Identification Number:
DI 11005 TN 60
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:Disability Interviews
Type:POMS Transmittals
Program:Disability
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part DI – Disability Insurance
Chapter 110 – Initial Claims Processing
Subchapter 05 – Disability Interviews
Transmittal No. 60, 06/26/2020

Audience

PSC: CA, CS, DE, DEC, DTE, ICDS, IES, ISRA, RECONR, SCPS, TSA, TST;
OCO-OEIO: BET, CR, CTE, ERE, FCR, FDE, FDEC, RECONE, RECONR, RECOVR;
FO/WSU/TSC: CS, CS TII, CS TXVI, CSR, CTE, DRT, FR, OA, OS, RR, TA, TSC-CSR;
OCO-ODO: BET, BTE, CR, CST, CTE, CTE TE, DE, DEC, DS, PAS, PETE, PETL, RCOVTA, RECONE, RECOVR;
ODD-DDS: REF;

Originating Component

ODP

Effective Date

Upon Receipt

Background

On February 25, 2020, the final rule “Removing Inability to Communicate in English as an Education Category” was published. Under the new rules, we classify a claimant's level of education into one of the four remaining categories: (1) Illiteracy, (2) Marginal Education, (3) Limited Education, and (4) High School Education and Above. To provide guidance on assessing a claimant's education using the four remaining categories, we issued the Social Security Ruling 20-01p, "How We Determine an Individual's Education Category.” We updated the affected POMS sections to reflect the changes in the regulation and the guidance provided in SSR 20-01p.

Summary of Changes

DI 11005.023 Completing the Disability Report Adult Form SSA-3368

We revised subsection C.5. to reflect the changes we made to the "Education and Training" section of SSA-3368.

 

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

We revised subsection A.5. to reflect the changes we made to the "Observations/Perceptions" section of SSA-3367.

Conversion Table
Old POMS ReferenceNew POMS Reference
DI 11005.023DI 11005.023
DI 11005.045DI 11005.045

DI 11005.023 Completing the Disability Report Adult Form SSA-3368

A. Introduction

The following instructions are for completing the preprinted paper Form SSA-3368 (Disability Report – Adult). The Disability Determination Services (DDS) uses the information on the 3368 to develop medical and other evidence that can be used to establish the correct onset date. The 3368 is also used to assess the alleged disability in conjunction with nonmedical factors, such as education and work history.

B. When to obtain a Form SSA-3368

Obtain Form SSA-3368 in:

  • Title II disability or blindness claims for Disability Insurance Benefits (DIB), Disabled Widow(er)’s Benefits (DWB), Childhood Disability Benefits (CDB), and Disabled Minor Child (DMC) claims.

  • Title XVI disability or blindness claims for an adult, that is, an individual who is age 18 or over (unless the claimant will be denied for nonmedical reasons).

NOTE: Use the claimant’s own words whenever possible to record the information.

C. Completing the sections of Form SSA-3368

1. Section 1 -- Information about the Disabled Person

Enter identifying information about the claimant:

  1. a. 

    Name (first, middle initial, last);

  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 phone number;

    IMPORTANT: Check the box if the claimant does not have a phone, or cannot provide a number where we can leave a message.

  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 the preferred language;

  8. h. 

    Ability to read and understand English;

  9. i. 

    Ability to write more than his or her name in English; and

  10. j. 

    Any other names or aliases on the claimant’s medical or educational records, such as maiden name, other married name, initials (for example, T. Joseph for Thomas Joseph, or E.J. for Erwin Joseph, or nickname (for example, Becky for Rebecca, or Bob for Robert).

2. Section 2 -- Contacts

Enter the name of someone other than the claimant’s doctors, such as a friend or relative to contact who knows about the claimant’s physical or mental condition(s), and can help him or her throughout the claim process. 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 daytime telephone number;

  4. d. 

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

  5. e. 

    The contact person’s preferred language if he or she does not speak and understand English. The DDS can arrange for an interpreter in the preferred language;

  6. f. 

    Identity of the person who is completing the report:

    • If the person completing the report is applying for disability, go to Section 3 – Medical Conditions;

    • If the person completing the report is the same person listed in 2.A., go to Section 3 – Medical Conditions;

    • If someone else is completing the report, complete the rest of Section 2;

  7. g. 

