C. In this job, did you:
6.B. Describe this job. What did you do all day?
(
If
y
ou need mo
r
e space, use Section 11 - Rema
r
ks on the last pa
g
e.
)
6.D. In this job, how many total hours each day did you do each of the tasks listed:
Walk
Stand
Sit
C
l
i
m
b
Stoop (Bend down & forward at waist.)
Kneel (Bendlegstorestonknees.)
Crouch (Bend legs & back down & forward.)
Crawl (Move on hands & knees.)
Handle large objects
Write, type, or handle small objects
Reach
Task Hours Task Hours Task Hours
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.
Check the box below that applies to you.
Did
y
ou hire and fire emplo
y
ees?
What part of
y
our time did
y
ou spend supervisin
g
people?
How man
y
people did
y
ou supervise?
(
if No,
g
oto6.I.
)
YES NO
YES NO
NOYES
NOYES
NOYES
7. Are you taking any medicines (prescription or non-prescription)?
NO
YES
Name of Medicine
If prescribed, give name of
doctor
Reason for medicine
FORM SSA-3368-BK (01-2010) ef (04-2010) (Destroy Prior Editions)
PAGE 5
SECTION 8 - MEDICAL TREATMENT
SECTION 7 - MEDICINES
YES NO
NOYES
If
y
ou need to list othe
r
medicines,
g
o to Section 11 - Rema
r
ks on the last pa
g
e.
Ifyouanswered"No"toboth8.A.and8.B.,goto
Section 9 - Other Medical Information on page 11.
8.A. For any physical condition(s)?
(GotoSection8-MedicalTreatment.)
(Give the information requested below. You may need to look at your medicine containers.)
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.B. For any mental condition(s) (including emotional or learning problems)?
What treatment did you receive for the above conditions?
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
(Do not describe medicines or tests in this box.)
8.C. Name of Facility or Office
Name of health care professional who treated you
Phone Number
Patient ID# (if known)
Mailing Address
ZIP/Postal Code
City Country (If not USA)
Dates of Treatment
First Visit
Last Visit
Next scheduled appointment (if any)
What medical conditions were treated or evaluated?
Tell us who may have medical records about any of your physical and/or mental condition(s) (including
emotional or learning problems) that limit your ability to work. 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.
Check the boxes below for any tests this provider performed or sent you to, or has scheduled you to take.
Please give the dates for past and future tests. If you needtolistmoretests,useSection11-Remarksonthe
last page.
Check this box if no tests by this provider or at this facility.
Treadmill (exercise test)
Hearing Test
Cardiac Catheterization
Speech/Language Test
Vision Test
Breathing Test
Kind of Test
Dates of Tests Kind of Test
Dates of Tests
EKG (heart test)
HIV Test
EEG (brain wave test)
Blood Test (not HIV)
Biopsy (list body part)
X-Ray (list body part)
MRI/CT Scan (list body part)
Other (please describe)
State/Province
A
.
B.
C.
A
. Date in
B. Date in
C. Date in
Date out
Date out
Date out
FORM SSA-3368-BK (01-2010) ef (04-2010)
PAGE 6
SECTION 8 - MEDIC
A
LTRE
A
TMENT
(
continued
)
ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROVIDER ABOVE.
If you do not have any more doctors or hospitals to describe, go to Section 9 on page 11.
What treatment did you receive for the above conditions?
8.D. Name of Facility or Office
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
(Do not describe medicines or tests in this box.)
Name of health care professional who treated you
Phone Number
Patient ID# (if known)
Mailing Address
State/Province
ZIP/Postal Code
City Country (If not USA)
Dates of Treatment
First Visit
Last Visit
Next scheduled appointment (if any)
What medical conditions were treated or evaluated?
Tell us who may have medical records about any of your physical and/or mental condition(s) (including
emotional or learning problems) that limit your ability to work. 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.
Tell us about any tests this 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 tests by this provider or at this facility.
Treadmill (exercise test)
Hearing Test
Cardiac Catheterization
Speech/Language Test
Vision Test
Breathing Test
Kind of Test Dates of Tests Kind of Test Dates of Tests
EKG (heart test)
HIV Test
EEG (brain wave test)
Blood Test (not HIV)
Biopsy (list body part) X-Ray (list body part)
MRI/CT Scan (list body part)
Other (please describe)
A
.
B.
C.
A
. Date in
B. Date in
C. Date in
Date out
Date out
Date out
FORM SSA-3368-BK (01-2010) ef (04-2010)
PAGE 7
SECTION 8 - MEDICAL TREATMENT (continued)
ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROVIDER ABOVE.
If you do not have any more doctors or hospitals to describe, go to Section 9 on page 11.
What treatment did you receive for the above conditions?
X-Ray (list body part)
Name of health care professional who treated you
8.E. Name of Facility or Office
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
(Do not describe medicines or tests in this box.)
Phone Number
Patient ID# (if known)
Mailing Address
State/Province
ZIP/Postal Code
City Country (If not USA)
Dates of Treatment
First Visit
Last Visit
Next scheduled appointment (if any)
What medical conditions were treated or evaluated?
Tell us who may have medical records about any of your physical and/or mental condition(s) (including
emotional or learning problems) that limit your ability to work. 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.
Tell us about any tests this 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 tests by this provider or at this facility.
Treadmill (exercise test)
Hearing Test
Cardiac Catheterization
Speech/Language Test
Vision Test
Breathing Test
Kind of Test
Dates of Tests
Kind of Test
Dates of Tests
EKG (heart test) EEG (brain wave test)
Blood Test (not HIV)
Biopsy (list body part)
Other (please describe)
A
.
