How to fill out Form SSA-3368-BK
Bother@forgedpostsanonymous.unorg Cymbal Man Freq.
http://www.socialsecurity.gov/disability/3368/steps.htm
http://www.socialsecurity.gov/disability/3368/3368guidetext.htm
Disability Report Form Guide (Text Version)
Go To Section:
1) Information About the Disabled Person
2) Your Illnesses, Injuries or Conditions and How They Affect You
3) Information About Your Work
4) Information About Your Medical Records
5) Medications
6) Tests
7) Education / Training Information
8) Vocational Rehabilitation, Employment, or Other Support Services Information
9) Remarks
Information about Person Completing this Form.
Select Back to top to return to the top of this page.
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Section 1 - Information About the Disabled Person
A. Name, B. Social Security Number
We need your name and Social Security number to identify your medical and work
records. If you have used other names, please list those names in Section 4.C.
Many doctors and hospitals use Social Security numbers as patient identification
numbers. Your number may help them to locate and send us your medical records
faster.
C. Daytime Telephone Number
We need an area code and phone number where we can reach you or leave a message,
because we may need to contact you for additional information. If you do not
have a phone, please give us the name and phone number of someone who can get in
touch with you quickly. Let them know that we may call them with a message for
you.
D. Name of a Friend or Relative
We ask you to identify a friends or relatives who know about your illnesses,
injuries, or conditions because they can often tell us how your medical problems
affect you. Reports from doctors and hospitals provide a lot of information we
need, but they don't always give us a complete picture of how your illnesses,
injuries, or conditions affect you in your daily life. For this reason, we may,
with your permission, contact a friend or relative who may be able to help with
your claim, help you obtain medical records, or get you to a medical
examination. Please give a complete mailing address of your friend or relative.
If you need to give us more than one name, please write the other name(s), phone
number, and relationship to you in Section 9 - Remarks.
FREQUENTLY ASKED QUESTIONS:
Can I list my husband or wife or older children?
Yes. In fact, we are very interested in hearing from people who know you best
and can tell us about your illnesses, injuries, or conditions and how they
affect you.
Should I tell the person that I list that you may be calling them?
Yes. You should tell the person that we may call or write them for information
about your illnesses, injuries, or conditions or your activities.
E. Height and F. Weight
We ask you for your height and weight because this information may be important
in evaluating your illnesses, injuries, or conditions. Even though your height
and weight may be in your medical records, the information you give us can show
us if it is the most accurate and up-to-date information.
FREQUENTLY ASKED QUESTIONS:
What if I don't know my height or weight?
If you don't know your height or weight, just write the words "don't know" on
the line. However, if you know approximately how tall you are or how much you
weigh, you can write the word "about" followed by your height or weight. For
example, "about 5 feet, 6 inches".
I haven't been weighed recently and I am not sure if my weight has changed. What
should I write?
You can write the last weight that you remember and tell us approximately when
you were last weighed. For example, "150 pounds last summer". If you think that
you may have gained or lost weight since you were last weighed, you can also
mention that in Section 9 - Remarks.
I don't like to tell people how much I weigh. Do I need to tell you?
We certainly understand your feelings. However, the information that you give us
is private, and we use it only as part of your medical evaluation. Medical
reports don't always include your height or weight, so the information you give
us may be very helpful.
G. Medical Assistance Card
If you have a Medicaid, Medi-Cal, or other medical assistance card from your
State government, your card number can help us obtain your medical records. This
may help us complete your claim sooner.
FREQUENTLY ASKED QUESTIONS:
Do you want the number of any health insurance card that I have?
No. We only want your card number if you receive medical assistance from your
State government, such as Medicaid or Medi-Cal. This number may help us obtain
your medical records more easily. We do not need a number if you have commercial
health insurance, such as Blue Cross, Medicare, or an HMO.
What if I don't know my number?
If you know the State office that gave you the card, you can call them for your
number. Or, you can call your doctor's office. If you still do not know what
your card number is, just write the words "don't know" on the line.
H., I., J. Can You Speak, Read, Write, and Understand English?
We need to know if you can speak and understand English for several reasons:
If you cannot speak or understand English, we will be able to help you by
providing an interpreter, free of charge, when we talk with you about your
claim.
If you cannot speak, read, or write English, is there someone who does, and will
give you messages, if we need to contact you?
Many of our booklets and letters are written in languages other than English. If
we know that you read another language, we may be able to give you information
in a language that you understand.
