TN 11 (06-04)

DI 11005.016 Forms Used in Disability Claims

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

An SSA-3367 must be completed by the FO in each disability claim. The form records basic information available to the FO interviewer that does not involve requesting input from the applicant, and includes information used to determine onset, as well as earnings record, prescribed period and prior claim information, observations, etc. (See DI 11005.045 for completion instructions.)

B. Policy- Disability Interview Applicant Forms

1. SSA-3368 (Disability Report -- Adult)

For disability insurance benefits (DIB), disabled widow(er) benefits (DWB), title II childhood disability benefits (CDB) (including disabled minor child (DMC)) and title XVI disability or blindness claims for an adult (i.e., an individual who is age 18 or over) to obtain basic information about the claimant's condition, sources of medical evidence, and other information needed to process the claim to a decision. (See DI 11005.023 for completion instructions. Also see DI 81007.040 — Receiving the i3368 (Internet Adult Disability Report) for the Internet SSA-3368 information.)

2. SSA-3820 (Disability Report -- Child)

For title XVI disability or blindness claims for children (i.e., an individual who is under age 18) to record information about the claimant's condition and medical sources. (See DI 11005.030 for completion instructions.)

NOTE: Do not complete an SSA-3368 or an SSA-3820 when it is obvious that the claim will be disallowed in the FO on the basis of a non-disability factor of entitlement (e.g., DIB insured status not met, DWB outside of prescribed period, or Supplemental Security Income (SSI) nonmedical factors of eligibility are not met) or because the claimant is clearly doing substantial gainful activity (SGA). Retain forms in the claims folders as documentation if partially completed before it is discovered that the claim will be disallowed.

3. SSA-3369 (Work History Report)

For obtaining work history information in the circumstances listed in DI 11005.025.

4. SSA-3371 (Pain Report - Child)

An SSA-3371 must be completed whenever an SSA-3820 is required and pain must be developed. The Disability Determination Services (DDS) will determine when pain must be developed and will 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)

This form is to collect 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 (e.g., many cases that meet a listing do not need functioning information). The information detailed on the SSA-3373 may be obtained by telephone and recorded on an SSA-5002 in lieu of using the SSA-3373.

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.)

One of these five forms must be completed whenever an SSA-3820 is required. The specific form to be completed is dictated by 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 on functional abilities.

(See DI 11005.035 for additional instructions.)

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

The DDS will use 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. (The SSA-3380 is not mandatory for use in all cases. The DDS will use it if they determine that collateral development is appropriate.) The DDS will not send an SSA-827 when requesting a third party to complete the SSA-3380, unless the DDS knows from past experience that the source requires it. In the rare instance in which the third party insists on receiving an SSA-827 before providing evidence, the DDS will effectively black out all but the last four digits of the SSN in the box in the upper right corner of the SSA-827 and underneath the SSA-827 barcode. (See DI 11005.055.) The DDS may obtain the information detailed on the SSA-3380 by telephone and record it on an SSA-5002 in lieu of using the SSA-3380.)

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

For the claimant's request to a medical or other source to release information to SSA. (See DI 11005.055.)

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

For developing work activity.

10. SSA-3441 (Disability Report-Appeal)

For appeal cases to update information previously obtained or to identify additional impairments and/or medical sources.

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

For title XVI child appeals (reconsiderations, hearings) and CDRs to record information about nonmedical sources of evidence of the claimant's functioning.

When an appeal is requested, obtain a new SSA-3881 and complete only those sections that will provide updated information.

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

For assisting hospitals and claimants who file on behalf of children in providing local FOs and DDSs with medical information for determining disability of low birth weight infants. FOs use the forms as protective filing statements, and the medical information for making presumptive disability findings, which allow expedited payment to eligible claimants. DDS's use the medical information, when the form is signed by a physician, to determine disability and the most appropriate continuing disability review diaries. (See DI 11055.242)

C. References

See DI 11005.151 through DI 11005.153, DI 11055.242G, and DI 12095.000 for exhibits of the forms.

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DI 11005.016 - Forms Used in Disability Claims - 01/02/2015
Batch run: 01/02/2015