Form SSA - 3368-BK: Medical Information for SSDI and SSI
SSA 3368-BK is the basic form which must be completed by every adult who applies for any Social Security disability insurance benefits, including SSDI, SSI, disabled spouse, ex-spouse or widow(er) benefits and disability benefits claims. It is also used for adults who are age 18 or over who became disabled prior to age 22. (For younger individuals, see SSA Form 3881 BK: http://www.ssa.gov/online/ssa-3881.pdf .) By completing the form, you automatically apply for both SSDI and SSI.
If you apply for SSDI in person, the official version of this form will be completed by the Social Security representative directly into the Social Security computers. The form is provided here so you can think about the answers, gather the requested information, and not leave anything out. You can take your work copy to the meeting. You can also ask that your copy be made a part of the file.
If you apply by telephone, you can keep the copy with you during the call.
All of the disability forms are entered electronically into Social Security's computer system. You will usually receive a copy of the actual application form (not this SSA-3368 or other forms.) Social Security will not keep paper copies of forms once they are entered into the computer. The electronic file becomes the official file for Social Security purposes. If you want a copy of any forms that are online, feel free to ask for it.
To see the form, click here.
Completing the form: In general:
- For safety, in case they get separated, write your name and Social Security Number at the top or bottom of each page - including extra sheets.
- Each address should include a ZIP code.
- Each telephone number should include an area code.
- When a question refers to "you", "your" or the "Disabled Person," it refers to the person who is applying for disability benefits.
- If you need more space to answer any question, use the "Remarks" section on page 12 or add an extra page or pages.
- If you use the "Remarks" section, include the number of the question being answered. For example, "Section 4, C: xxxxxxxxxxxx".
- If you use extra sheets, please to include on each sheet:
- Your name
- Your Social Security number.
- The form number to which it is attached (in this case: SSA-3368-BK)
- The section to which you are responding.
- Do not let the questions confuse you. Just give the answer that is correct for you.
- In general, see: Tips When Completing All Questionnaires Concerning Your Medical Condition.
- Before submitting the completed form to Social Security, it is advisable to make a photocopy for your files. See: Where To Store Important Papers And Documents.
The form SSA-3368-BK
To see the form: Click here .
Section 1: Information About The Disabled Person
The purpose of this section is to provide enough information so that an examiner can identify your medical and work records.
- 1.D. If you do not have an email address, write "None"
- 1.E. The purpose of asking for a daytime telephone number is so that an examiner can contact you if needed to clear up something that is confusing or for additional information. If you do not have a phone, please provide a name and phone number of someone who can get in touch with you quickly. (It is advisable to let that person know that he or she may be called with a message for you.)
- 1.G. If you cannot speak or understand English:
- Social Security will provide an interpreter, free of charge, when you talk with the agency about your claim.
- Social Security has booklets and letters written in languages other than English that may help.
- Social Security takes this into account when deciding whether you can do other types of work. If you cannot speak, read or write English, it may be more difficult to do some jobs.
- 1.J. Please be sure to include all names you have used, including maiden name, to help avoid examiner confusion - and delay in processing your claim.
Section 2A -- Contact
This section asks for a contact person other than yourself. This should be someone who is aware of your condition and how it it has affected you when you worked if you are no longer working or your ongoing ability to work if you are still working. It would also be helpful if that person knows about the problems you are experiencing outside of work because of your health condition(s). Examples of people who are listed most often: a relative, friend, and co-worker. (Do not list your medical doctor.)
The person you name should be informed that you are applying for Social Security Disability and that you are listing his/her name. There is a form called Daily Activities Questionnaire, Third Party that this person may be asked to complete. It would be helpful if that person reviewed the form before you submit the SSA 3368-BK form so you are both in sync.
It can save time to get a statement from that person to give to Social Security when you go for your interview. See Affidavits From Friends, Family and Co-Workers.
Do not list your current doctor in this section.
- 2.A IF you want to include additional people because they know your condition and how it affects your ability to work, feel free to include them in Section 11 or an extra page.
