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
