Enter the claimant’s identifying information:

1. a. 

   Name (first, middle initial, last, and suffix if applicable). Ask the claimant if they use any other names on their medical or educational records, such as a maiden name, other married name, other name, or nickname (e.g., Becky for Rebecca, or T.J. for Thomas Joseph);

2. b. 

   Social Security Number;

3. c. 

   Mailing address (include apartment, unit, or lot numbers, if applicable);

4. d. 

   Email address (do not share Personally Identifiable Information (PII) when corresponding by email);

5. e. 

   Daytime telephone number, where we can speak with, or leave a message for, the claimant;

6. f. 

   Another telephone number where the claimant can be reached;

7. g. 

   Ability to speak and understand English. If the claimant is unable to speak and understand English, find out their preferred language. Let them know we will provide an interpreter free of charge, if needed.;

8. h. 

   Ability to read and understand English; and

9. i. 

   Ability to write more than their name in English.

Ask the claimant for the names of up to two people we can contact (other than the claimant’s doctors), such as a friend or relative, who know about the claimant’s medical condition(s), can help them with their claim, and knows how to reach them if they become unavailable.

If the claimant is unable or unwilling to identify a designated contact person, let them know that providing a contact person may help us make a decision on their claim. If the claimant is still unwilling or unable to provide a third party contact, select “No” and go to Section 3.

If the claimant provides a designated contact person(s), select “Yes” and document the following information:

1. a. 

   The name of the contact person (first, middle initial, last);

2. b. 

   The relationship of the contact person to the claimant;

3. c. 

   The contact person’s mailing address (include apartment, unit, or lot numbers, if applicable), City, State/Province, ZIP/Postal Code, and Country (if not USA);

4. d. 

   The contact person’s daytime telephone number; and

5. e. 

   The contact person’s preferred language if they do not speak and understand English. The DDS will provide an interpreter free of charge, if needed.

Enter information about the claimant’s alleged medical condition(s) that limits their ability to work.

1. a. 

   List all alleged physical or mental conditions (including emotional or learning problems) separately, using the claimant’s own words whenever possible.

   NOTE: If the claimant has CANCER, document the type and stage.

2. b. 

   Document the claimant’s height in feet and inches. You may document the height in centimeters, if applicable.

3. c. 

   Document the claimant’s weight in pounds. You may document the weight in kilograms, if applicable.

Using the claimant’s alleged conditions, document the claimant’s own perception of when they became unable to work because of their medical condition(s). We refer to this as the alleged onset date (AOD).

1. a. 

   In 4.A., ask if the claimant is currently working. If they answer:

   • •

     “No, I have never worked,” go to question 4.B.

   • •

     “No, I have stopped working,” go to question 4.C.

   • •

     “Yes, I am currently working,” go to question 4.F.

   NOTE: If there are other non-medical factors that affect onset, address those on the SSA-3367 (Disability Report – Field Office) or Electronic Disability Collect System (EDCS) 3367, in the potential onset date (POD) field. For instructions on completing the SSA-3367, see DI 11005.045 and DI 81010.025.

2. b. 

   Question 4.B., IF YOU HAVE NEVER WORKED: If the claimant has never worked, document the month/day/year when they believe their condition(s) became severe enough to keep them from working, even though they have never worked. This date is the AOD for a claimant who has never worked. In EDCS, the AOD propagates from Modernized Claim System/Modernized Supplemental Security Claims System (MCS/MSSICS). Then, go to Section 5.

3. c. 

   Question 4.C., IF YOU HAVE STOPPED WORKING: If the claimant has stopped working, obtain the month/day/year when they stopped working. Generally, this is the AOD for a claimant who has stopped working. Check the appropriate box for why the claimant stopped working:

   • •

     Because of my condition(s), or

   • •

     Because of other reasons. If this option is selected, enter the claimant’s explanation in the space provided to state why they stopped working. For example, the claimant may say “because the plant closed.” However, if the claimant states, “I was fired,” “I quit,” or “I was laid off,” document the reasons why.

     Even though the claimant stopped working for other reasons, document the month/day/year when the claimant believes their condition(s) became severe enough to keep them from working.

4. d. 

   Ask whether the claimant’s condition(s) caused them or their employer to make changes in their work activity (for example, job duties, hours worked, or rate of pay) prior to the date they stopped working. If the claimant answers:

   • •

     “No,” go to Section 5 – Education, Training, and Literacy.

   • •

     “Yes,” document the month/day/year the claimant or their employer made changes in their work activity. Then, go to 4.E.

     NOTE: The date documented in item 4.D. may or may not be the same as the dates in item 4.C.