- 2.F. Note that if someone other than you or the contact person listed above completes the SSA 3368-BK for you, that person should complete the rest of Section 2.
Section 3 -- Medical Conditions
Social Security considers all your illnesses, injuries and conditions when deciding if you are disabled. It does not matter whether or not you received treatment for them.
- List all of your health conditions by diagnosis, all injuries, and all conditions and symptoms. Do not try to judge what does and does not affect your work. Include old ailments that may still affect you, such as a bad back. Include symptoms or impairments that you may consider to be embarrassing. For example, some people don't list an inability to control bowels or urine, yet those very symptoms could be very important to help explain why you can't work.
- While any single condition may not be disabling, the combination of conditions can qualify you for SSDI benefits by limiting your ability to work.
- The health conditions do not have to be work related conditions.
- Keep in mind that these illnesses may be mental/emotional as well as physical, including the nervous system. If you have not already considered it, think about whether you are experiencing anxiety and/or depression. Anxiety and depression are likely to accompany not being able to work because of a health condition. Even if the condition on its own is not enough to obtain a disability determination, it may be a contributing factor that together with your physical health condition(s) allows you to be considered to be "disabled" for SSDI purposes.
- Include health conditions for which you have not seen a medical professional. NOTE: If mental or nervous symptoms are included as reasons you cannot work, a therapist or other practitioner who is treating you should be listed in Section 4. Social Security tends not to give much credence to untreated depression and other mental symptoms.
- Do not exclude current health conditions because they do not seem relevant to your ability to work.
- Side effects of medications should be treated as symptoms and listed if they are a factor limiting your ability to work.
- Use your own words if you do not know the medical name.
- If you need more room to write, use Section 11 or add an extra page.
- Alcohol and drug abuse are not symptoms and cannot be used to determine if you are disabled for Social Security purposes. However, any physical or mental problems you suffer as the result of past abuse can be usable symptoms. For example, current addiction to cocaine will not be considered in determining whether you are disabled. However, cirrhosis of the liver due to past alcoholism will be considered.
- If you are not keeping a health journal, consider starting one. In addition to being helpful with Social Security, it is likely to improve your relationship with your health care provider.
- 3.B, 3.C If you do not know your height and/or weight, you can say "about". For instance: "about 150 pounds" or "about 5'6"
- 3.D For many people filing for disability, pain is a symptom that keeps them from working. Answering "yes" to this question will usually cause Social Security to send you a "Pain Questionnaire" which will give you a chance to fully explain the severity of the pain and how it has affected your ability to work. For information, see Pain Questionnaire.
Section 4 - Work Activity
- 4.B, 4.C, 4.D, 4.F -- These are important dates.
- For purposes of SSCI, disability is based on your inability to work because of your illnesses, injuries, or conditions, even if you have never worked.
- The date(s) you provide should be as close to the date you became unable work.
- The beginning date is your Onset Date. It helps determine the waiting period before benefits start. The Onset Date is also the date from which the months are counted before you become eligible for Medicare.
- The waiting period begins the first full month you are considered to be disabled. The 24 month period before Medicare starts also begins at that time. For more information, see How Is The Waiting Period Calculated concerning the waiting period for SSDI, and Medicare for the Medicare waiting period. While Social Security will use medical and employment records to actually determine the Onset Date, what you put here tells Social Security the date to look for in the records.
- If you are applying for Supplemental Security Income, your benefits begin the first month after either the date your disability began or the date you filed your application, whichever is later.
- The Onset Date may or may not be the date you stopped working. Some people continue to work even after a disability begins.
- The Onset Date is not the date when you stopped being paid by your employer which may have extended beyond when you stopped working.
- There are exceptions. For instance:
- If you had a period of disability and returned to work for a brief period such as a week or less, you can put the date you left on the earlier disability, but it needs to be explained in Section 11 -- Remarks.