    The name of the person completing the form, if someone other than the claimant or the person listed in 2.A.;

  8. h. 

    The relationship of the person in 2.G. to the person applying for benefits;

  9. i. 

    The daytime telephone number of the person in 2.G.; and

  10. j. 

    The mailing address of the person in 2.G.

NOTE: Use Section 11 - Remarks to record the name, address, phone number, and relationship to the claimant of an additional third party contact who knows about the claimant’s medical conditions and can help with the claim. Or indicate that, no additional third party contact is available. For i3368 (iClaims) and paper SSA-3368 submitted by mail, see DI 11005.023C.11.b in this section.

3. Section 3 -- Medical Conditions

Enter information about the claimant's condition(s) that restricts his or her ability to work.

  1. a. 

    List all of the physical or mental conditions (including emotional or learning problems) that limit the claimant’s ability to work. List each condition separately, using the claimant’s own words whenever possible.

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

  2. b. 

    Indicate the claimant’s height in feet and inches without shoes. If outside of the USA, you may document the height in centimeters.

  3. c. 

    Indicate the claimant’s weight in pounds without shoes. If outside of the USA, you may document the weight in kilograms.

  4. d. 

    Answer yes or no to the question that asks if the claimant’s conditions cause him or her pain or other symptoms.

4. Section 4 -- Work Activity

Use the claimant's allegations, and document the claimant's own perception of when he or she became unable to work because of his or her physical or mental condition(s). We refer to this as the alleged onset date (AOD).

  1. a. 

    Find out if the claimant is currently working. If he or she answers:

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

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

    • “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 or Electronic Disability Collect System (EDCS) 3367 in the potential onset date (POD) block. For more detailed instructions on completing the SSA-3367, see DI 11005.045 and DI 81010.025.

  2. b. 

    IF YOU HAVE NEVER WORKED: If the claimant has never worked, document the month/day/year when he or she believes the condition(s) became severe enough to keep him or her from working, even though the claimant has never worked. This 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. 

    IF YOU HAVE STOPPED WORKING: If the claimant has stopped working, obtain the month/day/year when he or she 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 so, enter the claimant’s explanation in the space provided to state why he or she stopped working. For example, the claimant may indicate because “the plant closed.” However, if the claimant states, “I was fired,” “quit,” or “laid off,” document the reasons why. Even though the claimant stopped working for other reasons, document the month/day/year when the claimant believes his or her condition(s) became severe enough to keep him or her from working.

  4. d. 

    Ask whether the claimant’s condition(s) caused him or her to make changes in his or her work activity (for example, job duties, hours worked, or rate of pay) prior to the date he or she stopped working. If the claimant answers:

    • “No,” go to Section 5 – Education and Training; or

    • “Yes,” document the month/day/year the claimant made the changes in his or her 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 gross earnings greater than the substantial gainful activity (SGA) amount (see DI 10501.015) in any month since he or she made changes in work activity. Consider impairment-related work expenses (IRWE) see 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 and Training.

  6. f. 

    IF YOU ARE CURRENTLY WORKING: Find out whether the claimant’s condition(s) caused him or her to make changes in his or her work activity. For example, changes in job duties or hours worked. If the claimant answers:

    • “No,” document the month/day/year when his or her condition(s) first started bothering him or her; or

    • “Yes,” document the month/day/year when the claimant made changes.

      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 gross earnings greater than the SGA amount (see DI 10501.015) in any month since his or her condition(s) first bothered him or her, check the “Yes” box, otherwise, check the “No” box.

    NOTE: Consider impairment-related work expenses (IRWE) see 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).

5. Section 5 -- Education and Training

  1. a. 

    Check the box corresponding to the highest grade of school completed by the claimant. 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 details about the highest grade of school completed, in particular, the date completed and the school's name/location (city, state/province, and country (if not USA)).

  2. b. 

    Check the box corresponding to whether the claimant received special education ("Yes" or "No"). If the claimant answers "No," then go to 5.C. If the claimant answers "Yes," then enter details about the special education the claimant received, in particular, the "from/to" dates the claimant received special education, the last grade the claimant received special education, the reason(s) for the special education, and the school's name/location (check the box corresponding to whether school is same or different from 5.A., and if different, enter the school's name/location (city, state/province, country (if not USA)).

  3. c. 

