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USSSARev. 11-2023

Official form guide

Form SSA-3368-BK: Disability Report — Adult

Provides detailed medical and work history information to support a Social Security disability claim. Documents how your conditions affect your ability to work.

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Form Overview

SSA Form SSA-3368-BK - Disability Report — Adult

Provides detailed medical and work history information to support a Social Security disability claim. Documents how your conditions affect your ability to work.

A comprehensive report of your illnesses, injuries, conditions, medications, medical providers, and work history.

Risk Radar

Scan points
  • 1Being vague about limitations — SSA evaluators need specific details about what you cannot do, not just that you have a condition.
  • 2Omitting any medical provider — all treating sources must be listed so SSA can request records.
  • 3Not listing all medications including over-the-counter treatments and side effects.

Plain English

This form collects details about your medical conditions, doctors, medications, and work history to help SSA evaluate your disability claim.

Submission Date

  • Filing date: Complete with your initial disability application or when SSA requests updated medical information.
  • Preparation window: collect IDs, supporting records, and signatures in advance.
  • Final review: verify names, dates, and required fields before submission.

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Glossary Terms

medical

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Field map

Compact field-by-field guide

7 fields

Medical Info

3 items

Disabling Conditions

All illnesses, injuries, or conditions limiting your ability to work.

Requiredtext
Date Conditions Became Disabling

When your conditions first prevented you from working.

Requireddate
Medical Providers

All doctors, hospitals, clinics, and therapists who have treated you.

Requiredtext

Medications

1 items

Current Medications

All prescription and over-the-counter medications with dosages.

Requiredtext

Work History

1 items

Jobs in Last 5 Years

All jobs you have held in the past 5 years with dates and duties.

Requiredtext

Daily Activities

1 items

Daily Activities

What activities you can and cannot do due to your conditions.

Requiredtext

Signature

1 items

Signature

Sign to certify accuracy.

Requiredsignature

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Quick Facts

Adults applying for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) based on disability.
A comprehensive report of your illnesses, injuries, conditions, medications, medical providers, and work history.
Complete with your initial disability application or when SSA requests updated medical information.
Submit with your disability application or mail to SSA.
This report helps SSA evaluate how your conditions limit your ability to work by gathering detailed functional information.
Be as thorough and specific as possible. List all medical conditions, all providers, all medications, and describe in detail how conditions affect daily activities.

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Source transparency

Copyright & Licensing - US Government Forms

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Public DomainCreated by the U.S. federal government. Not subject to copyright (17 USC § 105). Freely copyable without restriction.
Public DomainCreated by the U.S. federal government. Not subject to copyright (17 USC § 105). Freely copyable without restriction.
Public DomainCreated by the U.S. federal government. Not subject to copyright (17 USC § 105). Freely copyable without restriction.
Public DomainCreated by the U.S. federal government. Not subject to copyright (17 USC § 105). Freely copyable without restriction.
Verify current license terms with the source agency before reuse outside this platform.

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