- If you missed work prior to actually stopping so that your income dropped below what Social Security refers to as Substantial Gainful Activity (SGA) - the date your income fell below SGA can be the Onset Date. The SGA dollar amount changes in January of each year to reflect cost of living adjustments. For more information about SGA, see Substantial Gainful Activity.
- If you worked after your illnesses, injuries or conditions first bothered you, you may have made changes in your job such as working fewer hours, doing lighter job duties, or receiving extra help. Some examples of extra help include extra supervision, help lifting or carrying, or extra rest breaks. Explain any changes in the way you did your job because of your illnesses, injuries or conditions in Section 11- Remarks or on a separate page.
- If you stopped working because you were laid off and you became ill later, put that in. It will not hurt your claim although it will have an effect on what date Social Security decides is your Onset Date, or the date you became totally disabled.
- 4.C -- Social Security is not going to make their decision based solely on your answer here. However, it helps to state a specific problem rather than something like: "because I was too sick to work." Give a symptom that kept you from working. For example: "Diarrhea was so uncontrollable that I couldn't leave my house." Or "The pain in my hands was so severe I couldn't type or handle papers." or "I could no longer see." This is also where you would explain failed attempts to work after the date you entered in E above.
- 4.E: The amount described in this section is the dollar amount for the year's Substantial Gainful Activity. The dollar amount can change from year to year.
Section 5 -- Education History
This section gives Social Security an idea of other types of work for which you may be suited. Note that this section focuses on formal training, while Section 4 focused on the types of work you've done. Between these two sections, Social Security will get a good idea of the types of work you might be able to do. Keep in mind that to qualify for "Disability" within Social Security's definition, you must not only be unable to do the work you've done, but any work for which you're qualified.
If you were a slow learner at school: be sure to let Social Security know by writing it in this section or in Section 11 - Remarks. This could affect whether your claim is approved.
All questions must be answered honestly. Do not overstate anything.
- 5.A If you did not complete the entire school year, check the previous year that you completed.
- If your health condition affected your ability to attend school, note it in Section 11 - Remarks.
Section 6 -- Job History
While Social Security does not just use your own occupation in measuring whether or not you are disabled, it does consider the type of work you have done as well as your age. By asking for a list of the various jobs you have held in the last 15 years, Social Security can get an idea of what you may be capable of doing. The older you are when you become disabled, the less likely that Social Security will expect you to retrain for another type of work.
Information about the kind of job that you did and the skills that you needed to that job are not in Social Security's records. Their records only show who paid you and how much they paid you in a given year.
Do not skip any jobs you held during this period of time either for your current or former employers.
- If you held more than 5 jobs, list them in Section 11 or on a separate piece of paper.
- If you have had a lot of jobs and cannot recall them all, do your best. The key is for the examiner to be able to determine vocational factors, such as your skills, and physical and mental abilities and experience.
If you have only had one job in the last 15 years, complete Section 6B. If you had more than one job, skip Section 6B and move on to Section 7. Do not be surprised if Social Security contacts you for additional information about your other jobs.
- Is about the type of work you have done in the 15 years before you became unable to work, not employment positions you have held. For example, if you have been a cook at seven different restaurants, you will only fill out "Cook" once. The form does not ask for the names of employers, only the types of work you have done and for how long.
- List your most recent jobs first and work backwards.
- For each job, list the title of the job (for example, waitress, truck driver, bank teller), the type of business where you worked (fast food, laundry, bank), the dates you worked there (month and year are enough), the number of hours a day you worked, the number of days per week, and your most recent pay rate.
- The answer gives Social Security a better idea of what you did in your job. Include what you actually did on the job so Social Security will understand what your job was like. There are jobs that have the same name but have very different duties. There are also jobs that have the same duties, but have very different names.
- Social Security is looking to get a picture of what you did in a normal workday. The information needed is enough so that someone who have never done it will understand how you did your job.
- It is advisable to particularly focus on the parts of the job that are most affected by your medical condition.
- Machines, tools or equipment: This section helps provide an understanding of you did on the job. For instance, if you were a carpenter, did you only use hand tools such as hammers and saws? If you were a secretary, did you use a computer for word processing?
