Effective Dates: 09/26/2023 - Present Previous | Next

TN 101 (09-23)

DI 11005.045 Completing the SSA-3367 (Disability Report – Field Office)

The field office (FO) completes the paper form SSA-3367 or the Electronic Disability Collect System (EDCS) 3367 Disability Report for initial claims, reconsiderations, hearing level claims, escalated claims, and continuing disability reviews. Complete the SSA-3367 or EDCS 3367 before transferring jurisdiction of a claim to the Disability Determination Services (DDS) or the Office of Hearing Operations (OHO).

The information on the paper form SSA-3367 or EDCS 3367 alerts the DDS or OHO to factors that could affect entitlement and guides case development. The entries provide the DDS or OHO with information about:

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current filing including the potential onset date (POD);
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work before or after the alleged onset date (AOD);
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non-blind and blind date last insured (DLI), if applicable;
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prior filings;
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presumptive disability and presumptive blindness (Title XVI only); and
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interviewer observations.

NOTE: The FO completes the paper form SSA-3367 for all EDCS exclusions. The FO must complete the paper form SSA-3367 for Expedited Reinstatements (EXRs) since EXRs are EDCS exclusions. Follow procedures for EXR Title II interviews in DI 13050.045. For additional EDCS exclusions, see DI 81010.030.

A. FO completes the SSA-3367

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Complete one entire paper form for multiple or concurrent EDCS exclusion claims.
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Complete page 1, items 1 through 6 for each additional claim.
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Complete the EDCS 3367 as detailed in DI 81010.025.

1. IDENTIFYING INFORMATION (items 1-5)

For data propagation into EDCS, see DI 81010.035. Complete the following information on the SSA-3367.

a. Item 1: Name, Social Security number, gender, date of birth

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Enter the number holder’s (NH) full name and social security number (SSN).
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Enter the claimant’s full name, gender, date of birth, and SSN, if different from the NH.

NOTE: The claimant’s information is required for auxiliary or survivor claims (for example, a disabled widow(er) beneficiary (DWB) filing on the deceased spouse’s record, or a disabled minor child (DMC) filing on a parent’s record).

b. Item 2: Claimant’s Alleged Onset Date (AOD)

Enter the AOD on the SSA-3367. The AOD is propagated from the mainframe into the EDCS 3367.

For MCS exclusion cases, enter the AOD on the EDCS MCS Exclusion Information page.

For Manually Created T16 Claims, enter the AOD in the Disability Information section of the EDCS Manually Created T16 Information page.

For claims established in the Modernized Claims System (MCS) and the Modernized Supplemental Security Income Claims System (MSSICS), the AOD propagates into EDCS and cannot be entered or changed by manual keying. To change an AOD in EDCS, make the AOD change in MCS or MSSICS first, then the revised AOD propagates into EDCS (see DI 81010.045). If the claim has been transferred to DDS, use the Update after Transfer utility (see DI 81010.095) to notify the DDS of any changes to the AOD.

The AOD is the date the claimant alleges he or she became unable to work because of his or her medical condition, regardless of whether that date appears appropriate. See DI 25501.210.

If the claimant never worked, enter the date he or she believes the condition(s) became severe enough to keep him or her from working as the AOD.

If the AOD conflicts anywhere in the file (e.g., the AOD on the application is different from the date on the SSA-3368-BK (Disability Report - Adult)):

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resolve the conflict with the claimant,
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enter the date selected by the claimant, and
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explain why the AOD conflicts and how it was resolved in the Remarks section on the SSA-3367

c. Item 3: Potential Onset Date (see DI 25501.220 Potential Onset Date (POD))(check type of claim(s) and enter potential onset date)

To complete items 3 through 6, follow detailed instructions in subsection B. Form SSA-3367 supplemental instructions for specific claim types:

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DIB and freeze claims with a non-blind DLI and an allegation of blindness, vision problems or low vision;
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Medicare for Qualified Government Employment (MQGE) claims; and
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DWB claims.

