DI 11005.045 Completing the SSA-3367 (Disability Report – Field Office)
The field office (FO) completes Form
or the Electronic Disability Collect System (EDCS) 3367 Disability Report
for initial claims, reconsiderations of initial claim, escalated claims,
and continuing disability reviews (CDRs). Complete the SSA-3367 or EDCS
3367 before transferring jurisdiction of a claim to the disability
determination services (DDS).
This information alerts the DDS to factors that could affect entitlement
and guides case development. The entries provide the DDS with information
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;
presumptive disability and presumptive blindness (Title XVI only); and
EXCEPTIONS: Although EDCS supports electronic CDR
processing, complete the paper SSA-3367 for EDCS exclusions i.e.,
expedited reinstatements (EXRs). For additional EDCS exclusions, complete
the paper SSA-3367 as detailed in DI 81010.030.
A. FO completes the SSA-3367
Complete one entire paper form for multiple or concurrent EDCS exclusion
Complete page 1, items 1 through 6 for each additional claim.
Complete form 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
Enter the claimant’s full name, gender, date of birth, and SSN, if
different from the NH.
Enter the claimant’s name and SSN for auxiliary or survivor claims
(e.g., a disabled widow(er) beneficiary (DWB) filing on the deceased
spouse’s record, or a disabled minor child (DMC) filing on a
b. Item 2: Claimant’s Alleged Onset Date (AOD)
Enter the AOD.
The AOD is the date the claimant alleges he or she became unable to work
because of his or her medical condition, see DI 25501.210.
If the claimant never worked, enter as the AOD, the date he or she
believes the condition(s) became severe enough to keep him or her from
If the AOD conflicts anywhere in the file (e.g., the AOD is different on
the application from the date on the
(Disability Report - Adult)):
resolve the conflict with the claimant,
enter the date selected by the claimant, and
explain why the AOD conflicts in the Remarks section on the
Make all AOD changes in the Modernized Claims System (MCS) and in the
Modernized Supplemental Security Income Claims System (MSSICS).
c. Item 3: Potential Onset Date (see DI 25501.220 Potential Onset Date (POD))(check type of claim(s) and enter potential onset date)
The POD alerts the DDS examiner of work issues, insured status, and other
non-medical factors that may affect the established onset date (EOD). The
POD is claim specific.
Before transferring jurisdiction of a claim to the DDS, the FO must enter
the POD for each Title II disability claim at the initial and
reconsideration levels, including escalated claims, and continuing
disability review claims (CDRs). The POD must be after 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 Title II disability insurance benefit (DIB) 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
Consider the POD separately for each disability claim type in concurrent
or multiple Title II claims.
To complete items 3 through 6, follow detailed instructions in subsection
B. Supplemental instructions for Form SSA-3367 for specific claim types:
NOTE: Be aware that the POD may be in a previously adjudicated
period; including a period decided by an administrative law judge (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
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 believes 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.
d. Item 4: Reason for Potential Onset Date
Check the appropriate block for the reason for the POD.
IMPORTANT: You must complete Form
(Report of SGA Determination - For SSA Use Only) in all initial claims
that require an
(Work Activity Report - Self-Employment) or an
(Work Activity Report - Employee).
Do not complete an SSA-821-BK or SSA-823 if the work is clearly not SGA
per DI 10505.003.
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
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. (You must 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.
2. Item 6: MISCELLANEOUS INFORMATION
Provide the following information:
Enter the protective filing date. Find the protective filing date in the
electronic folder under the case data tab in eView.
Enter the non-blind DLI for DIB and Freeze claims.
Enter the blind DLI if the claimant is insured for blind benefits, and
alleges blindness, a visual impairment, or low vision. For claims
involving potential blindness, see Remarks Section, 9.f.
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, verify that the propagated prescribed
period and controlling date are correct. For detailed guidance, see
Check “yes” or “no” for a closed period of
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,
Indicate whether the claimant has a prior filing(s).
If yes, and you are not sending the prior folder(s) to the DDS,
provide the following information:
Type of prior claim(s);
SSN(s) of prior claim(s);
Date of prior decision(s) (MM/DD/YYYY);
Level of prior decision(s) (initial, reconsideration, etc.);
Outcome of prior decision(s) (allowance or denial);
Location of prior folder; and
Prior folder requested; if “yes” include the date requested or
For instructions on prior filings, see Prior Claims Activity in
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.
Refer to detailed FO procedures on processing PD and PB claims in
5. Item 9: OBSERVATIONS/PERCEPTIONS
How was the interview conducted?
Observations are very valuable to DDS examiners for both face-to face and
telephone interviews. Record the following information:
type of interview
if claimant communicated in a language other than English, record that
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
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.
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),
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
9. Remarks Section:
Use the Remarks section
to add explanations, descriptions, expansion of the answers to questions,
to 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
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.
See MQGE policy and procedures:
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
EXAMPLE: lack of transportation, home confinement due to
disability, inability to read, no telephone to reach the claimant, or
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
EXAMPLE: Telephone contact with a homeless claimant may be
difficult, or a claimant may be on an extended trip and unavailable for
e. Curtailing completion of Form SSA-3368-BK (Disability Report – Adult) or SSA-3820-BK (Disability Report – Child)
If you curtail completion of the
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
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.
Print the interviewer’s name, area code, and phone number
Print the name of the person completing the form (if different from the
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:
vision problems, or
When there are both non-blind and blind allegations, provide the non-blind
DLI and the blind DLI. In these claims:
In item 6, Miscellaneous Information,