This form contains 444 fields organized into 31 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
Additional Information
SECTION 11 - REMARKS Please provide any additional information you did not give in earlier parts of this report. If you did not have enough space in the sections of this report to provide the requested information, please use this space to provide the additional information requested in those sections. Be sure to include the section and question number to which you are referring. If you need additional space, use Section 11 - Remarks (continued)	Text	Provide any additional information that was not included in earlier sections of this report. Mention the section and question number you are referring to. Use this space if you need more room to provide the requested information.
Page 15 of 15 SECTION 11 - REMARKS (continued)	Text	Continue providing any additional information that was not included in earlier sections of this report. Mention the section and question number you are referring to.
Contact Information
1.D. Mailing Address (Street or P O Box) Include apartment number, if applicable	Text	Enter the mailing address of the person applying for disability benefits, including street or P.O. Box and apartment number if applicable.
City	Text	Enter the city of the mailing address for the person applying for disability benefits.
State/Province	Text	Enter the state or province of the mailing address for the person applying for disability benefits.
ZIP/Postal Code	Text	Enter the ZIP or postal code of the mailing address for the person applying for disability benefits.
Country (If not U S Ay)	Text	Enter the country of the mailing address if it is not within the USA.
1.E. Email Address	Text	Enter the email address of the person applying for disability benefits.
1.F. Daytime Phone Number(s) where we can call to speak with you or leave a message, if needed. Include area code or I D D and country code if outside the USA or Canada. Primary	Text	Enter the primary daytime phone number where the Social Security Administration can contact you or leave a message. Include the area code or IDD and country code if outside the USA or Canada.
Secondary: (if available)	Text	Provide a secondary phone number if available.
SECTION 2 - CONTACTS Is there someone we can contact who can help with your claim, if needed? Examples include a family member, friend, or neighbor. Yes Please provide the names of two people (other than your doctors) we can contact who know about your medical condition(s) and can help you with your claim and can help us reach you if you become unavailable	CheckBox	Check this box if there is someone we can contact who can help with your claim, such as a family member, friend, or neighbor. Provide the names of two people who know about your medical condition(s) and can help with your claim.
No We recommend that you provide at least one contact, if available. Providing the name of someone who knows you may help us to make a decision on your claim	CheckBox	Check this box if there is no one we can contact to help with your claim. It is recommended to provide at least one contact.
2.Ay. Name (First, Middle Initial, Last)	Text	Provide the full name (First, Middle Initial, Last) of the contact person.
2.B. Relationship to the Person in 1.Ay	Text	Specify the relationship of the contact person to you.
2.C. Mailing Address (Street or PO Box) Include apartment number, if applicable	Text	Provide the mailing address (Street or PO Box) of the contact person, including the apartment number if applicable.
city	Text	Provide the city of the contact person's mailing address.
2.D. Daytime Phone Number (as described in 1.F. above)	Text	Enter your daytime phone number as described in section 1.F.
Page 4 of 15 Section 2 - Contacts (continued) 2. E. Can this person speak and understand English? Yes	CheckBox	Check this box if the person can speak and understand English.
No	CheckBox	Check this box if the person cannot speak and understand English.
If no, what language is preferred	Text	If the person cannot speak and understand English, specify the preferred language.
2.F. Name (First, Middle Initial, Last)	Text	Enter the name of the contact person (First, Middle Initial, Last).
2.G. Relationship to the Person in 1.Ay	Text	Specify the relationship of the contact person to the individual in section 1.A.
2.H. Mailing Address (Street or P O Box) Include apartment number if applicable	Text	Enter the mailing address of the contact person, including street or P.O. Box and apartment number if applicable.
city	Text	Enter the city of the contact person's mailing address.
State/Province	Text	Enter the state or province of the contact person's mailing address.
ZIP/Postal Code	Text	Enter the ZIP or postal code of the contact person's mailing address.
Country (If not U S Ay)	Text	Enter the country of the contact person's mailing address if it is not the United States.
2.I. Daytime Phone Number (as described in 1.F. above)	Text	Enter the daytime phone number of the contact person as described in section 1.F.
PHONE NUMBER	Text	Enter the phone number of the healthcare provider or facility.
ADDRESS	Text	Enter the address of the healthcare provider or facility.
city	Text	Enter the city where the healthcare provider or facility is located.