If you are unable to do the type of work you did in the past, we will decide if
you can do other types of work. We will consider your age, education, and skill
level. Education includes your ability to communicate in English. If you cannot
speak, read, or write English, it may be harder for you to do some jobs.
MORE INFORMATION:
Publications in Non-English Languages
Interpreter Services
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Section 2 - Your Illnesses, Injuries, or Conditions and How They Affect You
General Information About Section 2
We will consider all the facts, including medical evidence from your doctors,
hospitals, and clinics where you have been treated in deciding if you are
disabled. Please describe your illnesses, injuries, or conditions, when they
began, and how they limit your activities. If you give us a full description of
your illnesses, injuries, or conditions, it will help us decide your case
quicker.
We will consider all your illnesses, injuries, and conditions, whether or not
you have been receiving treatment for them.
It is important that you give the date you became unable to work. If you are
disabled, the date you became unable to work may affect when you can begin
receiving benefits and the amount of your benefits. We also ask about any work
you have done after the date your condition first bothered you because this
helps us decide the earliest date that your disability began.
A. What are the illnesses, injuries, or conditions that limit your ability to
work?
It is important that you list all of your illnesses, injuries, or conditions
that affect your ability to work, including any mental and emotional illnesses.
We will consider all your illnesses, injuries, or conditions, whether or not you
have been receiving treatment for them. Use your own words if you don't know the
medical names.
If you need more room to write, use the space in Section 9 - Remarks.
B. How do your illnesses, injuries, or conditions limit your ability to work?
To help us decide if you are disabled you should describe how your illnesses,
injuries, or conditions limit your ability to do work-related activities, such
as walking, sitting, lifting and carrying, or remembering instructions. See
Section 2.C., for information about how symptoms, such as pain, shortness of
breath, or fatigue may affect your ability to function. If you need more room to
write, use the space in Section 9 - Remarks.
C. Do your illnesses, injuries, or conditions cause you pain or other symptoms?
We consider the effects of symptoms, such as pain, shortness of breath, or
fatigue on your ability to function. Symptoms may restrict your ability to do
daily activities, such as personal care (bathing, hair care, and dressing), food
preparation, household maintenance, and recreational activities. They may also
limit your ability to do work-related activities, such as walking, sitting,
lifting, and carrying or remembering instructions. You should tell us in Section
2.B how your symptoms affect your ability to work.
D. When did your illnesses, injuries, or conditions first bother you?
Some illnesses, injuries, or conditions may start suddenly or get worse over
time. To evaluate your illnesses, injuries, or conditions and decide when your
disability began, we will consider the date you list here and in Section 2.E.,
and Section 2.I. For illnesses, injuries, or conditions that occur suddenly,
such as a stroke or heart attack, the dates in Section 2.D., Section 2.E. and
Section 2.I. may be the same.
E. When did you become unable to work because of your illnesses, injuries, or
conditions?
Disability under our rules is based on your inability to work because of your
illnesses, injuries, or conditions, even if you have never worked. As closely as
possible, you should give the date that your illnesses, injuries, or conditions
caused you to become unable to work. This date may or may not be the same as the
date in Section 2.D.
To determine the beginning date of your disability, we will look at the date you
list here (even if you have never worked), the dates in Section 2.D., and
Section 2.I., and evidence from your medical records.
F. Have you ever worked?
We need to know if you have ever worked because you may have done work that is
not shown in our records. We will look at your age, education, past work
experience, and any work skills that you may have in deciding your claim. If you
have worked, we will need more information about your work in Section 3.
G. Did you work at any time after the date your illnesses, injuries, or
conditions first bothered you?
If we find that you are disabled, we will decide the earliest date that your
disability began. You must be unable to work because of your illnesses,
injuries, or conditions to qualify for disability under Social Security Rules.
However, some people keep working after their illnesses, injuries, or conditions
first started. To determine the earliest date that you became disabled, we need
to know if you tried to work after the date you wrote in Section 2.D. We also
need to understand how your illnesses, injuries, or conditions affected your
ability to work.
H. If you did work after the date your illnesses, injuries, or conditions first
bothered you, did they cause you to work fewer hours, change your job duties, or
make any other job-related changes?
If you worked after your illnesses, injuries, or conditions first bothered you,
you may have made changes in your job, such as working fewer hours, doing
lighter job duties, or receiving extra help from your employer. Please explain
any changes in the way you did your job because of your illnesses, injuries, or
conditions.