- Technical knowledge or skills: Knowledge and skills you needed to do our job. For example, an electrician needs to know about the basic laws of electricity, the electrical codes and how to use special tools.
- Writing and reports: An example: a bookkeeper completes accounting reports as part of his or her job duties.
- 6.D These boxes give Social Security a better idea of what you did in your job. If the list does not truly describe what you did on your job, explain it in Section 11 - Remarks.
- 6.F., 6.G
- Frequently with respect to lifting means from l/3rd to 2/3rds of your average day. If the answer doesn't seem to fit your job, explain more in Section 11- Remarks.
- If you do not know how much certain items weight, give your best estimate about how much you think they weigh. It may help to compare the item to items you can learn the weight of. For example, bags of sugar, flour and dry dog food have their weights listed on the package.
- 6.I A "lead worker" is someone who performs some kind of non-supervisory work but who may have additional responsibility for setting the pace of work, for ensuring the completion of work, or some other kind of supervisory duties as they work.
NOTE: For many people that had white collar type jobs, these questions do not seem relevant. Still, it is advisable to complete these blanks - even if you only carried two or three reams of paper to the copier every week or so, or changed the bottles in the water dispenser.
Section 7 -- Medicines
- List all your medications you take on a regular basis. In addition to prescription medications, include over-the-counter medications such as aspirin and laxatives. Also include any complementary medications, herbs such as St. John's Wort and home remedies,
- Include medicines even if they are not for the current illnesses, injuries or conditions for which you are filing a disability claim.
- For prescription medicines, you can get the name from the container. If you do not have the container, you can provide the common name or the type of medicine (such as heart medicine or arthritis medicine.
- Include dosage and frequency.
- The prescribing doctor does not have to be your current doctor. If you cannot remember the doctor's name, write "unknown" in the space.
- If the medicine was not prescribed by a doctor, you can write "over the counter" or the type of medication it may be such as "herbal" or 'home remedy"
- "Reason for medicine" is why you are taking the medicine. Examples include "to slow down my heart rate," "for high blood pressure," "to help me sleep at night," "for pain relief. " The reason is important because some medicines can be prescribed for different reasons.
Section 8 - Medical Treatment
Social Security wants the name and complete mailing address of all your treating doctors, medical practitioners, clinics and hospitals. Keep in mind that it is the records from these sources that Social Security will use to decide whether or not you're disabled so it is in your best interest to give a complete list. Make sure you give complete and accurate information including name, mailing address, ZIP code and telephone numbers. Social Security does not ask your doctors to decide if you are disabled. That will be determined by Social Security under its rules.
Start with the doctor who has the most current and complete records of your condition. If you are treated at a clinic or medical group by several doctors but all use the same medical record file, then you need only list the group but be sure to list all the doctors that you have seen.
List all other doctors who are treating you including specialists, therapists, physical therapists, acupuncturists, chiropractors, and other practitioners. Some of the records from alternative medical practitioners wouldn't be enough to prove a disability claim, but they can support the other records.
Include physicians you used to see but are no longer seeing as long as their records have information relating to any of the conditions that are causing your inability to work or contribute to that inability.
TIP: If some of your records were at a physician who is no longer in practice, consider trying to obtain those records yourself because Social Security is not likely to try all that hard. Possibly the practice was sold and you will be able to find the records with the new owner of the practice, or you may end up finding the doctor and pulling the records out of her garage.
- To get a mailing address, you can check online, your appointment card, your billing statement or call the doctor's office.
- If a doctor has more than one office, provide the address for the location where you are or were treated or where your medical records are kept.
- If you cannot remember exact dates, provide approximate dates. For example, you can write "about 2 years ago", "last year" or "6 months ago."
- Provide information at least since you became unable to work, and preferably before then. In addition to deciding whether you are disabled under the rules now, there must also be a decision about when you first became disabled.
- Consider contacting your doctors' office for the information and/or dates regarding your treatment.
