How to complete an SSA 3368 (Step by Step)

To complete a SSA-3368-BK, you will need to provide the following information:

• Section 1 - Information About the Disabled Person
  • Name
  • Social security number
  • Mailing address
  • Email address
  • Daytime phone number
  • Alternative phone number
  • Whether you can speak and understand English
  • Whether you can read and understand English
  • Whether you can write more than your name in English
  • Whether you used any other names on your medical or educational records
• Section 2 - Contacts
  • Name of someone other than doctors who knows about your medical conditions
  • Relationship to you
  • Daytime phone number
  • Mailing address
  • Whether the person can speak and understand English
  • Who is completing report
    • Relationship to person applying
    • Daytime phone number
    • Mailing address
• Section 3 - Medical Conditions
  • List of all physical or mental conditions
  • Height without shoes
  • Weight without shoes
  • Whether your conditions cause your pain or other symptoms
• Section 4 - Work Activity
  • Whether you are currently working
  • Whether you believe your condition was severe enough to keep you from working
  • If you have stopped working
    • When you stopped working
    • Whether you stopped working because of your condition or another reason
    • Whether your condition cause you to make changes in your work activity.
    • Whether you have had gross earnings greater than $1,090 in any month after your condition caused you to make changes in your work activity
    • Whether you had gross earnings greater than $1,090 in any month since your condition first started bothering you
• Section 5 - Education and Training
  • Highest grade of school completed
  • Date completed
  • Whether you attended special education classes
  • Name of school, address, dates of attending classes
  • Whether you completed any specialized job training, trade, or vocational school
  • Type of training and date completed
• Section 6 - Job History
  • List of jobs that you had in the 15 years before you became unable to work
  • Job title
  • Type of business
  • Dates worked
  • Hours per day
  • Days per week
  • Rates of pay
  • Indicate if you had only one job or more than one job in the 15 years before you became unable to work
  • If one job, describe it and indicate the hours that you did tasks such as: walk, stand, sit, climb, stoop, kneel, crouch, crawl, handle large object, write, type, or handle small objects, or reach
  • Lifting and carrying duty descriptions and amount of weight carried
  • Whether you supervise other people in your job, number of people supervised, whether you hired and fired employees, whether you were a lead worker
• Section 7 - Medicines
  • Whether you are taking any medications: name, prescribing doctor, reason for medication
• Section 8 - Medical Treatment
  • Whether you are currently seeing or plan to see a healthcare professional for any physical condition or mental condition
  • Who has medical records about any of your condition(s)
    • Name of facility or office
    • Name of health care professional who treated you
    • Phone number
    • Patient ID
    • Mailing address
    • Dates of the treatment for any office, clinic or outpatient visits; emergency room visits; or overnight hospital stays
    • What medical conditions were treated or evaluated
    • Treatments received
    • Indicate dates of any tests given: EKG, treadmill, cardiac catheterization, biopsy, hearing test, speech/language, vision, breathing, EEG, HIV, blood test, X-ray, MRI/CT
• Section 9 - Other Medical Information
  • Whether anyone else has medical information about your physical and/or mental conditions
  • Nme of organization, phone number, address
  • Name of contact person
  • Claim or ID number
  • Dates of first, last, and next contacts
  • Reason for contacts
• Section 10 - Vocational Rehabilitation, Employment, or Other Support Services
  • Whether you have participated or are participating in an individual work plan under the Ticket to Work Program; 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; or any program providing vocational rehabilitation, employment services, or any other support service
  • Name of organization or school
  • Name of counselor, instructor or coach
  • Phone number
  • Mailing address
  • Date you began participating in program
  • Whether you are still participating in the program
  • Types of services you are receiving from program
• Section 11 - Remarks
  • Additional information not already provided above