FREQUENTLY ASKED QUESTIONS:
Why do you want to know about changes in my work patterns caused by my
illnesses, injuries, or conditions?
We ask you questions about changes in your work patterns caused by your
illnesses, injuries, or conditions because it helps us decide the beginning date
of your disability.
What do you mean by extra help from my employer?
Some examples include extra supervision, help lifting or carrying, or extra rest
breaks. If you worked under special conditions during a period that you say you
were disabled, we will ask you to tell us about those special conditions.
I. Are you working now? If No, when did you stop working?
Because your work activity is important in determining whether you are disabled,
we must know if you are working now. If you stopped working, you should enter
the date you stopped working. This may or may not be the same as the date in
Section 2.E. If you are working now, we will be asking you for more information
about your work.
J. Why did you stop working?
If you stopped working for medical reasons, enter your illnesses, injuries, or
conditions here.
If you stopped work for any reason other than your disability, such as
retirement, plant closure, layoff, or you quit, please explain.
If we find you disabled under our rules, we need to know the date you became
unable to work because of your illnesses, injuries, or conditions. The date that
we find you disabled is your established onset date. This date may affect when
your benefits will start and the amount of your benefits.
MORE INFORMATION - HOW THE ONSET DATE MAY AFFECT YOUR BENEFITS:
If you are applying for Social Security Disability Insurance benefits, your
benefits may be paid beginning with the sixth full month after your disability
began. You may also receive up to 12 months of prior payments, depending on when
your disability began and when you filed your claim.
If you are applying for Supplemental Security Income, your benefits will begin
the first month after…. either the date your disability began or the date you
filed your application, whichever is later.
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Section 3 - Information About Your Work
General Information About Section 3
We need to find out about your past work to decide if you can still do it. To
make this decision, we need to know how you did your job. We also need to know
if you learned skills on your job.
We need this information to see if there are other jobs that you have done other
than your usual work. If you cannot do your usual work, we will decide if you
can do another job that you did in the last 15 years. Remember that you are not
disabled according to our rules unless your illnesses, injuries, or conditions
prevent you from doing any job. Because people lose job skills if they do not
use them for a long time, we do not consider them and you do not need to include
jobs you did more than 15 years ago. If you need more room to list your jobs,
use the space in Section 9 - Remarks.
FREQUENTLY ASKED QUESTIONS:
Can't you get this information from my Social Security records?
The information about the kind of job that you did and the skills that you
needed to do that job is not in our records. Our records only show who paid you
and how much they paid you in a given year.
A. List the jobs that you have had in the last 15 years that you worked.
Please list all your jobs in the past 15 years starting with your most recent
job and working back. For each job, list the title of the job (for example,
waitress, truck driver, bank teller), the type of business where you worked
(fast food, laundry, bank, etc.), the dates you worked there (month and year are
enough), the number of hours a day you worked, the number of days per week, and
your most recent pay rate.
B. Which job did you do the longest?
C. Describe this job. What did you do all day? (If you need more space, write in
Section 9- Remarks.)
This information is very important because we need to decide if your illnesses,
injuries, or conditions prevent you from doing your past work. Please tell us
about your job duties. This is your chance to tell us what you actually did on
the job. We need this information so we can understand what your job was like.
If you need more room, you can use Section 9 - Remarks to continue your
description, or you may add additional sheets of paper.
FREQUENTLY ASKED QUESTIONS:
Why can't I just list the job I did the longest without describing it?
We need more information than that. There are jobs with the same name but very
different job duties. There are also jobs that have the same job duties but have
different names. That is why a job title is not enough to describe your work.
Please try to describe what you did on the job so that someone who has never
done it will understand how you did it. We need this information to decide if
you can do your past work.
How much information do you want about my job(s)?
Tell us what you did on the job that you held the longest. We need enough
information to get a good picture of what you did in a normal workday. Remember
that most people have no idea what it takes to do your job.
What if I had more than one major job in the last 15 years?
If we need more information about these jobs, we will send you another form with
enough room to describe all of your jobs.
THE FOLLOWING QUESTIONS ASK FOR INFORMATION ABOUT THE JOB YOU DID THE LONGEST IN
THE LAST 15 YEARS THAT YOU DESCRIBED IN Section 3.C.
D. In this job (the one you described in 3.C), did you use machines, tools, or
equipment? Use technical knowledge or skills? Do any writing, complete reports,
or perform any duties like this?