State/Province	Text	Enter the state or province where the healthcare provider or facility is located.
ZIP/Postal Code	Text	Enter the ZIP or postal code of the healthcare provider or facility.
Country (If not U S Ay)	Text	Enter the country where the healthcare provider or facility is located, if it is not in the USA.
PHONE NUMBER	Text	Enter the phone number of the healthcare provider or facility.
ADDRESS	Text	Provide the address related to the medical appointment or facility.
city	Text	Enter the city related to the medical appointment or facility.
State/Province	Text	Enter the state or province related to the medical appointment or facility.
ZIP/Postal Code	Text	Enter the ZIP or postal code related to the medical appointment or facility.
Country (If not U S Ay)	Text	Enter the country if it is not the United States.
PHONE NUMBER	Text	Provide the phone number of the medical facility or healthcare provider.
ADDRESS	Text	Provide the address related to the medical appointment or facility.
city	Text	Enter the city related to the medical appointment or facility.
Zip/Postal Code	Text	Enter the zip or postal code of your current residence.
Country (If not U S Ay)	Text	Enter the country of your current residence if it is not the United States.
Name of Contact Person	Text	Provide the name of a person who can be contacted for additional information about your condition.
Date of First Contact	Text	Enter the date when you first made contact with the person or organization.
Date of last contact	Text	Enter the date when you last made contact with the person or organization.
Date of next contact (if any)	Text	Enter the date of your next scheduled contact with the person or organization, if any.
Reasons for contacts If you need to list other people or organizations, use Section 11	Text	Provide the reasons for your contacts. If you need to list other people or organizations, use Section 11.
ADDRESS (Street or P O Box) Include Suite, Building, etc	Text	Enter the street address or P.O. Box, including any suite or building number.
City	Text	Enter the city of the address provided.
State/Province	Text	Enter the state or province of the address provided.
Zip/Postal Code	Text	Enter the ZIP or postal code of the address provided.
Country (If not U S Ay)	Text	Enter the country of the address provided, if it is not in the United States.
City	Text	Enter the city where you currently reside.
State/Province	Text	Enter the state or province where you currently reside.
Zip/Postal Code	Text	Enter the zip or postal code for your current address.
Country (If not U S Ay)	Text	Enter the country where you currently reside, if it is not the USA.
DAYTIME PHONE NUMBER where we may reach you or leave a message, if needed. Include the area code or I D D and country code if outside the USA or Canada	Text	Enter a daytime phone number where you can be reached or where a message can be left. Include the area code or IDD and country code if outside the USA or Canada.
Earnings Information
4.G. Since your condition(s) first bothered you, have you had earnings greater than 1,550 dollars before tax in any month? Do not count sick leave, vacation, or disability pay. (We may contact you for more information.) Yes	CheckBox	Indicate if you have had earnings greater than $1,550 before tax in any month since your condition first bothered you. Do not count sick leave, vacation, or disability pay.
No	CheckBox	Indicate if you have not had earnings greater than $1,550 before tax in any month since your condition first bothered you.
Education History
Seventh Grade	CheckBox	Check this box if you completed the seventh grade.
Eighth Grade	CheckBox	Check this box if you completed the eighth grade.
Ninth Grade	CheckBox	Check this box if you completed the ninth grade.
Tenth Grade	CheckBox	Check this box if you completed the tenth grade.
Eleventh Grade	CheckBox	Check this box if you completed the eleventh grade.
Twelfth Grade	CheckBox	Check this box if you completed the twelfth grade.
G E D	CheckBox	Check this box if you obtained a General Educational Development (GED) certificate.
One Year of College	CheckBox	Check this box if you completed one year of college.
Two Years of College	CheckBox	Check this box if you completed two years of college.
Three Years of College	CheckBox	Check this box if you completed three years of college.
Four or more Years of College	CheckBox	Check this box if you completed four or more years of college.
Date completed: MM/Y Y Y Y	Text	Enter the date you completed your highest level of education in the format MM/YYYY.
Name of school	Text	Enter the name of the school where you completed your highest level of education.
City	Text	Enter the city where the school you attended is located.
State/Province	Text	Enter the state or province where the school you attended is located.
Country (if not U S Ay)	Text	Enter the country where the school you attended is located, if it is not in the USA.