    Check the box corresponding to whether the claimant completed any type of specialized job training, trade, or vocational school ("Yes" or "No"). If the claimant answers “No,” then go to Section 5.D. If “Yes,” then enter details, in particular, the type of training/schooling and the date completed. List additional education or training under Section 11 – Remarks.

  4. d. 

    Identify 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 corresponding to whether the claimant can or cannot 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 corresponding to whether the claimant can or cannot write a simple message, such as a shopping list or short and simple notes ("Yes" or "No").

6. Section 6 -- Job History

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

  1. a. 

    List the jobs (up to 5) that the claimant has had in the 15 years before he or she became unable to work because of the physical or mental conditions. List the most recent job first and do not exclude jobs from the list just because earnings are under SGA. Consider listing jobs other than the most recent if the claimant requests a specific job be added. For example, the claimant may have worked more than 5 jobs in the past 3 years, but had a steady job for the previous 10 years.

    If the claimant did not work at all in the 15 years before he or she became unable to work, check the box and go to Section 7 – Medicines.

    List for each job:

    • Job title: Enter the type of job performed, not the name of the employer. Even common jobs are performed quite differently from employer to employer. For example, if the claimant was a “waiter” at three different restaurants from 2005 to 2009, and the job duties were different at each job, include three separate titles and descriptions in Section 6.A. If the job duties and physical and mental requirements were the same, one entry in Section 6.A is sufficient.

    • Type of business: For example, enter “restaurant.”

    • Dates worked: Enter the first day the waiter (job title) began working at a restaurant (type of business) in the “From” (month/year) area and the last day the waiter worked at a restaurant in the “To” (month/year) area.

    • Hours per day: Enter hours worked per day.

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

    • Rate of pay: Enter the rate of pay. For example, a cook earned “$12.00 hourly”; document the $12.00 in the “Amount” field and hourly in the “Frequency” field.

      NOTE: The field office (FO) may use the Detail 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. Do not fax queries into the Electronic Folder. DDSs are not required to obtain queries as part of their process.

      Check the appropriate Job History box that applies to the claimant:

      • If the claimant had only one job in the last 15 years, answer the rest of the questions in Section 6.

      • If the claimant had more than one job in the last 15 years before he or she became unable to work, do not answer the rest of the questions in Section 6 go to Section 7. Advise the claimant that we may contact him or her for more information, such as, completing the Form SSA-3369 (Work History Report).

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

  2. b. 

    If the claimant had only one job, describe in detail the basic job duties performed. If the claimant is working or has worked under sheltered conditions (see DI 10505.025D.), include the information in this section. If you need more space, use Section 11 – Remarks.

  3. c. 

    Answer “Yes” or “No” to the following information about the claimant's job:

    • Use machines, tools, equipment;

    • Use technical knowledge or skills;

    • Do any writing, complete reports, or perform any duties like this.

      The answers to this descriptive data may provide a clearer picture of the nature and duties of the job performed.

  4. d. 

    The total number of hours per day the claimant performed each of the following tasks: walk, stand, sit, climb, stoop (bend down and forward at the waist), kneel (bend legs to rest on knees), crouch (bend legs and back down and forward), crawl (move on hands and knees), handle large objects, handle small objects, write/type, and reach.

    NOTE: The hours of each task when totaled may exceed the total hours worked in a day when the claimant can only give an estimate of a typical workday.

  5. e. 

    Document the claimant's explanation of what he or she lifted and how far he or she carried it, and how often he or she did this on the job.

  6. f. 

    Indicate the heaviest weight lifted by checking: less than 10 pounds, 10 pounds, 20 pounds, 50 pounds, 100 pounds or more, or by entering another weight in the space for “Other” pounds (or kilograms, if outside the USA).

  7. g. 

    Indicate the weight frequently lifted by checking: less than 10 pounds, 10 pounds, 25 pounds, 50 pounds or more, or by entering another weight in the space for “Other” pounds (or kilograms, if outside the USA).

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

  8. h. 

    If the claimant did not supervise other people in this job, check, “No,” and go to 6.I., otherwise fill-in numbers for the following items:

    • How many people did the claimant supervise?

    • What part of the claimant’s time was spent supervising people?

    • Did the claimant hire and fire employees?

  9. i. 

    A lead worker is an employee who plans and coordinates work, and guides and trains others while doing the same kind of work. Answer “Yes” or “No” if the claimant was a lead worker.

