BASIC (07-08)

DI 11020.025 Forms Used in Childhood Disability Benefit (CDB) Claims

A. General

In addition to obtaining appropriate applications in disability cases, the Field Office (FO) is responsible for the completion of appropriate forms either on Electronic Disability Collect System (EDCS) (see DI 81010.020) or via eForm. These capture other essential information used by the FO, Disability Determination Services (DDS), and others, to develop Substantial Gainful Activity (SGA), medical evidence, and other aspects of the disability claim. This section provides a brief explanation of most developmental forms used in disability claims.

B. Forms Commonly Used

1. SSA-3368-BK (Disability Report-Adult), in an initial or subsequent CDB claim

Complete the SSA-3368-BK for all CDB cases either electronically via EDCS, or on paper via eForm, if it is an EDCS exclusion (see DI 81010.030 “Certified Electronic Folder (CEF) Exclusions and Limitations”) except when a currently entitled CDB files a CDB claim on another NHs record.

Complete an SSA-3368-BK without an application form if:

  1. A child was entitled to child’s benefits

    • for the month before he or she attained age 18; or

    • for the month before he or she attained age 19 + 2 months, if still in high school;

      AND

  2. The child is reapplying for CDB benefits within four years of the termination and alleges disability since prior to termination.

Reference:

RS 00203.080B.3. Childhood Disability Benefits - Disability Report – Adult, Form SSA-3368-BK

2. SSA-3367 (Disability Report – Field Office (FO))

Complete an EDCS 3367 (or a paper SSA-3367 in exclusion claims) in all disability claims. The FO is responsible for sending a complete and accurate EDCS 3367 to the DDS.

For completion of the form, see:

  • DI 11005.045 Completing the Paper Form SSA-3367–F5 (Disability Report-Field Office); and

  • DI 81010.030 CEF Exclusions and Limitations.

NOTE: For multiple or concurrent EDCS exclusion claims in which different SSNs are involved, only fill out page 1 of the SSA-3367 for the second claim.

3. SSA-827 (Authorization to Disclose Information to the Social Security Administration (SSA))

Obtain one signed and dated SSA-827 (see DI 11005.055 “Completing the Authorization to Disclose Information to the Social Security Administration (SSA) Form SSA-827”).

4. SSA-820-F4 (Work Activity Report-Self Employed Person)/SSA-821-BK (Work Activity Report-Employee)

Complete the applicable form in the following situations:

  • There is evidence of work after the date the claimant alleges his or her work stopped because of an impairment; or

  • The file indicates that a CDB claimant performed SGA at any time (unless the claim is for re-entitlement to CDB and work activity precedes the alleged onset date).

For completion of the forms, see:

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

  • 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).

    NOTE: If the forms are taken with claims at the initial level, signature proxy applies to the SSA-820/821.

For policy and procedures for the use of signature proxy for SSA-820/821 reports, see:

C. Subsequent Claims

When a subsequent claim is filed, update the medical information by completing SSA-3368-BK and SSA-3367. If work is involved, complete an SSA-821/SSA-820 before transferring the claim to the DDS. If the subsequent claim is being entered into EDCS and the prior claim is a closed electronic folder, some data may be propagated from the prior claim. (See DI 81010.035C “Data P