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Form SSA3368BK (XXX XXX) OF Discontinue Prior Editions Social Security Administration Page 1 of 15 OMB No. 09600579DISABILITY REPORT ADULT PLEASE READ THIS INFORMATION BEFORE COMPLETING THIS REPORT The
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Fill out all personal information accurately, including name, address, date of birth, and contact information.
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The Disability Report - Adult form is a document used by the Social Security Administration (SSA) to collect comprehensive information about an adult's medical condition, work history, and daily functioning to assess eligibility for disability benefits.
Individuals aged 18 and older who are seeking Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) due to a disability must file the Disability Report - Adult form.
To fill out the Disability Report - Adult form, individuals should carefully read each section, provide complete and accurate information about their medical conditions, treatments, work history, daily activities, and family background, and ensure that all information is up-to-date.
The purpose of the Disability Report - Adult form is to gather detailed information about an applicant's medical and personal history to determine their eligibility for disability benefits from the SSA.
The form requires information about the applicant's medical conditions, treatment details, hospitalizations, medications, work history, education, daily activities, and any other impairments that affect their ability to work.
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