7. Section 7 -- Medicines

List all brand name or generic medicines the claimant is taking, including those prescribed by a medical source(s), and any over-the-counter medicines, to treat the physical and mental conditions that the claimant alleges prevents him or her from working. If the claimant answers “Yes,” collect the following information:

  • Name of medicine;

  • If prescribed, give name of doctor; and

  • Reason for medicine.

If possible, collect this information from the prescription(s) or prescription bottles. If the claimant does not know this information, enter the word “don’t know” in the “Name of Medicine” block and in the “Reason for medicine” block enter why the claimant takes the medicine, for example, anxiety attacks. (If you need more space to list additional medicines, go to Section 11 – Remarks).

8. Section 8 -- Medical Treatment

Include all medical sources that have examined or treated the claimant for the alleged physical or mental conditions, even if they are not recent. Medical sources should not be limited to any specific timeframes. The DDS uses judgment in developing medical sources based on a number of factors, such as, claim type, date last insured, and prescribed period.

If the claimant received treatment at a hospital or clinic by a doctor or other health care professional, or if the claimant has a future appointment scheduled:

  1. a. 

    For any physical condition(s)? (Check “Yes” or “No.”)

  2. b. 

    For any mental condition(s) including emotional and learning problems? (Check “Yes” or “No.”)

    If the claimant answers “No” to both questions 8.A. and 8.B., go to Section 9 – Other Medical Information. If the claimant answers “Yes” to 8.A. or 8.B., obtain the source information for the claimant’s medical records about his or her condition(s) that limits his or her ability to work. This also includes doctors’ offices, hospitals (including emergency room visits), clinics, and other health care facilities.

  3. c. 

    Collect the following medical treating source information:

    • Name of facility or office

    • Name of health care professional who treated the claimant

    • Phone number

    • Patient identification (ID) number (if known). The patient ID number is essential to request medical evidence.

    • Mailing address (complete street address), City, State/Province, ZIP/Postal Code, and Country (if not USA).

      NOTE: Use the telephone book or online directory to obtain or verify names, addresses, and telephone numbers for medical sources. Always include ZIP codes to eliminate DDS recontacts.

    • Dates of treatment (or approximate dates): Include the date of the next scheduled appointment to a doctor, hospital, or clinic. See, Special Documentation Requirements – Medical Sources of National Significance DI 11005.060.

      • Office, clinic, or outpatient visits (collect the dates of the first visit, last visit, and the next scheduled appointment, if any).

      • Emergency Room visits (list the most recent dates first).

      • Overnight hospital stays (list the most recent dates first, giving the “Date in” and “Date out” for each stay).

    Enter information in the appropriate boxes about:

    • What medical conditions were treated or evaluated?

      NOTE: If the claimant will be seeing a new medical source for the first time, also complete all of 8.C., including the scheduled appointment date and the condition to be treated or evaluated.

    • What treatment did you receive for the above conditions?

      EXAMPLE: “To get my blood pressure monitored.” (Do not describe medicines or tests in this box.)

Check the appropriate Kind of Test boxes for any tests the provider performed, to which the claimant was sent, or are scheduled for the claimant in the future. Document the dates for past and future tests. If you need more space to list more tests, use Section 11 – Remarks.

NOTE: If no tests by this provider or at this facility, check the appropriate box provided above “Kind of Test.”

Additional medical sources may be entered in Section 8.D. through 8.G.

  • If more than five doctors or hospitals have treated the claimant, use Section 11 – Remarks and give the same detailed information for each healthcare provider.

  • If the claimant does not have any more doctors or hospitals to describe, go to Section 9 – Other Medical Information.

9. Section 9 -- Other Medical Information

Obtain from the claimant the name of anyone else who has medical information about the claimant’s physical or mental condition(s), including emotional and learning problems. Prison records are sometimes a source for medical records. The history in the medical evidence may indicate the circumstances under which an impairment(s) arose or aggravated the condition(s). To locate records, follow procedures in the Prisoner Update Processing System (PUPS) GN 02607.520 and Field Offices Identifying and Documenting Prisoner Status for Title II Disability Benefits DI 10105.094.