This checklist asks you about your job skills. Check "YES" or "NO" for each of
the items listed.
FREQUENTLY ASKED QUESTIONS:
What do you mean by machines, tools, and equipment?
We are trying to understand what you did on the job. For example, if you were a
carpenter, did you only use hand tools like hammers and saws? For another
example, if you were a secretary, did you use a computer for word processing?
What do you mean by technical knowledge?
We mean special skills you learned on the job. For example, an electrician
learns about the basic laws of electricity, the electrical codes and how to use
special tools.
What do you mean by writing and completing reports?
This question asks you if you did any writing or if you had to complete reports
as part of your job. For example, a bookkeeper completes accounting reports as
part of his or her job duties.
E. In this job (the one you described in 3.C) , how many total hours each day
did you: walk, stand, sit, climb, stoop, kneel, crouch, crawl, handle, grab, or
grasp big objects, write, type, or handle small objects?
This item asks you for the number of hours that you usually did certain physical
activities in a normal day on your job. If the list does not really describe
what you did on your job, then be sure to explain it in Section 9 - Remarks. In
a normal workday, most people would have to do some of the activities listed.
Please try to tell us how long you did the activities in a normal workday. For
example, a security guard might sit for 4 hours and walk for 4 hours in an
8-hour workday.
FREQUENTLY ASKED QUESTIONS:
Why are standing and walking separated?
Some jobs may require standing in one place for long periods of time and other
jobs require mostly walking or a combination of walking and standing. We need
this information to understand the physical requirements of your job.
F. Lifting and Carrying (Explain what you lifted, how far you carried it, and
how often you did this)
This item asks you what lifting and carrying you had to do on your job (the one
you described in 3.C) . Be sure to tell us how often and for how long you had to
lift and carry things on your job. We use the information in deciding how your
illnesses, injuries, or conditions affect your ability to work.
G. Check heaviest weight lifted.
This item asks you to check the heaviest weight you had to lift on the job (the
one you described in 3.C) every day. We need this information to decide if you
can still do this job.
H. Check weight frequently lifted (By frequently, we mean from 1/3 to 2/3 of the
workday).
This item asks you how much weight you had to lift frequently on your job (the
one you described in 3.C). We realize that it is difficult to know exactly how
much certain items weigh, but you may give us an estimate about how much you
think they weigh.
For example, a gallon of milk weighs about 8 pounds, and bags of sugar, flour,
dry dog food, and kitty litter have their weights listed on the package. You can
compare those weights to the weights you had to lift frequently on the job.
I. Did you supervise other people in this job?
Check “Yes” or “No”. If “No” go to question J. If “Yes”, tell us how many people
you supervised, how much of your day was spent supervising the work of others,
and whether you hired and fired employees in your job.
J. Were you a lead worker?
What we mean by “lead worker” is someone who performs some kind of
non-supervisory work but who may have additional responsibility for setting the
pace of work, for ensuring the completion of work, or some other kind of
supervisory duties as they work.
All of the information we ask you to provide about your job gives us a good idea
about the physical requirements of your job. We will use this information to
decide if your illnesses, injuries, or conditions prevent you from doing your
past work.
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Section 4 - Information About Your Medical Records
General Information About Section 4
If you have received treatment, we will ask for your medical records. We use
your medical records and other information to decide if you are disabled under
our rules.
We need information about your medical treatment for any illnesses, injuries, or
conditions that limit your ability to work. If you already have copies of your
medical records in your possession from your doctors, hospitals, clinics, and
other medical sources, we will not have to request them. This will allow us to
decide your claim faster. Do not wait to file your claim if you do not have
these records. With your permission, we will ask the medical sources you list to
send them to us. If you have not received treatment, or we do not get enough
information about your illnesses, injuries, or conditions, we may ask you to
have a special examination or test.
We need this information because we use your medical records and other
information to decide if you are disabled. We will contact the medical sources
that have treated you for illnesses, injuries, or conditions and ask them to
send us copies of your medical records.
We also ask for information such as:
What are your illnesses, injuries, or conditions?
When did they begin?
How do they limit your activities?
What did medical tests show?
What treatment did you receive?
In addition, we ask for information about your ability to do work-related
activities, such as walking, sitting, lifting, carrying, and understanding and
remembering instructions.
We do NOT ask your doctors to decide if you are disabled. Rather, we decide if
you are disabled under our rules.