5. e. 

   Since the date in 4.D., ask if the claimant had earnings greater than the substantial gainful activity (SGA) amount before tax (see DI 10501.015) in any month since they made changes in work activity. Consider impairment-related work expenses (IRWE), as discussed in DI 10520.001. Do not count sick leave, vacation, or disability pay. Obtain a “No” or “Yes” answer from the claimant and go to Section 5 -- Education, Training, and Literacy.

6. f. 

   Question 4.F., IF YOU ARE CURRENTLY WORKING: Find out whether the claimant’s condition(s) caused them or their employer to make changes in their work activity (for example, job duties, hours worked, or rate of pay). If the claimant answers:

   • •

     “Yes,” document the month/day/year when these changes started.

   • •

     “No,” document the month/day/year when their condition(s) first started bothering them.

     This is the AOD for a claimant who is currently working. In EDCS, the AOD propagates from MCS/MSSICS if the claimant alleges no changes in work activity.

     NOTE: AODs will not propagate from the mainframe for MCS Exclusion cases.

7. g. 

   If the claimant had earnings greater than the SGA amount before taxes (as discussed in DI 10501.015) in any month since their condition(s) first bothered them, check the “Yes” box, otherwise, check the “No” box.

   NOTE: Consider impairment-related work expenses (IRWE), as discussed in DI 10520.001. Do not count sick leave, vacation, or disability pay. For more information about completing work activity reports, 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).

1. a. 

   Check the box indicating the highest grade of school the claimant completed, including homeschooling, online education, and education received in another country.

   For example, check “0” if the claimant completed less than a first-grade education, or check “9” if that is the last grade completed by the claimant. If the claimant completed education equivalent to high school from another country, check “12.”

   Enter the date of the highest grade of school the claimant completed and the school’s name and location (City, State/Province, and Country (if not USA)).

2. b. 

   Check the box corresponding to whether the claimant was in special education (“Yes” or “No”). If the claimant answers “No,” go to 5.C. If the claimant answers “Yes,” enter the dates the claimant was in special education, ; the last grade of special education the claimant completed; the reason(s) for special education; and the school’s name and location (If different from the school in 5.A., enter the school’s name and location (City, State/Province, and Country (if not USA)).

3. c. 

   Check the box corresponding to whether the claimant completed any type of training, such as specialized job, trade, or vocational school (“Yes” or “No”). If the claimant answers “No,” then go to Section 5.D. If “Yes,” then enter details about the claimant’s training (specifically, the name and address of the training facility, phone number, type of program, and the date completed). List any additional education or training under Section 11 – Remarks, if applicable.

4. d. 

   Document the written language the claimant uses every day in most situations (at home, work, school, in community, etc.).

5. e. 

   With respect to the language identified in 5.D., check the box indicating whether the claimant can read a simple message, such as a shopping list or short and simple notes (“Yes” or “No”).

6. f. 

   With respect to the language identified in 5.D., check the box indicating whether the claimant can write a simple message, such as a shopping list or short and simple notes (“Yes” or “No.”)

For the evaluation and development of employment and documenting employment cases, see DI 10505.001 through DI 10505.035.

Indicate whether the claimant had a job in the five years before becoming unable to work because of their medical condition(s) (select “No” or “Yes”).

1. a. 

   If “No,” go to Section 7, Medicines.

2. b. 

   If “Yes,” list all the jobs that the claimant had in the five years before they became unable to work because of their medical condition(s), starting with their most recent job. Include all job titles (even if they were for the same employer), self-employment, and work performed in a foreign country. Do not include any jobs that the claimant started and stopped in fewer than 30 calendar days.

   If more space is needed to list additional jobs, use Section 11 – Remarks.

   List for each job:

   • •

     Job title: Enter the type of job performed, for example a “cashier”.

   • •

     Type of business: For example, enter “grocery store” instead of the business name.

     NOTE: Jobs are performed quite differently from employer to employer. For example, if the claimant was a “cashier” at three different businesses and the job duties differed in each job, include three separate titles and descriptions in Section 6.A. If the job duties and the physical and mental requirements were the same, one entry in Section 6.A. is sufficient.

   • •

     Dates worked: Enter the month and year the claimant worked in this job.

   • •

     Hours per day: Enter the hours worked per day.

   • •

     Days per week: Enter the number of days worked per week.

   • •

     Rate of pay: Enter the amount and frequency of pay. For example, if a cook earned $12.00 per hour, enter the “$12.00” in the “Amount” field and “hourly” in the “Frequency” field.