If the claimant is scheduled to see anyone else, get this information. This may include sources such as workers’ compensation, vocational rehabilitation, insurance companies, prisons, attorneys, social service agencies, and welfare. If the claimant answers “Yes,” document the following information:

  • Name of organization

  • Phone number

  • Mailing address (complete street address), City, State/Province, ZIP/Postal code, and Country (if not USA)

  • Name of contact person, claim or ID Number (if any), date of first contact, date of last contact, date of next contact (if any), and reasons for contacts.

    NOTE: If the claimant is unable to remember the exact dates, obtain approximate dates.

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

10. Section 10 – Vocational Rehabilitation, Employment, or Other Support Services

Complete this section for Age 18 Redetermination claims (already receiving SSI). Indicate if the claimant has received services from Vocational Rehabilitation or any other organization(s) to help him or her get back to work.

  1. a. 

    Ask if the claimant has participated or is participating in:

    • 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 a student age 18 - 21); or

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

      Check “Yes” if the claimant has participated or is participating in any of the above, and go to 10.B.

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

  2. b. 

    If the claimant has received such services, collect the following information:

    • Name of organization or school;

    • Name of counselor, instructor, or job coach;

    • Phone number; and

    • Mailing address (complete street number and name), City, State/Province, ZIP/Postal code, and Country (if not USA).

  3. c. 

    Indicate the date when the claimant started participating in the plan or program.

  4. d. 

    Ask if the claimant is still participating in the plan or program. Check the appropriate box and fill-in the information:

    • Yes, I am scheduled to complete the plan or program on (date), or

    • No, I completed the plan or program on (date), or

    • No, I stopped participating in the plan or program before completing it because (give explanation).

  5. e. 

    List the types of services, tests, or evaluations that the claimant received. For example, intelligence or psychological testing, vision or hearing test, physical exam, work evaluations, or classes.

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

11. Section 11 – Remarks

a. Claimant information

Use this section to document any additional information or explanation the claimant did not give in other parts of this report:

  • If the claimant did not have enough space in the sections of this report to enter the requested information, use this area for additional information requested in those sections.

  • Show the section(s) and item(s) of the question(s) to which the claimant is referring.

  • If the claimant has not seen any of his or her medical sources for the conditions alleged in Section 3, annotate “No treating source for (alleged condition).” For example, if the claimant never sought treatment for eye floaters, enter in Remarks: “No treating source for eye floaters.”

b. Third party information

Use Section 11 - Remarks to document:

  • the name, address, phone number, and relationship to the claimant of an additional third party contact who knows about the claimant’s medical conditions and can help with the claim. If claimant decides not to provide an additional contact or does not have an additional contact indicate no additional third party contact is available, see DI 11005.023.C.2.

  • For the i3368 submitted online or the SSA-3368 submitted by mail, obtain an additional third party contact only when contact with the claimant is required for other development. If no other development is necessary, annotate "Internet/mailed in claim- no additional third party contact obtained" in the remarks. IMPORTANT: when contact with the claimant is needed, request an additional third party contact by phone or mail and document contact information or attempt to obtain the contact. If the claimant contacts the FO to provide the additional third party contact after the claim has transferred, document the third party contact information in the electronic folder via the Update-After Transfer (UAT) per DI 81010.095.

12. Date Report Completed

Enter the date (month/day/year) the form was completed.

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:

  • current filing including the potential onset date (POD);

  • work before or after the alleged onset date (AOD);

  • non-blind and blind date last insured (DLI), if applicable;

  • prior filings;

  • presumptive disability and presumptive blindness (Title XVI only); and

  • 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

  • Complete one entire paper form for multiple or concurrent EDCS exclusion claims.

  • Complete page 1, items 1 through 6 for each additional claim.

  • 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

  • Enter the number holder’s (NH) full name and social security number (SSN).

  • 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)):

  • resolve the conflict with the claimant,

  • enter the date selected by the claimant, and

  • 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:

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

  • Medicare for Qualified Government Employment (MQGE) claims; and

  • 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.

  • 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:

    • claims at the initial level,

    • claims at the reconsideration level,

    • claims at the hearings level, and

    • 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.

  • The POD cannot be earlier than the date the claimant meets all non-medical requirements.

  • The FO does not have the capability to enter the POD on the 3367 in EDCS at the appeals council or federal court levels.

  • 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.

  • 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;

  • Consider the POD separately for each disability claim type in concurrent or multiple Title II claims.

  • 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.

  • 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.

  • 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.