The POD alerts the DDS examiner or administrative law judge (ALJ) of work issues, insured status, and other non-medical factors that may affect the established onset date (EOD). The POD is claim specific.

NOTE: In EDCS, the Title II POD is a required field and will propagate from the prior level case to the new case (for example, from initial to recon), though the POD field will be editable.

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Before transferring jurisdiction of a claim to the DDS or OHO, the FO must enter the POD for each Title II disability claim at each level of adjudication (except at the appeals council (AC) level). This includes:
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  claims at the initial level,
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  claims at the reconsideration level,
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  claims at the hearings level, and
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  escalated claims.

NOTE: If the FO receives work activity information that affects the POD after the claim has been transferred to DDS, make a new POD determination and update the POD in EDCS.

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The POD cannot be earlier than the date the claimant meets all non-medical requirements.
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The FO does not have the capability to enter the POD on the 3367 in EDCS at the appeals council or federal court levels.
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For most Title II claims, the POD is the earliest possible date that the DDS can establish onset based on non-medical factors. The POD may be the same as, earlier, or later than the AOD. For guidance on how to consider the POD in Title II claims, see the chart in DI 25501.220C.1.b.
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Enter the POD for Title XVI supplemental security income (SSI) claims only if the POD is different from the protective filing date or the filing date. Some examples are:
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  The claimant performed SGA after the protective filing date or filing date (DI 11005.065A.3.)
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  The claimant has an SSI trust (SI 01150.121D.2.b.) and (SI 01120.203B.4.a.);
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Consider the POD separately for each disability claim type in concurrent or multiple Title II claims.
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For ALJ cases, enter the POD based on existing evidence in file. If there is undeveloped work activity, alert the ALJ to the existence of work activity which may affect the onset date, but do not initiate additional development unless requested to do so by the ALJ. See DI 12010.005 - Development of Administrative Law Judge (ALJ) Hearing Cases.

NOTE: Be aware that the POD may be in a previously adjudicated period; including a period decided by an ALJ.

If the FO sets a POD in a previously adjudicated period decided by an ALJ, the DDS does not have the authority to reopen the case but must consider whether reopening and revising a prior determination or decision is appropriate.

The DDS only has authority to reopen if the prior determination is below the ALJ hearing level, see DI 27510.005C.1.

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If the DDS determines reopening is appropriate, the DDS completes action on the subsequent claim and refers the prior and subsequent claims to the state or federal disability hearing unit (DHU) or the Office of Disability Operations (ODO) to consider reopening. See DI 27510.005C.2.
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In some situations, the DDS can establish onset within the prior period without reopening. See DI 27510.005D and DI 27510.005E.

IMPORTANT: For situations when a subsequent claim has been filed while there is a prior claim or appeal pending at the appeals council, review DI 51501.001 to determine if SSA can process the subsequent claim (for example, AC granted an exception to the subsequent disability application policy). If SSA can process the subsequent claim, follow the POD instructions in DI 12045.027C.1.e.

d. Item 4: Reason for Potential Onset Date

Check the appropriate block for the reason for the POD.

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SSI application date (Title XVI only)
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Date last insured (Title II only)
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Date first insured (Title II only)
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Controlling date (Title II only)
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Alleged onset date (AOD) (Title II only)
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Other (explain in item 5) (both Title II and Title XVI)

For EDCS, check the “Other” block if the reason for POD is “POD is the same as AOD.”

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Work before or after the AOD (check all that apply) (both Title II and Title XVI):
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  UWA;
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  SGA;
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  Not SGA;
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  SSA-823 in file

IMPORTANT: You must complete Form SSA-823 (Report of SGA Determination - For SSA Use Only) in all claims that require an SSA-820-BK (Work Activity Report - Self-Employment) or an SSA-821-BK (Work Activity Report - Employee).

