What is the SSA 3368 Form?

On This Page

1. What to Do if You Do Not Know the Answer to a Question
2. How to Provide More Information
3. What to Do with Your Medical Records
4. Section 1 of the SSA 3368 – Information About the Disabled Person
5. Section 2 of the SSA 3368 - Contacts
6. Section 3 of the SSA 3368 – Medical Conditions

LEGALLY REVIEWED BY

C. William Kenny

January 01, 2024

Board certified by National Board of Trial Advocacy

The Social Security Administration (SSA) provides a form, SSA-3368-BK (SSA 3368), “Disability Report Adult,” for you to use when applying for Social Security disability benefits. The SSA says that it will help them make a decision about your claim if you complete the report as accurately and completely as possible.

You should not ask your healthcare provider to complete this form for you, but you can have a member of the legal team at Berger and Green help you with your SSA 3368 form. Working with a member of our team can help you answer the questions on this form correctly to streamline the process of applying for your Social Security Disability benefits.

What to Do if You Do Not Know the Answer to a Question

You might not know how to answer a question on the form, or you might find that the form asks about something that might not apply to your situation. In these situations, you can write one of these options, whichever is the most accurate:

• Don’t know
• None
• Does not apply

How to Provide More Information

Sometimes you might want to offer an explanation for one of your answers, or you might need more space than the form provides. In those scenarios, flip to the last page. In the “Section 11 – Remarks” area, first, write the number of the question you are answering and then write the rest of your answer to that question.

What to Do with Your Medical Records

If you are mailing your form to the SSA, include a copy of your medical records that you already have in the envelope. This advice applies only to records that you already have on hand; you do not need to collect medical records from your doctors, hospitals, or other health care providers. The SSA makes the process easy for you by asking you to:

• Identify your doctors, hospitals, and other health care providers on the form;
• Provide the information the SSA needs, like addresses, for the agency to gather your records; and
• Give the SSA permission to get your medical records from those entities.

Section 1 of the SSA 3368 – Information About the Disabled Person

In the first section of the form, you will have to write your name, Social Security number, mailing address, email address, and phone numbers. If you ever used a different name on medical or educational records, you will need to write all such names where the form requests them.

The SSA will provide a free interpreter if you need one. If you do not read and understand English, identify the language you prefer for purposes of the disability application process.

Section 2 of the SSA 3368 – Contacts

In Section 2, you will need to provide information about a person the SSA can contact for information about your medical conditions. This person should not be one of your doctors but someone who knows you well.

Section 3 of the SSA 3368 – Medical Conditions

This section of the form is where you will list all of your medical conditions that limit your ability to work. You should include all relevant physical, mental, and emotional conditions as well as any learning problems. For cancer, the SSA will want to know the type and stage of the disease.

Section 4 of the SSA 3368 – Work Activity

Section 4 focuses on your current and previous employment and how your condition impacted your ability to work. You will also need to reveal information about your monthly earnings since the condition began.

Section 5 of the SSA 3368 – Education and Training

This part of the form asks for the highest level of education (0 – 12 and college) and any specialized job training, trade, or vocational school you completed. You also need to state whether you ever attended special education classes.

Section 6 of the SSA 3368 – Job History

You should identify the jobs you had in the 15 years before you became unable to work because of your physical or mental condition. This part of the form also asks about all the job skills you have and the physical demands of your previous jobs.

Section 7 of the SSA 3368 – Medicines

You need to list all the medicines you take, whether they are prescription drugs or over-the-counter formulas. If you have an appointment at your local SSA office, take all your medicine containers to the meeting.

Section 8 of the SSA 3368 – Medical Treatment

This section asks for information about all the medical treatments you have had for any physical or mental condition. You need to identify all health care providers, including doctors, hospitals, clinics, emergency rooms, and other health care facilities.

Section 9 of the SSA 3368 – Other Medical Information

You need to identify any other entity that might have medical information about your physical or mental condition. These listings can include things like workers’ compensation, vocational rehabilitation, insurance companies, prisons, attorneys, social service agencies, and welfare.

Section 10 of the SSA 3368 – Vocational Rehabilitation, Employment, or Other Support Services

You need to provide information about vocational rehabilitation, employment, or other support services.

Section 11 of the SSA 3368 – Remarks

You can write information in this section if you did not have enough space in an earlier section or you want to explain an aspect of your application in greater detail. Identify the question or section number that applies to your comment.

If your disability is so severe that it prevents you from working and you need assistance in completing your SSA 3368 form, a Social Security disability lawyer can help. Call Berger and Green at 412-661-1400 for more information.