DISABILITY REPORT - ADULT - Form SSA-3368-BK
PLEASE READ ALL OF THIS INFORMATION BEFORE YOU BEGIN
COMPLETING THIS FORM
THIS IS NOT AN APPLICATION
IF YOU NEED HELP
If you need help with this form, do as much of it as you can, and your interviewer will help
you finish it. However, if you have access to the Internet, you may access the Disability
Report Form Guide at http://www.socialsecurity.gov/disability/3368/index.htm.
HOW TO COMPLETE THIS FORM
The information that you give us on this form will be used by the office that makes the
disability decision on your disability claim. You can help them by completing as much of the
form as you can.
• Please fill out as much of this form as you can before your interview appointment.
• Print or type.
• DO NOT LEAVE ANSWERS BLANK. If you do not know the answers, or the answer is
"none" or "does not apply," please write: "don't know," or "none," or "does not apply."
• IN SECTION 4, PUT INFORMATION ON ONLY ONE DOCTOR/HOSPITAL/CLINIC
IN EACH SPACE.
• Each address should include a ZIP code. Each telephone number should include an area code.
• DO NOT ASK A DOCTOR OR HOSPITAL TO COMPLETE THE FORM. However,
you can get help from other people, like a friend or family member.
• If your appointment is for an interview by telephone, have the form ready to discuss with us
when we call you.
• If your appointment is for an interview in our office, bring the completed form with you or
mail it ahead of time, if you were told to do so.
• When a question refers to "you," "your" or the "Disabled Person," it refers to the person who
is applying for disability benefits. If you are filling out the form for someone else, please
provide information about him or her.
• Be sure to explain an answer if the question asks for an explanation, or if you want to give
• If you need more space to answer any questions or want to tell us more about an answer,
please use the "REMARKS" section on Pages 9 and 10, and show the number of the questi