BASIC (06-07)

DI 20502.015 Documents for Initial Disability Cases- Electronic Disability Collect System (EDCS) Exclusions

NOTE: For certified electronic folder (CEF) instruction, see DI 81010.020, DI 81010.025, and DI 81010.030.

A. SSA-831 – Disability Determination and Transmittal

Items 1 through 14 are completed by the field office (FO) for all cases - see DI 11010.205 for information needed in each field and DI 11055.130 for specific Title XVI entries.

In Title XVI claims, if the FO determines that the claimant is presumptively disabled (PD) or presumptively blind (PB), the FO will complete the SSA-831-U3 (Disability Determination and Transmittal) as above. In addition, the FO will complete items 15, 27, and 34 for PD/PB only cases. See DI 11055.240D for instructions on completing the paper form.

Flag the case with Form SSA-408 (Route Slip) and annotate “Expedite - Delayed Case” indicating “FO-PD (or PB) decision”. See DI 23535.020 for disability determination service (DDS) entries/actions in PD/PB cases.

B. SSA-820-F4/SSA-821-BK – Work Activity Report – Self Employed/Employee

Work issue cases sent to the DDS from the FO will contain a work issue determination on an SSA-821 (Work Report -- Employee) or SSA-820 (Work Activity Report -- Self Employed Person). (See DI 10510.025 and DI 10505.035 for instructions for completing reports. See GN 00201.015 for policy and procedure when signature proxy is involved.) See DI 81020.120 for electronic procedures.

C. SSA-3367 Disability Report – Field Office

The FO uses this report to record information that does not involve the claimant’s input. The DDS uses this information to determine the appropriate time period for developing medical evidence, the technical factors that must be considered in establishing the onset date of disability, the history of claimants’ prior case actions, claimants’ insured status, and to review observations about claimants recorded during contacts with the FO. (See DI 11005.045.)

D. SSA-3368 (Disability Report - Adult)

This report is used for all adult Title II initial claims Disability Insurance Benefits (DIB), Disabled Widow’s Benefits (DWB), Childhood Disability Benefits (CDB), including Disabled Minor Child (DMC) and all adult Title XVI initial disability or blindness claims. (See DI 11005.023.) This report is also used for Title XVI age 18 redeterminations.

E. SSA-3820 (Disability Report - Child)

This report is used for initial Title XVI disability or blindness claims for children under age 18 (See DI 11005.030 for additional instructions. The form incorporates the information collected on the SSA-3881 (Medical and Job Worksheet). Therefore, the SSA-3881 is no longer used in initial claims; however, the SSA-3881 is still used for appeals.)

F. SSA-3369 (Work History Report)

This report is used for obtaining work history information when needed as explained in DI 11005.025.

G. SSA-3371 (Pain Report – Child)

An SSA-3371 must be completed when an SSA-3820 is required and pain must be developed (Section 3, Question C. on the SSA-3820 is answered “Yes”).

NOTE: The DDS will determine when pain must be developed and will collect the information.

H. SSA-3373 (Function Report - Adult)

This report is used to collect information about a claimants' ability to function and to perform the activities of daily living. The DDS collects this form when necessary, except that the FO collects it in the circumstances listed in DI 11005.026.

I. 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.)

The FO must complete this report when