Form Ssa 3368 Bk

Form SSA-3368-BK is a disability report for adults that is used by the Social Security Administration. The purpose of the form is to help the SSA determine whether the individual completing is qualifies for disability income. It covers their daily routine, quality of living, and also provides information about the nature of the conditions that the applicant believes qualifies them to receive disability. In addition to this form, it may also be helpful to include test results and other relevant medical information as stored by a licensed doctor or facility.

What is a SSA 3368?

A Form SSA 3368-BK is known as an Adult Disability Report. This form will be used by the United States Social Security Administration. This form is a major part of any application for social security disability or SSI benefits. It is a very lengthy form that can be filled out either on paper or online. This form will demonstrate whether or not the applicant is disabled enough to receive social security benefits.
The form should include as much information as possible. This will include personal information about the applicant, their daily routine, quality of living, and the diagnosed medical conditions. To demonstrate the medical conditions, you can include test results, doctor’s notes, and other medical forms with your application. This information required may seem personal, but it is necessary in order for the Social Security Administration to process your application.

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

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