A. Have you been seen by a doctor/hospital/clinic or anyone else for the
illnesses, injuries or conditions that limit your ability to work?
We need to know if you have been treated for any illnesses, injuries, or
conditions that limit your ability to work, even if you have not been seen
recently.
B. Have you been seen by a doctor/hospital/clinic or anyone else for emotional
or mental problems that limit your ability to work?
We need to know if you have been treated for any emotional or mental problems
that limit your ability to work, even if you have not been seen recently. We
need this information because we consider emotional and mental difficulties, in
addition to physical problems, when we decide your claim. It's important that we
know about treatment for ALL of your illnesses, injuries, and conditions. If you
have received treatment, we will ask for your medical records.
C. List other names you have used on your medical records.
When we request your medical records, we must know the name you were using at
the time you received treatment. This information will help us get your medical
records faster. Include your maiden name or previous married name(s), nicknames,
or any other names that would appear on your medical records. When completing
Section 4.D. through Section 4.F. below, it is also helpful if you give other
names your records may be listed under for each doctor, hospital, or other
source of treatment.
D. List each DOCTOR / HMO / THERAPIST / OTHER.
We need names and addresses for your medical sources so that we can request your
medical records. We use these records along with other information to decide if
you are disabled under our rules.
List ALL health care professionals you have seen for your illnesses, injuries,
or conditions. Include physicians, psychologists, optometrists,
nurse-practitioners, physician's assistants, therapists, chiropractors, social
workers, and counselors. Also include alternative medicine professionals, such
as acupuncturists.
It is important that you provide the full name of the doctor or other medical
source, and the complete mailing address. For example, do not simply list "Dr.
Smith on Taylor Rd in Clarksville." We may not be able to obtain your records
with an incomplete address. You can check the phone book, your appointment card,
your billing statement, or call the doctor's office to get the mailing address.
Some doctors have more than one office, so give us the address for the location
where you are treated or where your medical records are kept. We also need a
phone number because we may need to call their office.
Your dates of treatment tell us how long you have been seen, and when your next
appointment will be. If you can't remember the exact dates, try to give us the
approximate dates. For example, you can write "about 2 years ago", "last year",
or "6 months ago". Information about the reasons for your visits and the
treatment received will help us decide which records to request. If you know
your patient identification number, it may help us get your medical records
faster.
If you need more room to list additional health care professionals, use the
space in Section 9 - Remarks. Remember that we need to know about all of your
treatment.
FREQUENTLY ASKED QUESTIONS:
How far back should I go when listing my medical treatment?
We need to know about your medical treatment since at least the time you became
unable to work. If you were treated for your illnesses, injuries, or conditions
before then, we also need to know about that treatment. In addition to deciding
if you are disabled under our rules now, we must also decide when you first
became disabled. We also use your medical records to see how your illnesses,
injuries, or conditions have changed over time.
If I have an appointment scheduled with a new doctor I haven't seen before,
should I list this? What about future hospital and clinic appointments?
Yes, you should list these appointments and give us the appointment dates. We
always need your most current treatment records.
What if I don't know my patient identification number or hospital/clinic number?
We can still get your records without this number, but sometimes the medical
source can find your records quicker if they have this information. This number
is usually available on your medical records or bills.
What happens if I don't know the complete addresses for the places where I have
been treated?
If you do not give us complete addresses, or if you give us the wrong addresses,
we may be delayed in getting your medical records. Therefore, it is important
that you try to find the complete address by checking the phone book,
appointment cards, billing statements, or calling the office for the address.
E. List each HOSPITAL / CLINIC.
We need the names and addresses of hospitals and clinics that have treated you
for your illnesses, injuries, or conditions so that we can request your medical
records. We use these records along with other information to see if you are
disabled under our rules.
Be sure to include the complete name, address, and phone number of the hospital
or clinic where you were treated. Some hospitals and clinics have more than one
location, so providing the exact address is important. You can check the phone
book, your appointment card, your billing statement, or call the hospital or
clinic to get the mailing address for requesting your medical records. If you
have already listed a clinic or clinic doctor in Section 4.D., you do not need
to list them again here.
We need your dates of treatment and the date of your next appointment. If you
can't remember the exact dates, try to give us the approximate dates. For
example, you can write "about 2 years ago", "last year", or "6 months ago."
Hospitals and clinics often need these dates to give us your medical records.
Also include your hospital or clinic number if you know it.