For detailed information on work activity reports, see:

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DI 10510.025 Documenting Self-Employment Cases Using the SSA-820-BK (Work Activity Report-Self-Employment) and the SSA-823 (Report of SGA Determination- For SSA Use Only)
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DI 10505.035 Documenting Employment Cases Using Forms SSA-821-BK (Work Activity Report-Employee) and SSA-823 (Report of SGA Determination-For SSA Use Only)

e. Item 5: Explanation for Potential Onset Date, when applicable

If you check “Other” in Item 4, explain the reason for the POD, for example:

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The POD and the AOD are inconsistent. Resolve and explain any inconsistencies in work activity or other non-medical factors that may affect the onset date.
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The claimant’s work is clearly not SGA per DI 10505.003.
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The date first insured (DFI) is the reason for the POD. Enter the DFI.
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The POD is the same as the AOD.
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The claimant has an SSI trust.

2. Item 6: MISCELLANEOUS INFORMATION

Provide the following information:

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Enter the protective filing date on the SSA-3367. The protective filing date is propagated from the mainframe and displayed in eView Case Information (Data View) page.
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Enter the non-blind DLI for DIB and Freeze claims.
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For appeal level cases, update the non-blind DLI if additional earnings resulted in a change to the non-blind DLI.
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Enter the blind DLI if the claimant is insured for blind benefits, and alleges blindness, a visual impairment, or low vision. For documenting claims involving potential blindness, see Remarks Section, 9.f.
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Enter both the non-blind DLI and blind DLI if the claimant alleges physical impairments and a visual impairment.

NOTE: It is possible that a claimant will be insured for blindness only and therefore, not be insured for non-blind benefits.

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Enter the prescribed period and controlling date for DWB claims, see subsection B.3. For EDCS cases, review the prescribed period information on the Miscellaneous, DWB and Prior Filing Information page of the 3367, and verify that the propagated information is correct. For detailed guidance, see DI 11005.050.
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Check “yes” or “no” for a closed period of disability case.

3. Item 7: PRIOR FILING INFORMATION – Use Remarks, if additional space is needed

List ALL prior filings with a medical determination or decision and SGA denials on the SSA-3367 (or the EDCS 3367). Use the Remarks section, if you need additional space. The DDS does not need filing information for technical denials (e.g., N13, N04, N18, 090), unless there was a medical determination associated with the technical denial.

NOTE: Only one entry is needed for the prior filing information. Enter information on the last adjudication level for a claim that may have been processed through an appeal.

Indicate whether the claimant has a prior filing(s).

If there is a prior filing provide the following information:

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Type of prior claim(s);
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SSN(s) of prior claim(s);
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Date of last decision(s) (MM/DD/YYYY);
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Level of last decision(s) (initial, reconsideration, etc.);
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Outcome of last decision(s) (allowance or denial);
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Location of prior folder; and
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Prior folder requested; if “yes” include the date requested or “no.”

For instructions on prior filings, see Prior Claims Activity in DI 11005.085.

NOTE: If a prior period of disability ended in a termination due to failure to cooperate, the FO must alert the DDS.

4. Item 8: PRESUMPTIVE

Check the block(s) for any presumptive disability (PD) or presumptive blindness (PB) criteria that apply in SSI (Title XVI) claims.

For a list of impairments that FOs are authorized to make PD and PB findings, refer to DI 11055.231 Field Office (FO) Presumptive Disability (PD) and Presumptive Blindness (PB) Categories Chart.

Refer to detailed FO procedures on processing PD and PB claims in DI 11055.240.

5. Item 9: OBSERVATIONS/PERCEPTIONS

How was the interview conducted?

Observations during face-to-face and telephone interviews are very valuable to adjudicators. Record the following information:

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type of interview:
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  Teleclaim with claimant,
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  Face-to-face with claimant, or
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  No contact with claimant;
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use of an interpreter or of bilingual staff during interview;
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difficulties with any of the activities listed (check “yes,” “no,” or “not observed/perceived”);
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description of the claimant’s behavior, appearance, grooming, or degree of limitations; and
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any additional comments about your observations.