5.B. Were you in special education? NO (Go to 5.C.)	CheckBox	Indicate whether you were in special education. If not, proceed to the next section.
YES (Complete below)	CheckBox	Check this box if you were in special education and complete the additional details below.
Dates from: MM/Y Y Y Y	Text	Enter the start date (MM/YYYY) when you began receiving special education services.
to MM/Y Y Y Y	Text	Enter the end date (MM/YYYY) when you stopped receiving special education services.
If Yes is checked, Check the last grade you received special education. Pre K	CheckBox	Check this box if you received special education in Pre-K.
Kindergarten	CheckBox	Check this box if you received special education in Kindergarten.
First Grade	CheckBox	Check this box if you received special education in First Grade.
Second Grade	CheckBox	Check this box if you received special education in Second Grade.
Third Grade	CheckBox	Check this box if you received special education in Third Grade.
Fourth Grade	CheckBox	Check this box if you received special education in Fourth Grade.
Fifth Grade	CheckBox	Check this box if you received special education in Fifth Grade.
Sixth Grade	CheckBox	Check this box if you received special education in Sixth Grade.
Seventh Grade	CheckBox	Check this box if you received special education in Seventh Grade.
Eighth Grade	CheckBox	Check this box if you received special education in Eighth Grade.
Ninth Grade	CheckBox	Check this box if you received special education in Ninth Grade.
Tenth Grade	CheckBox	Check this box if you received special education in Tenth Grade.
Eleventh Grade	CheckBox	Check this box if you completed the eleventh grade.
Twelfth Grade	CheckBox	Check this box if you completed the twelfth grade.
Reason(s) for special education	Text	Provide the reasons why you were placed in special education.
The school where you were last in special education: Same as 5.Ay	CheckBox	Check this box if the school where you were last in special education is the same as the one mentioned in section 5.Ay.
If different from 5.Ay., complete below	CheckBox	Check this box if the school where you were last in special education is different from the one mentioned in section 5.Ay. Complete the details below if checked.
Name of school	Text	Enter the name of the school where you were last in special education.
City	Text	Enter the city where the school you last attended for special education is located.
State/Province	Text	Enter the state or province where the school you last attended for special education is located.
Country (if not U S Ay)	Text	Enter the country where the school you last attended for special education is located, if it is not in the United States.
Education Level
SECTION 5 - EDUCATION, TRAINING, AND LITERACY 5.Ay. Select the highest level of school completed, including homeschooling, online education, and education received in another country. 0	CheckBox	Select if you have completed 0 years of school, including homeschooling, online education, and education received in another country.
Kindergarten	CheckBox	Select if you have completed Kindergarten, including homeschooling, online education, and education received in another country.
First Grade	CheckBox	Select if you have completed First Grade, including homeschooling, online education, and education received in another country.
Second Grade	CheckBox	Select if you have completed Second Grade, including homeschooling, online education, and education received in another country.
Third Grade	CheckBox	Select if you have completed Third Grade, including homeschooling, online education, and education received in another country.
Fourth Grade	CheckBox	Select if you have completed Fourth Grade, including homeschooling, online education, and education received in another country.
Fifth Grade	CheckBox	Select if you have completed Fifth Grade, including homeschooling, online education, and education received in another country.
Sixth Grade	CheckBox	Select if you have completed Sixth Grade, including homeschooling, online education, and education received in another country.
Facility Information
State/Province	Text	Enter the state or province where the facility is located.
ZIP/Postal Code	Text	Enter the ZIP or postal code for the facility.
Country (If not U S Ay)	Text	Enter the country where the facility is located, if it is not in the United States.
Form Navigation
This is the end of the form. If you tab, you will be at the beginning of the form	Text	This is the end of the form. If you press tab, you will be taken to the beginning of the form.
General Information
Instruction Read Confirmation	Text	Enter “Yes” to confirm you have read the information on this page before completing the Disability Report – Adult.
Information Availability Confirmation	Text	Enter “Yes” to confirm you have gathered the items listed under “What You Need to Complete This Report” (names, addresses, and phone numbers of two people, education history, and work history for the past five years).
Job Details
Tell us about lifting and carrying in this job. Explain what you lifted, how far you carried it, and how often you did it in a typical workday	Text	Describe the lifting and carrying tasks in your job. Explain what you lifted, how far you carried it, and how often you performed these tasks in a typical workday.