Your type of visit should be shown as:
Inpatient Stays (Stayed at least overnight)
Outpatient Stays (Sent home the same day)
Emergency Room (ER) Visits (Seen in ER and sent home after treatment)
Make sure you list ALL hospitals, clinics, and treatment centers where you
received treatment for your illnesses, injuries, or conditions. If you do not
have enough room, use the space in Section 9 - Remarks.
Include as much information as possible about the reasons for your visits, the
types of treatment you received, and the names of the doctors or other health
care professionals that treated you. This information allows us to ask for the
specific records we need from your doctors.
F. Does anyone else have medical records or information about your illnesses,
injuries or conditions?
We need information about anyone else who would have medical records or
information about your illnesses, injuries, or conditions. Sometimes sources
other than the doctors, hospitals, and clinics you listed in items 4.D. and 4.E.
will have copies of your medical records, and they may give them to us more
quickly.
These sources may include State workers' compensation, insurance companies,
prisons, attorneys, public welfare offices, and others. If you have any of your
medical records, you should give them to us with the Disability Report.
Be sure to provide all information, including the complete name and address. We
need a phone number because we may have to call these sources about your medical
records. Your dates of visits, next appointment, claim number, and reasons for
visits help us ask for the information we need. If you do not have enough room,
please use the space in Section 9 - Remarks.
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Section 5 - Medications
General Information About Section 5
This section tells us a little more about you and how you are being treated for
your illnesses, injuries, or conditions. We need to know about the medicines
your doctor(s) prescribed and any "over-the-counter" medicines you take, such as
aspirin or Tylenol. It is very important that you list ALL of the medicines you
take, even if they are not for the current illnesses, injuries, or conditions
for which you are filing a disability claim.
The kinds of medication, how often you take them, and how they affect you can
help us learn more about you so that we can make a better decision on your
claim. If you are using any other types of medicines, such as herbs or home
remedies, we also need to know this because it may tell us about other medical
problems that may affect your current illnesses, injuries, or conditions. We
will look at all other illnesses, injuries, or conditions you may have when we
make a decision on your claim.
FREQUENTLY ASKED QUESTIONS:
Why don't you get this information from my doctor?
We not only need the medicines that are prescribed by a doctor, but also any
over-the-counter medicines or herbal remedies you may be taking. These other
types of medicines might not be listed in your doctor’s records. Also, a
doctor's records don't always show how the medicine "makes you feel."
Name of Medicine
For prescription medicine, you will be able to get this information from the
container. If you do not have the container, you can give us the common name or
the type of medicine (such as heart medicine or arthritis medicine).
For non-prescription (over-the-counter) or herbal medicines, give us the name of
the medicine.
If Prescribed, Give Name of Doctor
We need the name of the doctor who prescribed the medicine you are taking. This
does not have to be your current doctor. It may be a doctor you have seen before
for another illness, injury, or condition. If you cannot remember the doctor's
name, please write "unknown" in the space.
Reminder: If you have not already listed the name of this doctor, please enter
the information in Section 4. If there is not enough room to list this doctor in
Section 4, list the doctor in Section 9 - Remarks. Be sure to include all the
information that Section 4 asks for.
If you give us complete information, we will be able to get a better picture of
you and how your illnesses, injuries, or conditions affect your ability to work.
When we review your claim, we look at your entire physical and mental medical
history to decide if you are disabled under our rules. By giving us complete
information, you will help us decide your claim quicker.
If the medicine you are taking was not prescribed by a doctor, just write
"over-the-counter" or what other type of medication it may be (like "herbal" or
"home remedy").
Reason for Medicine
What we need for you to write here is why you are taking the medicine. Examples
of this would be "to slow down my heart rate," "for high blood pressure," "to
help me sleep at night," "for pain relief," "for headaches," or "for
depression." This is important because some medicines can be prescribed for
different reasons.
This helps us find out how you are being treated for your illnesses, injuries,
or conditions and how well that treatment is working for you. We will use this
information to help us, as we decide how your illnesses, injuries, or conditions
affect your ability to work.
Side Effects You Have
This section describes how the medicine you take affects you either physically
or mentally. Examples here would be "It just makes me so tired that I can't do
anything but sleep," or "I can't go anywhere because I get diarrhea when I take
my medicine," "or "It makes me sick to my stomach." You should also list any
allergic reactions you have to the medicines you are taking.
Your reaction to the medicine you take may affect your ability to work. We need
to know this information since the ability to work is an important part of how
we decide whether or not you are disabled.