- Include every treatment you have undergone whether it relates directly to your disability or not. Although all of the tests should be evidenced in the medical record, some may be buried or overlooked by Social Security personnel, so it is important that you be thorough and list them here. Use Section 11 -- Remarks for tests that aren't listed on this form.
- Note that Social Security is interested in tests that are planned for you in the future as well as tests that have been completed.
- Social Security looks to some tests to confirm the presence of a medical problem. Other kinds of tests may indicate the extent of physical limitations caused by an illness, injury or condition. For example, a breathing test can show limitations caused by a lung condition.
- If you had, or are going to have a test performed that is not listed in this section, provide the information in Section 11 - Remarks. Include the contact information of the doctor who sent you for testing.
- A quick summary of the tests:
- EKG (Heart test): The patient sits, stands or lies down while wires are placed on the skin. A machine attached to the other ends of the wires prints out wavy lines on a chart that shows the electrical activity of the heart.
- Treadmill (Exercise test): The most common of these tests conducted while the patient exercises involves a treadmill. An EKG records the patient as he or she walks on a treadmill.
- Cardiac Catherization: A heart test in which the doctor passes a thin wire into the heart through an artery - usually through a groin area.
- Biopsy: The doctor removes tissue from a part of the body to see if disease is present. (Include the name of the body part biopsied)
- Hearing test: A specialist plays different tones through earphones to test hearing loss
- Speech-Language test: Used to evaluate your ability to use speech and language to communicate with others.
- Vision test: an eye test to check your vision - usually by reading letters from a chart.
- IQ test: A series of short tasks that require either a written or spoken response to help measure your understanding of information and ability to solve problems.
- EEG: (Brain Wave Test) - Wires placed on the scalp lead to a machine that measures and records brain wave activity.
- HIV test: Tests blood for the presence of the human immunodeficiency virus (HIV)
- Blood test: Tests blood for abnormalities in a laboratory
- Breathing test: The patient exhales into a machine that measures breathing capacity of the lungs
- X-ray A machine which takes pictures of body parts. Include the name of the body part x-rayed. For more information, see X-ray.
- MRI/CT scan: different methods of imaging body parts. For more information, see: MRI, CT Scan
- If you already have copies of your medical records in your possession from your doctors, hospitals, clinics and other medical sources, it will help speed processing of your claim because they will not have to be requested. If you do not have the records, it can help to let the health care provider(s) know the request will be coming in order to speed the process when the request is received.
- If you have not received treatment, or Social Security does not get enough informatoin about your illnesses, injuries or conditions, it may ask you to have a special examination and/or test.
Section 9 -- Other Medical Information
The form asks about other places that may have medical information about you including such places as workers compensation, vocational rehabilitation, insurance companies that have paid disability compensation, prisons, attorneys, social service agencies and welfare.
If there is someone who is aware of your condition and knows that you are applying for Social Security Disability - consider adding that person's name and contact information in Section 11 - Remarks. There is a form called Daily Activities Questionnaire, Third Party that the person may be asked to complete so make sure it is someone who knows the problems you had when you worked. It would also be helpful if that person knows about the problems you're experiencing outside of work because of your health condition(s). Let that person know you are giving his or her name to Social Security. It would be helpful to get a statement from that person to give to Social Security when you go for your interview. See Affidavits From Friends, Family and Co-Workers.
Section 10 - Vocational Rehabilitation, Employment Or Other Support Services
Only complete this section is you are receiving Supplemental Security Income (SSI)
For information about the following programs, click on the link:
Section 11 - Remarks
This section provides the opportunity to provide any other important information you feel may not have been covered in the other sections of the form. Use this space (and extra sheets if needed) to provide a complete description of your disabling condition and how it affects your work and daily life.
If you need even more space, use a separate sheet of paper that includes your name and Social Security Number and the form number. Note in Section 11: "See attached sheet(s)." Make sure you label the information provided on the additional sheet by Section and Letter so a reviewer will know which question you are answering.