6. Item 10: FO DEVELOPMENT

Document any development initiated by the FO.

For information about FO development, see

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DI 11010.485 through DI 11010.495 for medical evidence
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DI 22501.002B. for non-medical evidence.

CAPABILITY/REMARKS

7. Item 11: If medical evidence was brought in to the FO by the claimant, check here

Indicate whether the claimant submitted medical evidence of record (MER) to the FO by checking the block.

For EDCS cases, follow the procedures in DI 81010.125 - Receiving Medical Evidence in the Field Office. FOs must either fax the additional medical evidence into the electronic folder or forward the medical evidence to the DDS under cover of the EDCS routing sheet.

8. Item 12: Is DDS capability development needed?

If capability is questionable and you cannot make a capability determination, (e.g., allegation of mental disorder(s) or noticeable abnormal behavior of the claimant),

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ask the DDS to provide a capability opinion, and
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explain in the Remarks section on the SSA-3367.

While the DDS may provide an opinion regarding the evidence of capability, the FO is responsible for the final determination of capability. For more detailed information, see

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DI 11055.215A Policy for an FO request for DDS capability development
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GN 00502.040A.3 How much consideration should I give to medical evidence?

9. Remarks Section:

Use the Remarks section to:

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add explanations, descriptions, expansion of the answers to questions, or
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record other pertinent information about the claim for the DDS.

a. Medicare for Qualified Government Employment (MQGE) claims

Enter the following information:

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When applicable, alert the DDS that a claimant filed an application with the Office of Personnel Management for an annuity based on disability, or is receiving an annuity based on disability; include the Civil Service annuity claim number, see DI 11035.010;
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When forwarding MQGE only claims to the DDS for a disability determination, annotate “MQGE claim for Medicare entitlement only”;
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If a claimant is potentially entitled to both MQGE and DIB benefits with different DFIs, DLIs, and PODs, alert the DDS to develop evidence based on multiple onset dates.

Multiple Periods of Entitlement are EDCS exclusions per DI 81010.030; follow paper processing procedures.

For MQGE policy and procedures, see:

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DI 11035.001 Medicare for Qualified Government Employment (MQGE) Claims Based on Disability
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DI 11035.005 Developing Medicare for Qualified Government Employment (MQGE) Claims Using the Electronic Disability Collect System (EDCS)
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DI 25501.365 Established Onset for Medicare Qualified Government Employment (MQGE) Claims

b. Consultative examination (CE) appointment

If the claimant expects difficulties in keeping a CE appointment, document the reason.

EXAMPLE: lack of transportation, home confinement due to disability, inability to read, no telephone to reach the claimant, or homelessness.

c. Prisoner claims

For applicable remarks to document prisoner claims, refer to:

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DI 10105.094B.2 Documenting the SSA–3367
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DI 23530.001B.1 FO actions upon receipt of referral

d. Recontacting the claimant

If re-contacting the claimant is difficult, document the reason, see DI 11005.001A.2.

EXAMPLE: Telephone contact with a homeless claimant may be difficult, or a claimant may be on an extended trip and unavailable for contact.

e. Curtailing completion of Form SSA-3368-BK (Disability Report – Adult) or SSA-3820-BK (Disability Report – Child)

If you curtail completion of the SSA-3368-BK or SSA-3820-BK, explain why per DI 11005.020.

f. Blindness claims

In blindness, visual impairment, and low vision claims:

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enter “If the claimant is found statutorily blind, the blind DFI is MM/DD/YYYY.”
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you may need to provide two DFIs and two DLIs (non-blind and blind) if the claimant alleges both a physical impairment and blindness or a visual impairment, see DI 11005.071.

g. Potential parent’s benefits claims

If the DIB claimant alleges providing half support to a parent at the time of onset, enter the following statement: “Potential Parent’s Benefits - Do not use the DIB expedient when establishing the EOD,” see DI 25501.300.

h. Fraud or Similar Fault cases

Describe any fraud or similar fault issues, see DI 11006.010.

i. Medicare Waiting Period cases

If onset is more than five years after the prior termination, enter:

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“Medicare Waiting Period Determination Needed,”
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the diagnosis code from the prior entitlement, and
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the month of prior termination.

