How to Fill Out and Submit Form SSA-3368-BK: Adult Disability Report

Form SSA-3368-BK, the Adult Disability Report, is the document you complete when applying for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) as an adult. Your state’s Disability Determination Services office uses your answers to pull your medical records, review your work history, and decide whether you meet the federal definition of disability.¹ You can complete it three ways: through the online disability application at ssa.gov, on paper at a local field office, or by printing the PDF from the SSA website and mailing it back.²

What to Gather Before You Start

The form moves faster and produces a stronger record when you pull everything together first. Gaps and vague entries force the SSA to call back or leave records unrequested. Have these ready:

A list of every doctor, hospital, clinic, and therapist who treated the conditions you are claiming. For each one: full name, street address, phone number, dates seen, and the condition treated. The form does not cap this at a year — list every relevant provider.²
Every medication you take or recently stopped taking, with dosage and the reason prescribed.
Any MRIs, blood work, X-rays, or other tests, with where and when they were done.
Every job you held in the five years before you became unable to work: title, start and end dates, daily duties, and physical demands like standing time, lifting weights, and whether you supervised anyone.³
Your highest grade completed, any special education services, and vocational or trade training.
One or two contact people, other than your doctors, who know about your conditions and can help with the claim. Include name, address, and daytime phone.¹

The duty to provide evidence is yours, and it is ongoing. If new medical evidence surfaces later, during review or appeal, you have to disclose it.⁴

Completing the Form Section by Section

The paper form is broken into numbered sections. The section numbers below match the current version (revised June 2024). Online, the same questions appear as a guided sequence of screens rather than a numbered PDF.

Section 2: Contacts

Give up to two people the SSA can reach if it cannot reach you — a spouse, relative, or close friend who knows about your medical situation. For each, list the name, relationship, mailing address, and daytime phone. If the person does not speak English, note their preferred language; the Disability Determination Services provides a free interpreter.¹

Section 3: Medical Information

List each physical and mental condition that limits your ability to work, one at a time. Use your own words rather than medical jargon copied from a report. The SSA tells its own staff to record conditions in the claimant’s language wherever possible.¹ If a doctor calls something “lumbar radiculopathy,” you can write “severe lower back pain that radiates down my left leg.” Include the formal diagnosis too if you know it, so what you write matches what the records say.

Section 4: Work Activity and Alleged Onset Date

Enter the date you believe you became unable to work because of your conditions. The SSA calls this your alleged onset date. Also describe any changes your condition forced on your job before you stopped entirely: reduced hours, lighter duties, lower pay. Specifics beat generalities. “In March 2024 my employer moved me from the warehouse floor to a desk because I could no longer lift boxes” gives the reviewer real information; “my duties changed” does not.¹

Section 5: Education, Training, and Literacy

Check the highest grade you completed, including homeschool or schooling from another country, and note any special education classes. List vocational or trade school programs too. Your education matters more than most applicants realize: at the last step of the disability evaluation, the SSA weighs it against your age and work experience to decide whether you could adjust to different work.⁵

Section 6: Job History

List every job you held in the five years before your disability began. A 2024 rule change shortened this window from fifteen years to five, so you do not need to dig up decades-old records.³ For each job, describe the duties, the physical requirements, and whether you supervised anyone. Skip any job that lasted fewer than 30 calendar days. If you held more than two jobs in the five-year window, the SSA may send you a separate Work History Report (Form SSA-3369-BK) for additional detail.

Sections 7 and 8: Medical Providers and Treatment

These sections are the roadmap the Disability Determination Services uses to collect your records. For every doctor, hospital, clinic, and therapist, enter the name, full address, phone number, patient ID or account number if you have it, dates seen, condition treated, and any tests performed. Tie each provider to the specific condition so the reviewer can follow the trail. Include prescriptions, counseling, physical therapy, and emergency room visits.²

Section 9: Other Sources of Medical Information

This section asks whether anyone besides your healthcare providers holds medical information about you. Common examples: the Department of Veterans Affairs, a workers’ compensation insurer, a vocational rehabilitation agency, an attorney, or a prison medical unit. If any hold records related to your condition, list them.¹

Choosing Your Alleged Onset Date

The date you enter in Section 4 is one of the most consequential entries on the entire form. It controls how far back the SSA looks at your medical evidence and, for SSDI, how much retroactive pay you may receive.

