TN 50 (07-17)

DI 11005.016 Forms Used in Title II & Title XVI Disability Claims

A. Policy – Disability Interview Form SSA-3367 (Disability Report – Field Office)

The SSA-3367 is used for title II and title XVI disability or blindness claims. The field office (FO) must complete an SSA-3367 for each disability claim. The form records basic information available to the FO interviewer. This includes information used to determine a potential onset date (POD), obtain information from the earnings record, determine the prescribed period of disability, include prior claim information (if any), and observations made by the interviewer. For complete instructions, see DI 11005.045.

B. Policy – Disability Interview Applicant Forms

1. SSA-3368 (Disability Report – Adult)

The SSA-3368 is used for title II and title XVI disability or blindness claims. Reviewers obtain basic information on an adult claimant's medical conditions medical treatment (including sources of medical evidence), and any other information needed to process the claim to a decision. The form also reserves the claimant’s protective filing date. For complete instructions, see DI 11005.023 and DI 81007.030. We discuss the POMS reference referred to as i3820 in Section two of this policy.

2. SSA-3820 (Disability Report – Child)

The SSA-3820 is used for title XVI childhood disability or blindness claims. Reviewers obtain basic information about the child's condition and medical sources. For complete instructions, see DI 11005.030 and DI 81007.040.

NOTE: The FO should not complete an SSA-3368 or an SSA-3820 when it is obvious that the claim will be denied based on a non-disability factor of entitlement or because the claimant is clearly doing substantial gainful activity (SGA). Retain any partially completed forms in the claims folder.

3. SSA-3369 (Work History Report)

The SSA-3369 is used to supplement the SSA-3368 with detailed information about jobs that the claimant has performed in addition to his or her usual job. The FO records work history information only in the circumstances listed in DI 11005.025.

4. SSA-3371 (Pain Report – Child)

The SSA-3371 is used by the Disability Determination Services (DDS) when developing symptoms of pain. The DDS determines when to develop symptoms of pain and sends the form to collect the information. The form records information on the location, duration, frequency, and intensity of pain, the precipitating and aggravating factors, and medication or treatment received for relief of the pain.

5. SSA-3373 (Function Report – Adult)

The SSA-3373 records information about a claimant's ability to function and to perform the activities of daily living, in the circumstances listed in DI 11005.026. The SSA-3373 is not mandatory in all cases (for example, listing-level impairments).

6. SSA-3375, SSA-3376, SSA-3377, SSA-3378 and SSA-3379 (Function Report - Child) (Separate form for each age group: Birth-1, 1-3, 3-6, 6-12, 12-18.)

Complete one of these five forms whenever an SSA-3820 is required. The form completed is based on the age of the child at the time of completion (or if mailed, age at the time the form is mailed to the applicant). The form records information about the child’s functional abilities. For complete instructions, see DI 11005.035.

7. SSA-3380 (Function Report-Adult-Third Party)

The DDS uses the SSA-3380 to collect evidence about a claimant's ability to perform the activities of daily living from third parties familiar with the claimant's ability to function, such as the claimant's spouse, relatives, neighbors, friends, clergy, teachers, or employers.

Use of the SSA-3380 is not mandatory all cases. The DDS will use it if they determine that development from someone familiar with the claimant is appropriate.

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

The SSA-827 records the claimant's signed consent to allow a medical or other source to release information to SSA. For complete instructions, see DI 11005.055.

9. SSA-820 (Work Activity Report – Self-Employed Person) or SSA-821 (Work Activity Report - Employee)

The SSA-820 is used for developing work activity.

10. SSA-3441 (Disability Report-Appeal)

The SSA-3441 is used for appeal cases to update information previously obtained or to identify additional impairments and medical sources.

11. SSA-3881 (Questionnaire for Children Claiming SSI Benefits)

The SSA-3881 is used for title XVI child appeals (reconsiderations, hearings) and continuing disability reviews (CDRs) to record information about nonmedical sources of evidence who can provide information about the claimant's functioning. Complete only those sections that provide updated information.

