Form SSA-3368-BK Disability Report - Adult

What Is SSA Form 3368-BK?

Form SSA-3368-BK, Disability Report - Adult is a form used to provide information when you claim Social Security disability benefits for adults. The report - also known as the SSA Form 3368-BK - was issued by the Social Security Administration (SSA). The latest version of the document was released in October 2015. An SSA-3368-BK fillable form is available for digital filing and download below.

The SSA-3368-BK is considered one of the main documents you need to submit when applying for disability benefits. It is very extensive and requires a lot of information about yourself, your disabilities, education, job history, medicines you take, and treatment you receive. The SSA understands the word "disability" as the inability to work. The SSA will consider you a disabled person if you are unable to do any job you are fit for and if your condition will last or has lasted longer than a year.

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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.
YOU 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 (10-2015) UF (10-2015)
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.
YOU 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 (10-2015) UF (10-2015)
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.
You will be considered disabled if you are unable to do any kind of work for which you are suited and if
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.
Privacy Act Statement
Collection and Use of Personal Information
Section 205(a), 223(d), and 1631(e)(1) of the Social Security Act, as amended, authorize us to
collect this information. We will use the information you provide to make a decision on the named
claimant’s claim.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information could prevent us from making an accurate and timely decision on the named
claimant’s claim.
We rarely use the information you supply for any purpose other than to make decisions regarding
claims. 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 an 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 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 and improvement of 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 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.
A complete list of routine uses for this information is available in Systems of Records Notice entitled,
Claims Folders Systems, 60-0089. This notice, additional information regarding this form, and
information regarding our programs and systems, are available on-line at
www.socialsecurity.gov
or at
your local Social Security office.
- This information collection meets the requirements of
Paperwork Reduction Act Statement
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 90 minutes to read the instructions, gather the facts, and answer the
questions. SEND OR BRING THE COMPLETED FORM TO THE OFFICE THAT REQUESTED IT.
You can find your local Social Security office through SSA’s website at www.socialsecurity.gov.
Offices are also 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.
AFTER COMPLETING THIS REPORT, REMOVE THIS SHEET
AND KEEP IT FOR YOUR RECORDS
Form SSA-3368-BK (10-2015) UF (10-2015)
Form Approved
SOCIAL SECURITY ADMINISTRATION
OMB No. 0960-0579
For SSA Use Only- Do not write in this box.
DISABILITY REPORT
Related SSN
ADULT
Number Holder
Anyone who makes or causes to be made a false statement or representation of material fact for use in determining a
payment under the Social Security Act, or knowingly conceals or fails to disclose an event with an intent to affect an
initial or continued right to payment, commits a crime punishable under Federal law by fine, imprisonment, or both, and
may be subject to administrative sanctions.
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.
SECTION 1 - INFORMATION ABOUT THE DISABLED PERSON
1.A. Name (First, Middle Initial, Last)
1.B. Social Security Number
1.C. Mailing Address (Street or PO Box) Include apartment number or unit if applicable.
City
State/Province
ZIP/Postal Code
Country (If not USA)
1.D. Email Address
1.E. Daytime Phone Number, including area code, and the IDD and country codes if you live outside the USA
or Canada.
Phone number
Check this box if you do not have a phone or a number where we can leave a message .
1.F. Alternate Phone Number - another number where we may reach you, if any.
Alternate phone number
1.G. Can you speak and understand English?
Yes
No
If no, what language do you prefer?
If you cannot speak and understand English, we will provide an interpreter, free of charge.
No
1.H. Can you read and understand English?
Yes
Yes
No
1.I. Can you write more than your name in English?
1.J. Have you used any other names on your medical or educational records? Examples are maiden name, other
Yes
No
married name, or nickname.
If yes, please list them here:
SECTION 2 - CONTACTS
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.
2.A. Name (First, Middle Initial, Last)
2.B. Relationship to you
2.C. Daytime Phone Number (as described in 1.E. above)
2.D. Mailing Address (Street or PO Box) Include apartment number or unit if applicable.
City
State/Province
ZIP/Postal Code
Country (If not USA)
2.E. Can this person speak and understand English?
Yes
No
If no, what language is preferred?
Form SSA-3368-BK (10-2015) UF (10-2015)
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Destroy Prior Editions
SECTION 2 - CONTACTS (continued)
2.F. Who is completing this report?
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)
2.G. Name (First, Middle Initial, Last)
2.H. Relationship to Person Applying
2.I. Daytime Phone Number
2.J. Mailing Address (Street or PO Box) Include apartment number or unit if applicable.
City
State/Province
ZIP/Postal Code
Country (If not USA)
SECTION 3 - MEDICAL CONDITIONS
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.
1.
2.
3.
4.
5.
If you need more space, go to Section 11-Remarks on the last page
3.B. What is your height without shoes?
OR
feet
inches
centimeters (if outside USA)
3.C. What is your weight without shoes?
OR
pounds
kilograms (if outside USA)
3.D. Do your conditions cause you pain or other symptoms?
Yes
No
SECTION 4 - WORK ACTIVITY
4.A. Are you currently working?
No, I have never worked (Go to question 4.B. below)
No, I have stopped working (Go to question 4.C. below)
Yes, I am currently working (Go to question 4.F. on page 3)
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/day/year)
(Go to Section 5 on page 3)
IF YOU HAVE STOPPED WORKING:
4.C. When did you stop working? (month/day/year)
Why did you stop working?
Because of my condition(s).
Because of other reasons. Please explain why you stopped working (for example: laid off, early
retirement, seasonal work ended, business closed)
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: job duties, hours, or
rate of pay)
No (Go to Section 5 - Education and Training on page 3)
Yes When did you make changes? (month/day/year)
Form SSA-3368-BK (10-2015) UF (10-2015)
Page 2
SECTION 4 - WORK ACTIVITY (continued)
4.E. Since the date in 4.D. above, have you had gross earnings greater than $1,090 in any month? Do not count sick
leave, vacation, or disability pay. (We may contact you for more information.)
No (Go to Section 5)
Yes (Go to Section 5)
IF YOU ARE CURRENTLY WORKING:
4.F. Has your condition(s) caused you to make changes in your work activity? (for example: job duties or hours)
No
When did your condition(s) first start bothering you? (month/day/year)
Yes
When did you make changes? (month/day/year)
4.G. Since your condition(s) first bothered you, have you had gross earnings greater than $1,090 in any month? Do not
count sick leave, vacation, or disability pay. (We may contact you for more information.)
No
Yes
SECTION 5 - EDUCATION AND TRAINING
5.A. Check the highest grade of school completed.
College:
0
1
2
3
4
5
6
7
8
9
10
11
12
GED
1
2
3
4 or more
Date completed:
5.B. Did you attend special education classes?
Yes
No (Go to 5.C.)
Name of School
City
State/Province
Country (If not USA)
to
Dates attended special education classes:
from
5.C. Have you completed any type of specialized job training, trade, or vocational school?
Yes
No
If "Yes," what type?
Date completed:
If you need to list other education or training use Section 11 - Remarks on the last page.
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.
Hours
Days
Dates Worked
Rate of Pay
Type of
Job Title
Per
Per
Business
Day
Week
From
To
Amount
Frequency
MM/YY
MM/YY
1.
2.
3.
4.
5.
Form SSA-3368-BK (10-2015) UF (10-2015)
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Download Form SSA-3368-BK Disability Report - Adult