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Section 6- Tests
General Information About Section 6
We need the results of your medical tests to better understand the nature of
your illnesses, injuries, or conditions. We are interested in tests that are
planned for you in the future and also tests that have been completed. We use
the results of some kinds of tests to confirm the presence of a medical problem.
For example, an x-ray can show the presence of a bone fracture. We use the
results of other kinds of tests to find out the extent of physical limitations
caused by an illness, injury, or condition. For example, a breathing test can
show limitations caused by a lung condition. We will use this information and
other evidence to decide what you can still do.
NOTE: Select the name of any test (on page 7) for more information.
FREQUENTLY ASKED QUESTIONS:
Why can't you get this information from my doctor?
You may have tests scheduled in the future, and your doctor will not have the
results of those tests. You may also have had tests done as an outpatient or as
an emergency room patient, and your doctor may not have the results from such
testing. Or, you may have been tested while you were in the hospital, and the
hospital did not include the results in your records. We will try to get your
test results but we have to know what tests you had and when and where you had
them done so that we can get all the information that tells us about your
illnesses, injuries, or conditions.
What information do I put in this section of the form?
Several tests are listed in this section. If you had or are going to have any of
these tests, please give us the dates, location and who asked you to have the
test(s). If you had or are going to have a test performed that is not listed in
this section, you can give us the information in Section 9 - Remarks on page 10.
Be sure to tell us the name of the doctor who sent you for testing so we can
obtain these records.
EKG (Heart Test)
In this test the patient sits, stands, or lies down while wires are placed on
the skin. A machine attached to the other ends of the wires prints out wavy
lines on a chart that shows the electrical activity of the heart.
Treadmill (Exercise Test)
This is a heart test done while the patient exercises. There are different kinds
of exercise methods but the most common is the treadmill test in which the
patient has an EKG recorded as he or she walks on a treadmill.
Cardiac Catheterization
This is a test of the blood circulation in the heart. In this test the doctor
passes a thin wire into the heart through an artery (usually through the groin
area). With this test, a doctor can see pictures of the inside of the heart.
Biopsy
Name of body part-This is a test in which the doctor removes tissue from a part
of the body to see if disease is present. You should enter the name of the body
part on the line.
Hearing Test
This a test in which a specialist plays different tones through earphones to
detect any hearing loss.
Speech-Language Test
This is a test that helps a speech-language pathologist to evaluate your ability
to use speech and language to communicate with others.
Vision Test
This is an eye test that may require reading letters from a chart. It may also
require reading letters through a machine with adjustable lenses, or it may
check side vision with dots of light.
IQ Testing
This is a test that measures a person's ability to understand information and
solve problems. This test is made up of a series of short tasks that require
either a written or spoken response.
EEG (Brain Wave Test)
This test involves placing wires on the scalp. These wires lead to a machine
that measures and records brain wave activity. This test can detect seizure
activity and other problems in the brain.
HIV Test
This is a blood test that detects the presence of the human immunodeficiency
virus (HIV).
Blood Test (Not HIV)
In this test, a technician draws blood that is tested for abnormalities in a
laboratory.
Breathing Test
In this test, the patient exhales as hard and as long as possible into a machine
that measures the breathing capacity of the lungs.
X-Ray
This is a test in which a large machine takes pictures of body parts. You should
enter the name of the body part on the line.
MRI / CT Scan
These testing methods are like x-rays, but use different methods in making
images of the body parts. Both methods show soft tissue far better than x-ray. A
CT scan is also called a CAT scan. You should enter the name of the body part on
the line.
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Section 7- Education / Training Information
General Information About Section 7
Information about your education and training are very important to us. If you
cannot do your past job, we look at your age, education, training, and job
skills to see if you can do other kinds of work.
A. Check the highest grade of school completed.
If you did not complete the entire school year, check the previous year that you
completed. For example, if you started the 10th grade but did not finish the
entire school year, check 9 as the highest grade completed.
If you are not sure how many college credits are in a school year, you may list
the number of college credits you have completed. We also need for you to list
the date you most recently completed your education.
B. Did you attend special education classes?
By "special" education classes, we mean any kind of education services that you
received other than what is provided for in a regular classroom. Examples of
this could be special classes related to a physical, emotional, or learning
disability.