B.
C.
A
. Date in
B. Date in
C. Date in
Date out
Date out
Date out
FORM SSA-3368-BK (01-2010) ef (04-2010)
PAGE 8
SECTION 8 - MEDICAL TREATMENT (continued)
ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROVIDER ABOVE.
If you do not have any more doctors or hospitals to describe, go to Section 9 on page 11.
HIV Test
MRI/CT Scan (list body part)
What treatment did you receive for the above conditions?
8.F. Name of Facility or Office
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
(Do not describe medicines or tests in this box.)
Name of health care professional who treated you
Phone Number
Patient ID# (if known)
Mailing Address
State/Province
ZIP/Postal Code
City Country (If not USA)
Dates of T
r
eatment
First Visit
Last Visit
Next scheduled appointment (if any)
What medical conditions were treated or evaluated?
Tell us who may have medical records about any of your physical and/or mental condition(s) (including
emotional or learning problems) that limit your ability to work. 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.
Tell us about any tests this 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 tests by this provider or at this facility.
Treadmill (exercise test)
Hearing Test
Cardiac Catheterization
Speech/Language Test
Vision Test
Breathing Test
Kind of Test Dates of Tests Kind of Test Dates of Tests
EKG (heart test)
HIV Test
EEG (brain wave test)
Blood Test (not HIV)
Biopsy (list body part)
X-Ray (list body part)
MRI/CT Scan (list body part)
Other (please describe)
A
.
B.
C.
A
. Date in
B. Date in
C. Date in
Date out
Date out
Date out
FORM SSA-3368-BK (01-2010) ef (04-2010)
PAGE 9
SECTION 8 - MEDICAL TREATMENT (continued)
ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROVIDER ABOVE.
If you do not have any more doctors or hospitals to describe, go to Section 9 on page 11.
What treatment did you receive for the above conditions?
8.G. Name of Facility or Office
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
(Do not describe medicines or tests in this box.)
Name of health care professional who treated you
Phone Number
Patient ID# (if known)
Mailing Address
State/Province
ZIP/Postal Code
City Country (If not USA)
Dates of Treatment
What medical conditions were treated or evaluated?
Tell us who may have medical records about any of your physical and/or mental condition(s) (including
emotional or learning problems) that limit your ability to work. 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.
Tell us about any tests this 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 tests by this provider or at this facility.
Treadmill (exercise test)
Hearing Test
Cardiac Catheterization
Speech/Language Test
Vision Test
Breathing Test
Kind of Test Dates of Tests
Kind of Test
Dates of Tests
EKG (heart test)
HIV Test
EEG (brain wave test)
Blood Test (not HIV)
Biopsy (list body part)
MRI/CT Scan (list body part)
Other (please describe)
A
.
B.
C.
A
. Date in
B. Date in
C. Date in
Date out
Date out
Date out
FORM SSA-3368-BK (01-2010) ef (04-2010)
PAGE 10
SECTION 8 - MEDICAL TREATMENT (continued)
ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROVIDER ABOVE.
If you have been treated by more than five doctors or hospitals, use Section 11 - Remarks on the last
page and give the same detailed information as above for each healthcare provider.
X-Ray (list body part)
First Visit
Last Visit
Next scheduled appointment (if any)
10.B. Name of Organization or School
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, atttorneys, social service agencies and welfare.)
10.A. Have you participated, or are you participating in:
An individual work plan with an employment network under the Ticket to Work Progam;
An individualized plan for employment 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
yougotowork?
Phone Number
Mailing Address
Name of Organization
Reasons for Contacts
State/Province
Claim or ID number (if any)Name of Contact Person
ZIP/Postal Code
City Country (if not USA)
Date of Next Contact (if any)Date of Last Contact
Date of Fi
r
st Contact
COMPLETE THIS SECTION ONLY IF YOU ARE ALREADY RECEIVING SSI.
SECTION 10 - VOCATIONAL REHABILITATION, EMPLOYMENT, OR OTHER SUPPORT SERVICES
NO (Go to Section 11)
YES (Complete the following information)
Name of Counselor, Instructor, or Job Coach
Phone Number
Mailing Address
City
State/Province
ZIP/Postal Code
Country (if not USA)
10.C. When did you start participating in the plan or program?
SECTION 9 - OTHER MEDICAL INFORMATION
YES
NO
FORM SSA-3368-BK (01-2010) ef (04-2010)
PAGE 11
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.
(Please complete the information below.)
(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 on the last page.)
10.D. Are you still participating in the plan or program?
YES, I am scheduled to complete the plan or program on:
NO.
NO.
10.E. List the types of services, tests, or evaluations that you received (for example: intelligence or psychological
testing, vision or hearing test, physical exam, work evaluations, or classes).
SECTION 10 - VOCATIONAL REHABILITATION, EMPLOYMENT, OR OTHER SUPPORT SERVICES
(
continued
)
NO.
NO.
YES, I am scheduled to complete the plan or program on:
I completed the plan or program on:
I stopped participating in the plan or program before completing it because:
If you need to list another plan or program use Section 11 - Remarks and give the same detailed
info
r
mation 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
PAGE 12
FORM
SSA-3368-BK (01-2010) ef (04-2010)
month, day, year
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07.SSA- Forms- Package - Adult Checklist March25

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Completed 19 July 2020

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