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Form SSA-3368-BK Instructions

Find the instructions for filling out the SSA Disability Report on the first two pages of the form. Read them attentively, detach, and keep for your reference. Although the form is very lengthy, do not leave any box unfilled, unless indicated otherwise. If you do not know the answer or the suggested answer does not apply, write, "don't know", or "does not apply". In case you feel any difficulties with the form, fill as much as you can. You can ask a Social Security representative to help you with the rest.

Do not ask your doctor or medical facility to complete this disability report. If you have your medical reports, submit them with the completed form. If your medical records are kept by your health-care provider, the SSA will request them on your behalf with your permission. The information this form contains will tell the agency where to request your records.

How to Fill out SSA-3368-BK and Receive Disability Approval?

The SSA Form 3368-BK consists of 14 pages, 12 of which are the form you need to fill out. Any mistake on the form may lead to delay or denial of your benefits.

  1. Section 1. Information about the Disabled Person. This section is self-explanatory and requires your personal information. If you cannot speak and understand English, indicate it in this section and specify the language you prefer. The SSA will provide you with a translator/interpreter at no costs to you;
  2. Section 2. Contacts. Provide information about a person who knows about your medical condition and can help you with your application. It can be anyone except for doctors that treat or have treated you;
  3. Section 3. Medical Conditions. Make sure you list every disability, illness, or other medical condition you have. A person with several medical conditions gets an approval more often even if none of these conditions qualifies separately taken;
  4. Section 4. Work Activity. Accurately describe how your medical condition affects your ability to work and the restrictions it places on you. Do not exaggerate your condition, but do not downplay it, either;
  5. Section 5. Education and Training. This part is self-explanatory;
  6. Section 6. Job History. Make sure you list all the jobs you have had over the last 15 years. Provide all the required details. If you conceal any part of the information required for this section, it may result in denial of your claim and legal troubles;
  7. Section 7. Medicines. List all the medications you take including pain relievers;
  8. Section 8. Medical Treatment. List all health care professionals you have visited, are visiting, or are going to visit and provide all the requested information as accurately, as possible. If you are not sure about any point, specify it to the appropriate health care provider;
  9. Section 9. Other Medical Information. If anyone else has information about your physical and mental condition, indicate contact information of this person;
  10. Section 10. Vocational Rehabilitation, Employment, or Other Support Services. Fill out this part only if you receive Social Security Income;
  11. Section 11. Remarks. Provide any sufficient additional information or explanations in this part;

Where Should I Mail Completed SSA-3368-BK?

Mail the completed SSA Disability Report to the specific office that requested it. Find the address of all the SSA offices on their official website. The full list of offices is also provided in your phone directory under U.S. Government Agencies. One more way to specify the address you need is to call the SSA at the phone number provided on the second page of the form.

Form SSA-3368-BK Related Publications

  1. Form SSA-3820-BK, Disability Report - Child is a form you need to complete when you request Social Security benefits on the behalf of a disabled child. This document requires a lot of details about the disabled child, including basic information and a thorough medical history;
  2. Form SSA-16, Application for Disability Insurance Benefits informs the recipient of the SSA disability benefits about the necessity to report specific changes. The list of changes you need to report and the ways to report are provided on the form;
  3. Form SSA-3441-BK, Disability Report - Appeal is a form you need to fill out if your Social Security disability claim was denied. The document is used to update the information you have provided.