If you attended these types of classes, we need information about them because
we may need to contact someone at the school to get your records to use in
deciding whether or not you are able to do different kinds of work. Please list
the name(s) of the school, the address (as close as you can remember it), the
dates you attended these classes, and the type of program you attended.
By "type of program," we mean the kind of services you may have received, like
special classes or special help for an emotional disability or a learning
disability, such as a reading disorder. Other examples include special classes
or special help for a physical disability, such as blindness or deafness.
C. Have you completed any type of special job training, trade or vocational
school?
If you completed any special job training, or trade or vocational school, you
should explain the type of training that you received and the approximate date
you completed the training. Examples of this could be auto mechanics,
electronics, cosmetology, heating and air conditioning, computer repair, data
entry or word processing courses. If you need more room, please go to Section
9 - Remarks.
--------------------------------------------------------------------------------
Section 8 - Vocational Rehabilitation, Employment, or other Support Services
Information
A. Are you participating in the Ticket Program or another program of vocational
rehabilitation or other support services to help you get back to work?
If “Yes”, provide the name of the organization, the name of your counselor, the
address, phone number, dates when you received services, and types of services
or tests performed.
Any information from Vocational Rehabilitation or other support services could
help us understand the nature and extent of your disabling illnesses, injuries,
or conditions more fully.
"Other support services" could include sheltered workshops, job coaches, or any
group that has given you job training, coaching, or evaluation services.
Provide all details to allow us to call or write for your records. If you cannot
get the complete address, show whatever information you know. For example, you
may not be able to obtain a full street address, but you know, "They were in the
tall office building next to the Smith County Courthouse." Or, you may not know
the name of the organization, but you know, "They worked with me at the request
of my guidance counselor, Ms. Jones, at Boone County Community College." Be sure
to show any such information you believe may help us obtain those records.
Once we obtain this information, we will consider what those trained
professionals say about your ability to work. We will consider such things as
environmental limitations, ability to carry out physical activities, ability to
work with others, ability to receive and understand work instructions, etc. We
will consider how their findings fit with other medical records to get a
complete picture of your medical limitations.
MORE INFORMATION:
Social Security Employment Support Programs
-------------------------------------------------------------------------------
Section 9 - Remarks
Remarks
Use this section for any information you could not fit into the designated space
for any question in earlier parts of this form. Be sure to show which section
your remarks relate to. For example, if you did not have enough room to list
your illnesses, injuries, or conditions in Section 2.A., you should write
"Section 2. A," followed by whatever additional information you want us to know.
You may use this section to show any other information you think would be
helpful in understanding your work limitations. For example, if you showed in
section 3 that you worked as a dishwasher, but the way you performed your job as
a dishwasher was different than for most dishwashers, you should explain those
differences in this section.
In this section, you can tell us anything else you wish to explain about why you
are unable to work.
If you run out of room in this section, please continue to write or type on
additional sheets, again referring to the sections of the form about which you
are providing additional information.
We will consider any information you give us in this section to gain a complete
picture of your illnesses, injuries, or conditions and any limitations you have.
When you are finished with this section (or if you don't have anything to add),
be sure to complete the information requested on the bottom of page 10.
--------------------------------------------------------------------------------
Name of Person Completing this Form
The person completing this form should print or type his or her name, enter his
or her address, and the date the form was completed. Providing an e-mail address
is optional.
Learn More About Disability Benefits and How We Decide If You Are Disabled
ella
Benefit office of USA Consulate Office here in Spain. Claimant will be
with doctor in Spanish SS system even though they qualify for USA
SSDI. Three clinics here can give updated info.
Thanks
"Cymbal Man Freq." <Don't Bot...@ForgedPostsAnonymous.unorg> wrote in message news:<walKc.77231$i in Spain. Any other comment...@twister.nyroc.rr.com>...
> the first month after?. either the date your disability began or the date you
> Check ?Yes? or ?No?. If ?No? go to question J. If ?Yes?, tell us how many people
> you supervised, how much of your day was spent supervising the work of others,
> and whether you hired and fired employees in your job.
>
>
> J. Were you a lead worker?
>
> What we mean by ?lead worker? is someone who performs some kind of
> types of medicines might not be listed in your doctor?s records. Also, a
> If ?Yes?, provide the name of the organization, the name of your counselor, the
ella
Should the first ones listed be the first occurences going back 16 years?
there are many different work situations.
Should the latest or earlier be listed first?
Thanks
hone...@yahoo.com (ella) wrote in message news:<c5f4c23f.04071...@posting.google.com>...