     NOTE: The field office (FO) may use the Detailed Earnings Query (DEQY) and Summary Earnings Query (SEQY) to assist in completing this section. However, do not use them as substitutes for completion of the Job History section of the SSA-3368-BK. Do not fax queries into the Electronic Folder. DDSs are not required to use queries to develop vocational information.

     Check the appropriate box that applies to the claimant:

     • –

       If the claimant had only one job , answer the rest of the questions in Section 6.

     • –

       If the claimant had more than one job , do not answer the rest of the questions in Section 6, go to Section 7. Advise the claimant that we may contact them for more information, such as asking them to complete Form SSA-3369-BK (Work History Report).

       NOTE: The FO is required to complete the SSA-3369-BK for cases in which the claimant is homeless, according to DI 11005.025. If the FO is completing the SSA-3369 along with the SSA-3368-BK and sending them to the DDS, cross out Section 6 of the SSA-3368-BK add the note “See SSA-3369,” and go to Section 7.

3. c. 

   When the claimant had only one job, describe in detail the basic job duties performed in 6.B.1 through 6.B.5.

   If any of the jobs listed in 6.A., or the job described in 6.B., is considered supported employment, document what kind of support(s) the claimant receives. If the claimant receives support(s) from a social services agency, vocational rehabilitation agency, or other type of support service document the agency or organization in Section 9 – Other Medical Information. If you need more space, use Section 11 – Remarks. For more information on supported employment, see DI 10505.025D.

4. d. 

   Ask the claimant to provide the physical and environmental requirements of the job listed in 6.C. Document how much time per day they performed each of the following activities: standing, walking, and sitting.

   IMPORTANT: The total number of hours spent standing, walking, and sitting should equal the hours per day the claimant reports working in 6.A. However, the hours spent performing other job activities, when totaled, may exceed the total hours worked in a typical workday because some job activities may be performed simultaneously (i.e. standing and reaching).

5. e. 

   Ask the claimant how much of their workday they performed any of the following activities:

   • •

     Climbing (such as stairs or ramps or ladders, ropes, or scaffolds),

   • •

     Stooping (bending down and forward at the waist),

   • •

     Kneeling (bending legs to rest on knees),

   • •

     Crouching (bending legs and back down and forward),

   • •

     Crawling (moving on hands and knees),

   • •

     Using fingers to touch, pick, or pinch (e.g., using a mouse, or buttoning a shirt),

   • •

     Using hands to seize, hold, grasp, or turn (e.g., holding a large envelope or a hammer), and

   • •

     Reaching at or below the shoulder or reaching overhead.

6. f. 

   For this job, ask the claimant to explain what they lifted, how far they carried it, and how often they did this in a typical workday.

7. g. 

   Select the heaviest weight they lifted: less than 1 pound, less than 10 pounds, 10 pounds, 20 pounds, 50 pounds, 100 pounds or more, or enter another weight in the space for “Other” pounds.

8. h. 

   Select the weight- they frequently lifted: less than 1 pound, less than 10 pounds, 10 pounds, 25 pounds, 50 pounds or more, or enter another weight in the space for “Other” pounds.

   NOTE: By frequently, we mean from 1/3 to 2/3 of the workday.

9. i. 

   Select whether the claimant was exposed to any of the following conditions (i.e., outdoors, wetness, moving mechanical parts, loud noises, extreme heat, humidity, high exposed places, extreme cold, hazardous substances, heavy vibrations, or other exposures).

   If the claimant indicated they were exposed to more than one condition, or reports an exposure not listed, ask them to provide additional information and how often they were exposed.

10. j. 

    Ask the claimant to explain how their medical condition(s) would affect their ability to do this job.

Ask the claimant if they are currently taking any prescription or non-prescription medicines. If “No,” go to Section 8. If “Yes,” document the following:

• •

  Name of medicine;

• •

  If prescribed, the doctor’s name; and

• •

  Reason for medicine (i.e., anxiety attacks), if known.

This information may be located on the claimant’s medicine containers. If the claimant does not know this information, enter “don’t know.” (If you need more space to list additional medicines, go to Section 11 – Remarks).

Ask the claimant if they have seen any healthcare providers who have evaluated or treated them for their medical conditions. Healthcare providers may include doctors, hospitals, clinics, psychiatrists, nurse practitioners, therapists, physical therapists, or other medical professionals.

Do not limit healthcare providers to any specific time frames. The DDS uses judgment in developing medical sources based on several factors, such as claim type, date last insured, and prescribed period.

If the claimant did not see any healthcare providers go to Section 9. If the claimant saw a healthcare provider, or he claimant has a future appointment scheduled, complete the information below:

1. a. 