The SSA does not automatically accept the date you pick. After reviewing your records and work history, a reviewer assigns an established onset date, meaning the first day the evidence shows you actually met the legal definition of disability. If the established date is later than the date you alleged, you lose months of potential benefits. Pick a date the evidence can support: a hospital admission, a diagnostic report showing a severe worsening, or the last day you were physically able to work.

Two guardrails matter. First, you generally cannot earn above the substantial gainful activity threshold and claim you were disabled at the same time. For 2026, that threshold is $1,690 per month for non-blind applicants and $2,830 per month for blind applicants.⁶ Second, SSDI carries a mandatory five-month waiting period after the established onset date before benefits begin, and retroactive benefits reach back only 12 months before your application date.⁷ Waiting to apply after you become disabled shrinks or eliminates that retroactive window.

The SSA-827 Medical Release

Alongside the 3368-BK, you have to sign Form SSA-827, which authorizes doctors, hospitals, schools, and other sources to release records to the SSA. Your application is considered incomplete without it.⁸ The authorization covers all medical records, including mental health treatment, substance abuse records, and HIV/AIDS-related records, plus educational evaluations and information about how your impairments affect daily living.⁹ If you apply online, you can sign it electronically in the same session. On paper, print the form, sign it, and submit it with your 3368-BK.

How to Submit the Form

The fastest route is the SSA’s online disability application at ssa.gov/applyfordisability.¹⁰ The 3368-BK questions are built into the application, screen by screen, rather than as a separate PDF. You can save your progress, come back later, and finish by signing the medical release and submitting everything at once. Even if you cannot answer every question, the SSA lets you submit what you have and will follow up on the gaps.⁸

If you prefer paper, print the PDF from ssa.gov/forms or pick up a copy at your local field office. Mail the completed form and the signed SSA-827 to your local office, or hand-deliver them. Certified mail gives you proof of the submission date, which matters if a deadline is close. Whichever route you take, keep a full copy of everything you send.

A friend, family member, or representative can help you fill it out.² If you have an attorney or non-attorney representative on your claim, they can assist with the answers, though the content should still reflect your own experience and your own words.

Penalties for False Information

The form carries a warning about false statements, and the SSA enforces it. Under federal law, each false statement or misrepresentation on a disability application can result in a civil penalty of up to $5,000 and an assessment of up to twice the amount of any benefits improperly paid as a result.¹¹ A fraud finding can also lead to termination of benefits and referral for criminal prosecution. None of this reaches honest mistakes or incomplete answers; the penalties target intentional falsehoods. If you are unsure about a date or detail, give your best estimate and mark it as approximate rather than inventing something.

What Happens After You Submit

Your local SSA field office first checks the non-medical eligibility requirements — your work credits for SSDI, your income and resources for SSI — then forwards the file to the Disability Determination Services in your state, which is the state agency that handles the medical evaluation.¹² Examiners use the provider information from your 3368-BK to request records directly. If those records are not enough to decide, the DDS will schedule a consultative examination with an independent doctor or your own treating physician, at no cost to you, and may reimburse your travel to attend.¹³ Do not skip that appointment. If you miss it without a good reason and do not reschedule before the case is finalized, the DDS can decide on whatever evidence is already in the file, which often means a denial.¹⁴ You will get the final decision by mail.

1
Social Security Administration. DI 11005.023 – Completing the SSA-3368-BK (Disability Report – Adult)
2
Social Security Administration. SSA Form 3368-BK – Disability Report – Adult
3
Federal Register. Intermediate Improvement to the Disability Adjudication Process Including How We Consider Past Work
4
Social Security Administration. 20 CFR 404.1512 – Responsibility for Evidence
5
Social Security Administration. 20 CFR 404.1520 – Evaluation of Disability in General
6
Social Security Administration. Substantial Gainful Activity
7
Social Security Administration. 20 CFR 404.315 – Disability Insurance Benefits
8
Social Security Administration. Apply Online for Disability Benefits
9
Social Security Administration. SSA-827 – Authorization to Disclose Information to the Social Security Administration
10
Social Security Administration. Apply Online for Disability Benefits
11
Office of the Law Revision Counsel. 42 USC 1320a-8 – Civil Monetary Penalties and Assessments for Fraud
12
Social Security Administration. Disability Determination Process
13
Social Security Administration. SSI Spotlight on Payment for Travel to Medical Exams or Tests
14
Social Security Administration. DI 22510.016 – Claimant Consultative Examination (CE) Notice and Confirmation