For more information, see DI 11010.261 Field Office Applying Prior Entitlement Months to the Medicare Waiting Period.

j. COBRA cases

Annotate “COBRA case” and the date the employee must notify the health plan administrator, see DI 11080.005.

INTERVIEWER INFORMATION

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Print the interviewer’s name, area code, and phone number.
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Print the name of the person completing the form (if different from the interviewer).
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Date the form.

B. Form SSA-3367 supplemental instructions for specific claim types

Document information properly as it could affect the claimant’s entitlement to benefits for the claim types described in this section. For each of the following claim types provide the following:

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supplemental claim information regarding insured status, and
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prescribed period or controlling date, or both.

1. DIB and freeze claims with a non-blind DLI and an allegation of blindness, vision problems, or low vision

The blind DFI and blind DLI could be material to the established onset date for blindness when applicant alleges:

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blindness,
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vision problems, or
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low vision

When there are both non-blind and blind allegations, provide the non-blind DLI and the blind DLI.

a.
In item 6, Miscellaneous Information, enter:
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  the non-blind DLI in the “Non-blind date last insured (DIB/Freeze case)” field and
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  the blind DLI in the “Blind date last insured (if applicable)” field.
b.

In the Remarks section enter, “If the claimant is found statutorily blind, the blind DFI is MM/DD/YYYY.”

For EDCS cases, the non-blind or blind DLI will propagate from MCS depending on whether the stat blind indicator is set in MCS. Only one DLI will propagate into EDCS; the other DLI must be keyed in.

2. MQGE claims

There may be a second, more recent DLI for Medicare purposes when the claimant meets insured status. For MQGE claims:

a.

In item 4, Reason for Potential Onset Date, check the “Date Last Insured” block.
b.

In item 5, Explanation for Potential Onset Date, when applicable, enter “Medicare Qualified Government Employee, DLI for Medicare purposes only is XX/XX/XXXX.”
c.

In item 6, Miscellaneous Information, “Non-blind date last insured (DIB/Freeze case)” field; enter the non-blind DLI in the space provided.
d.

If a claimant is potentially entitled to both MQGE and DIB benefits with different DFIs, DLIs, and PODs, you must indicate this in the Remarks section to alert the DDS to develop evidence based on multiple onset dates. Similar remarks regarding the DFI, POD, and prescribed period may be required if the claimant is potentially entitled to both MQGE and DWB benefits.
e.

For additional instructions for MQGE claims, refer to Capability/Remarks in this section.

3. DWB claims

In item 6, Miscellaneous Information, for DWB claims enter:

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the protective filing date;
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the beginning and ending dates of the prescribed period and the controlling date per DI 11005.050C;

For EDCS cases:

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verify that the controlling date from systems is correct;
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in a Medicare-only claim filed by a mother or father beneficiary, enter “Not yet started” in the line for “End of Prescribed Period,” because the prescribed period has not yet begun; see DI 11005.050B.1.

C. References

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DI 10515.000 Evaluation of Work Activity in Title II Blindness Cases – Table of Contents
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DI 25501.380 Establishing the Established Onset Date (EOD) of Statutory Blindness in Title II Disability Insurance Benefits (DIB) Claims
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DI 27500.000 Reopenings, Adoptions and Refilings – Table of Contents
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DI 81010.150 Processing Claims Appeals of Medical Decisions in Electronic Disability Collect System (EDCS)

To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0411005045

DI 11005.045 - Completing the SSA-3367 (Disability Report – Field Office) - 09/26/2023
Batch run: 09/26/2023
Rev:09/26/2023

Program Operations Manual System (POMS)