   Name of facility or office;

2. b. 

   Name of healthcare provider who treated the claimant;

3. c. 

   Information about what medical conditions this healthcare provider treated or evaluated;

   EXAMPLE: “To get my blood pressure monitored.”

4. d. 

   Phone number

5. e. 

   Dates of treatment (month/year), including the date of the next scheduled appointment, if known.

6. f. 

   Address, City, State/Province, ZIP/Postal Code, and Country (if not USA).

   NOTE: Claimants may have difficulty remembering specific information about the location of their healthcare providers. They may be able to find this information on medical bills, their online medical chart, or the Internet. To eliminate DDS recontacts, assist the claimant when necessary to provide complete names, addresses, and telephone numbers of their healthcare providers.

In Section 8.B., document any medical test(s) for which the claimant was sent, or that is scheduled in the future, and the name of the healthcare provider or facility that performed the test. If you need space to list additional tests, use Section 11 – Remarks.

Ask the claimant if anyone else (other than their healthcare providers) has their medical information.

Examples include Department of Veterans Affairs, workers’ compensation, vocational rehabilitation agencies, insurance companies, prisons, attorneys, social service agencies, and welfare.

If “No” and the claimant is receiving Supplemental Security Income (SSI) and has been asked to complete this report, go to Section 10. If not, go to Section 11.

If “Yes,” collect the following information:

• •

  Name of organization

• •

  Phone number

• •

  Address, City, State/Province, ZIP/Postal code, and Country (if not USA)

• •

  Name of contact person and claim number (if any)

• •

  Date of first contact, date of last contact, date of next contact (if any), and the reasons for contacts. If the claimant is unable to remember the exact dates, obtain approximate dates.

If the claimant indicates they receive, or received, support(s) from a social services agency, vocational rehabilitation agency, or other type of support service for a job listed in Section 6, document the agency or organization that helped them go to work. If you need more space, use Section 11 – Remarks. For more information on supported employment, see DI 10505.025D.

For additional information about locating prison records, follow procedures in GN 02607.520 PUPS Skeleton Record and DI 10105.094 Field Offices Identifying and Documenting Prisoner Status for Title II Disability Benefits.

If you need to list other people or organizations, use Section 11 – Remarks.

Complete this section only if the claimant is already receiving SSI.

1. a. 

   Ask the claimant whether they have participated, or are participating, in any support services, such as:

   • •

     An individual work plan with an employment network under the Ticket to Work Program;

   • •

     An individualized plan for employment (IPE) with a vocational rehabilitation agency or any other organization;

   • •

     A plan to achieve self-support (PASS);

   • •

     An individualized education program (IEP) through a school (if the claimant is a student age 18 - 21); or

   • •

     Any program providing vocational rehabilitation, employment services, or other support services to help the claimant go to work.

2. b. 

   Check “No” if the claimant has not participated, or is not participating, in any of the above, and go to Section 11.

3. c. 

   Check “Yes” if the claimant has participated or is participating in any of the above, and document the following information:

   • •

     Name of organization or school;

   • •

     Name of counselor, instructor, or job coach;

   • •

     Phone number; and

   • •

     Address, City, State/Province, ZIP/Postal code, and Country (if not USA).

4. d. 

   Ask the claimant if they are still participating in a plan or program. Check the appropriate box and complete the following information:

   • •

     If “Yes,” document the date when the claimant started participating in the plan or program and the date they are scheduled to complete the plan or program, or

   • •

     If “No,” document the date when the claimant started participating in the plan or program and the date they stopped participating in the plan or program, and the reason they stopped.

5. e. 

   List the types of services, tests, or evaluations that the claimant received. For example: vision test, intelligence or psychological testing, work classes, hearing test, or work evaluations. Explain any other type of services, tests, or evaluations.

If you need to list another plan or program, use Section 11 – Remarks.

Use this section to document any additional information or explanation the claimant did not give in other sections of this report. If you did not have enough space in previous sections of this report to provide all the requested information, use this space to provide the additional information. Be sure to include the section and question number to which you are referring.

If the claimant has not seen any medical sources for the conditions alleged in Section 3, note “No treating source for [alleged condition].”

Document the person completing this report as:

• •

  The person listed in 1.A.,

• •

  The person listed in 2.A.,

• •

  The person listed in 2.F., or

• •

  Someone else (if this option is selected, provide their name, relationship to the person listed in 1.A., their mailing address (include apartment, unit, or lot numbers, if applicable), City, State/Province, ZIP/Postal Code, and Country (if not USA) and a daytime phone number where they can be reached or we can leave a message.