  • SSI application date (Title XVI only)

  • Date last insured (Title II only)

  • Date first insured (Title II only)

  • Controlling date (Title II only)

  • Alleged onset date (AOD) (Title II only)

  • 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.”

  • Work before or after the AOD (check all that apply) (both Title II and Title XVI):

    • UWA;

    • SGA;

    • Not SGA;

    • 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:

  • 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)

  • 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:

  • 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.

  • The claimant’s work is clearly not SGA per DI 10505.003.

  • The date first insured (DFI) is the reason for the POD. Enter the DFI.

  • The POD is the same as the AOD.

2. Item 6: MISCELLANEOUS INFORMATION

Provide the following information:

  • 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.

  • Enter the non-blind DLI for DIB and Freeze claims.

  • For appeal level cases, update the non-blind DLI if additional earnings resulted in a change to the non-blind DLI.

  • 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.

  • 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.

  • 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.

  • Check “yes” or “no” for a closed period of disability case.

See also:

  • DI 25510.001 Closed Period of Disability

  • DI 25510.010 Establishing a Closed Period of Disability and Protecting a Closed Period Freeze Under Title II

  • DI 25510.015 Closed Period of Disability Under Title XVI

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:

  • Type of prior claim(s);

  • SSN(s) of prior claim(s);

  • Date of last decision(s) (MM/DD/YYYY);

  • Level of last decision(s) (initial, reconsideration, etc.);

  • Outcome of last decision(s) (allowance or denial);

  • Location of prior folder; and

  • Prior folder requested; if “yes” include the date requested or “no.”

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

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:

  • type of interview:

    • Teleclaim with claimant,

    • Face-to-face with claimant, or

    • No contact with claimant;

  • use of an interpreter or of bilingual staff during interview;

  • difficulties with any of the activities listed (check “yes,” “no,” or “not observed/perceived”);

  • description of the claimant’s behavior, appearance, grooming, or degree of limitations; and

  • any additional comments about your observations.

6. Item 10: FO DEVELOPMENT

Document any development initiated by the FO.

For information about FO development, see

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),

  • ask the DDS to provide a capability opinion, and

  • 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

  • DI 11055.215A Policy for an FO request for DDS capability development

  • GN 00502.040A.3 How much consideration should I give to medical evidence?

9. Remarks Section:

Use the Remarks section to:

  • add explanations, descriptions, expansion of the answers to questions, or

  • record other pertinent information about the claim for the DDS.

a. Medicare for Qualified Government Employment (MQGE) claims

Enter the following information:

  • 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;

  • When forwarding MQGE only claims to the DDS for a disability determination, annotate “MQGE claim for Medicare entitlement only”;

  • 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:

  • DI 11035.001 Medicare for Qualified Government Employment (MQGE) Claims Based on Disability

  • DI 11035.005 Developing Medicare for Qualified Government Employment (MQGE) Claims Using the Electronic Disability Collect System (EDCS)

  • 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:

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:

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

  • 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:

  • “Medicare Waiting Period Determination Needed,”

  • the diagnosis code from the prior entitlement, and

  • 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

  • Print the interviewer’s name, area code, and phone number.

  • Print the name of the person completing the form (if different from the interviewer).

  • 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:

  • supplemental claim information regarding insured status, and

  • 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:

  • blindness,

  • vision problems, or

  • low vision

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

  1. a. 

    In item 6, Miscellaneous Information, enter:

    • the non-blind DLI in the “Non-blind date last insured (DIB/Freeze case)” field and

    • the blind DLI in the “Blind date last insured (if applicable)” field.

  2. 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:

  1. a. 

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

  2. 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.”

  3. c. 

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

  4. 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.

  5. 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:

  • the protective filing date;

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

For EDCS cases:

  • verify that the controlling date from systems is correct;

  • 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

  • DI 10515.000 Evaluation of Work Activity in Title II Blindness Cases – Table of Contents

  • DI 25501.380 Establishing the Established Onset Date (EOD) of Statutory Blindness in Title II Disability Insurance Benefits (DIB) Claims

  • DI 27500.000 Reopenings, Adoptions and Refilings – Table of Contents

  • DI 81010.150 Processing Claims Appeals of Medical Decisions in Electronic Disability Collect System (EDCS)


DI 11005 TN 60 - Disability Interviews - 6/27/2020