12. SSA-3830 (Certification of Low Birth Weight for SSI Eligibility)

The SSA-3830 is used for assisting hospitals and claimants who file on behalf of children in providing medical information for determining disability of low birth weight infants. FOs use the forms as protective filing statements, and for making presumptive disability findings, which allow expedited payment to eligible claimants. DDS's use the medical information, when a physician signs the form, to determine disability and the most appropriate continuing disability review diaries. For complete instructions, see DI 11055.242.

C. Distribution and use of Spanish disability forms

1. Spanish forms in Puerto Rico

The Office of Disability Policy (ODP), the Office of Public Service and Operations Support (OPSOS), and the Regional Offices have a long-standing agreement that restricts the use of Spanish versions of our disability report forms to offices in Puerto Rico (PR) only. Spanish forms are available in PR because Spanish is the native language and all adjudicative personnel (FO, DDS, and ODAR) are able to read and understand forms completed in Spanish without translation. However, this is not true in the U.S. If an FO in the U.S. receives a form completed in Spanish, then the FO has the additional burden of obtaining an English translation of the form.
NOTE: All information entered into EDCS must be in English, regardless of the submission language. This is true for all jurisdictions, including PR.

2. Non-English forms usage outside PR

We use non-English translations of disability forms outside of PR, but only to help claimants complete those forms in English. There are several tools available. We have translation sheets (not actual forms) of the SSA-827 in the 15 Multilanguage Gateway languages.

The sheets are available for reference only by claimants and claims representatives (CRs) everywhere to help ensure that claimants have informed consent about the document they are signing. Similarly, the Spanish version of the SSA-3368-BK is available on the Intranet site for our bilingual CRs in the U.S. to use as an interviewing guide only.

These translation sheets are located on the:

3. Forms translation responsibility

If the FO gives out non-English forms to the public in error, then the FO is responsible for obtaining the translation of the form into English to include in the folder prior to releasing the case to the DDS.

If a DDS outside of PR mistakenly receives a disability form completed in Spanish, the DDS should send it to the appropriate FO for translation into English. The DDS is only responsible for the translation of medical evidence, or any other documents, that the DDS itself requested.

D. References

  • DI 11005.151: SSA-3368-BK, Disability Report - Adult -- Exhibit

  • DI 11005.152: SSA-3820-BK, Disability Report Child -- Exhibit

  • DI 11005.153: SSA-3369-BK, Work History Report -- Exhibit

  • DI 11055.242: Using the Certification of Low Birth Weight for SSI Eligibility (SSA-3830) Form in Making Presumptive Disability Determinations

  • DI 12095.005: SSA-561-U2 (Request for Reconsideration)

  • DI 12095.010: SSA-561-U2 SP (Solicitud Para Reconsideration) (Request for Reconsideration)

  • DI 12095.015: SSA-831-C3/U3 (Disability Determination and Transmittal)

  • DI 12095.020: SSA-832 (Cessation or Continuance of Disability or Blindness Determination and Transmittal -- Title XVI)

  • DI 12095.025: SSA-833 (Cessation or Continuance of Disability or Blindness Determination and Transmittal -- Title II)

  • DI 12095.030: SSA-3441-BK (Disability Report - Appeal)

  • DI 12095.040: SSA-789-U4 (Request for Reconsideration - Disability Cessation)

  • DI 12095.050: SSA-773-U4 (Waiver of Right to Appear - Disability Hearing)

  • DI 12095.055: SSA-769-U4 (Request for Change in Time/Place of Disability Hearing)

  • DI 12095.065: SSA-770-U4 (Notice Regarding Substitution of Party Upon Death of Claimant - Reconsideration of Disability Cessation)


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0411005016
DI 11005.016 - Forms Used in Title II & Title XVI Disability Claims - 07/26/2017
Batch run: 07/26/2017
Rev:07/26/2017