Effective Dates: 06/21/2024 - Present Previous | Next

TN 11 (06-24)

DI 22515.025 Use of Form SSA-3368-BK (Disability Report – Adult)

The SSA-3368-BK (Disability Report – Adult) collects information to develop technical aspects of a disability claim that can be used to establish the correct onset date, identify unsuccessful work attempts (UWA), and determine whether work is considered substantial gainful activity (SGA).

The SSA-3368-BK also collects information to develop medical and other evidence that can be used to assess the claimant’s alleged impairments in conjunction with non-medical factors, such as education and work history information.

A. Section 4 – Work activity

This section pertains to issues around onset, whether the claimant’s work is SGA, and the potential for a UWA.

For more information about SGA, see DI 24001.010.

For more information about UWAs, see DI 11010.045.

B. Section 5 – Education, training, and literacy

This section provides information about the claimant’s education, including whether they were in special education and the reasons for special education, any type of specialized job training, what written language they use in most situations, and whether they can read or write in the language they generally use.

C. Section 6 – Work history

This section includes a list of jobs the claimant had in the five years before they became unable to work due to their medical condition(s), with basic information about the kind of work the claimant performed, the dates they worked, the hours per day and days per week they worked, and their rate of pay.

When the claimant had only one job during the relevant period, they are asked to provide a complete vocational description of that job in Sections 6.B. through 6.D., as discussed in DI 11005.023C.6. Additional job history development may be necessary, particularly when the information is incomplete or the claimant indicated they had more than one job during the relevant five-year period. Be alert for job information located elsewhere in the file or in a prior folder and clarify any inconsistent information.

For more information about the relevant work period, see DI 25001.001A.65.

For more information about prior folders, see DI 20505.010.

D. Considering evidence for the medical-vocational profiles

Gather details specific to the medical-vocational profiles early in the development process, when applicable. For information on medical-vocational profiles, see DI 25010.001.

Be alert for information showing the claimant might have:

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    35 years or more of arduous unskilled work with no more than a marginal education (grade 6 or less) and a severe MDI(s) that prevents them from performing their past relevant work (PRW). In this situation, the claimant may meet the arduous unskilled work profile;

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    No past relevant work experience, age of 55 or older, no more than a limited education (grade 11 or less), and a severe MDI(s). In this situation, the claimant may meet the no work profile; or

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    30 years or more in one job or field of work that is unskilled, or that is skilled or semi-skilled but provided no transferable skills, age of 60 or older, no more than a limited education (grade 11 or less), and a severe MDI(s) that prevents them from performing their PRW. In this situation, the claimant may meet the lifetime commitment profile. For more information about transferable skills policy, see DI 25015.017.

If the claimant appears to meet the arduous work or lifetime commitment profile, adjudicators must document their work history beyond the relevant five-year period.

E. Information we need to know about the claimant’s work history

1. When the claimant had only one job

When the claimant had only one job in the five years before they became unable to work due to their medical condition(s), we need the following information about this job:

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    Job title,

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    Type of business,

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    Dates worked (month and year),

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    Hours worked per day and per week,

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    Rate of pay (i.e., amount and frequency),

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    Details about the tasks performed in a typical workday,

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    Details about writing or completing reports,

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    Details about supervising others,

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    Tools, machinery, and equipment used regularly,

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    Details about interactions with coworkers, the general public, or anyone else,

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    Physical and environmental demands of the job, and

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    How their medical condition would affect their ability to do this job.

2. When the claimant has a medical condition(s) causing mental limitations

Additional job information may be needed when the claimant has a medical condition(s) causing mental limitations. Based on the case facts, consider whether additional vocational development is needed to assess the mental demands of a claimant’s past work, such as:

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    Production requirements,

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    Quality requirements,

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    Complexity of tasks,

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    Use of independent judgment, and

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    Need to work with, or in close proximity to, other people.

3. When vocational information is inconsistent and material to the determination

DDS must resolve any inconsistent vocational information reported in the SSA-3368-BK when the information about that particular job is material to the determination and it is not possible to make a reasonable presumption about the inconsistency.

EXAMPLE: In a typical workday, the claimant reports they collected trash from individual offices which they emptied into a large dumpster at the end of the day. However, the claimant did not indicate that lifting or carrying was a part of their job duties, nor did they select the heaviest weight they lifted or the weight they frequently lifted.

If the claimant was required to dispose of trash by lifting it into the dumpster at the end of the day, lifting was a part of their job duties. How much they lifted is material to the determination, therefore the adjudicator must resolve the discrepancy between the claimant’s job as they describe it and their report about the specific task.

For more information on materially inconsistent evidence, see DI 24501.016B.4.b.

4. When vocational information is inconsistent but not material to the determination

A DDS does not need to resolve inconsistent vocational information reported in the SSA-3368-BK when it is not material to the determination. For instance, the total amount of time a claimant reports doing certain physical activities in a typical workday might exceed the time they report working in a typical day. These activities do not need to always match the total hours worked because some activities might be performed simultaneously. In other instances, inconsistent vocational information may not be material if the claimant does not have the residual functional capacity (RFC) to perform other aspects of their job. Further, vocational information is not material if the expedited vocational procedures apply, as discussed in DI 25005.005.

EXAMPLE 1: The claimant reports working as a waiter and states that they stood and walked for six hours and reached for six hours out of an eight-hour day. It is reasonable to interpret the claimant’s statements to mean that they intermittently or simultaneously performed these activities in a typical workday.

EXAMPLE 2: The claimant reports working as a bricklayer. According to the claimant, this job required standing and walking six hours out of an eight-hour day. They also report sitting, kneeling, stooping, and reaching four hours out of an eight-hour day. Additionally, they report frequently lifting 50 pounds or more and the heaviest weight they lifted was around 75 pounds. Due to the severity of their impairments, they are limited to a light RFC. Because the demands of their past work as described exceed their RFC, the inconsistencies in the total time they report performing physical activities for this job are immaterial to the determination.

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DI 22515.025 - Use of Form SSA-3368-BK (Disability Report – Adult) - 06/21/2024
Batch run: 12/06/2024
Rev:06/21/2024