Select the heaviest weight lifted: Less than 1 pound	CheckBox	Select this option if the heaviest weight you lifted was less than 1 pound.
Less than 10 pounds	CheckBox	Select this option if the heaviest weight you lifted was less than 10 pounds.
10 pounds	CheckBox	Select this option if the heaviest weight you lifted was 10 pounds.
20 pounds	CheckBox	Select this option if the heaviest weight you lifted was 20 pounds.
50 pounds	CheckBox	Select this option if the heaviest weight you lifted was 50 pounds.
100 pounds or more	CheckBox	Select this option if the heaviest weight you lifted was 100 pounds or more.
Other	CheckBox	Select this option if the heaviest weight you lifted does not fit into the other categories.
If other is checked enter weight	Text	Enter the weight if you selected 'Other' for the heaviest weight lifted.
Language Proficiency
1.G. Can you speak and understand English? Yes	CheckBox	Check this box if you can speak and understand English.
No	CheckBox	Check this box if you cannot speak and understand English.
If no, what language do you prefer? If you cannot speak and understand English, we will provide an interpreter, free of charge	Text	If you cannot speak and understand English, specify your preferred language. An interpreter will be provided free of charge.
1.H. Can you read and understand English? Yes	CheckBox	Check this box if you can read and understand English.
No	CheckBox	Check this box if you cannot read and understand English.
1.I. Can you write more than your name in English? Yes	CheckBox	Check this box if you can write more than your name in English.
No	CheckBox	Check this box if you cannot write more than your name in English.
2. J. Can this person speak and understand English? Yes	CheckBox	Indicate whether the person can speak and understand English by checking this box if the answer is 'Yes'.
No	CheckBox	Indicate whether the person cannot speak and understand English by checking this box if the answer is 'No'.
If no, what language is preferred	Text	If the person cannot speak and understand English, specify the preferred language in this text field.
5.D. What written language do you use every day in most situations (at home, work, school, in community, etc.)	Text	Specify the written language you use daily in most situations such as at home, work, school, or in the community.
5.E. READING - In the language you identified in 5.D., can you read a simple message, such as a shopping list or short and simple notes? Yes	CheckBox	Indicate if you can read a simple message in the language identified in 5.D. (e.g., a shopping list or short notes).
No	CheckBox	Indicate if you cannot read a simple message in the language identified in 5.D. (e.g., a shopping list or short notes).
5.F. WRITING - In the language you identified in 5.D., can you write a simple message, such as a shopping list or short and simple notes? Yes	CheckBox	Indicate if you can write a simple message in the language identified in 5.D. (e.g., a shopping list or short notes).
No	CheckBox	Indicate if you cannot write a simple message in the language identified in 5.D. (e.g., a shopping list or short notes).
Legal Information
Paperwork Reduction Act Statement Section Marker	Text	Section marker indicating the start of the 'Paperwork Reduction Act Statement' section for internal SSA use.
Medical Appointments
DATE OF NEXT APPOINTMENT: (IF KNOWN) MM/Y Y Y Y	Text	Enter the date of your next appointment, if known, in the format MM/YYYY.
DATE FIRST SEEN: MM/Y Y Y Y	Text	Enter the date you were first seen by the healthcare provider in the format MM/YYYY.
DATE last SEEN: MM/Y Y Y Y	Text	Enter the date you were last seen by the healthcare provider in the format MM/YYYY.
DATE OF NEXT APPOINTMENT: (IF KNOWN) MM/Y Y Y Y	Text	Enter the date of your next appointment, if known, in the format MM/YYYY.
Medical History
You may find this information on medical bills, online medical chart, or the internet. 8.Ay.1. NAME OF FACILITY OR OFFICE	Text	Enter the name of the medical facility or office where you received treatment. This information can be found on medical bills, online medical charts, or the internet.
NAME OF HEALTHCARE PROVIDER THAT TREATED YOU	Text	Provide the name of the healthcare provider who treated you.
What medical conditions were treated or evaluated	Text	Specify the medical conditions that were treated or evaluated at this facility.
PHONE NUMBER	Text	Enter the phone number of the medical facility or healthcare provider.
DATE FIRST SEEN: MM/Y Y Y Y	Text	Provide the date when you were first seen by this healthcare provider. Use the format MM/YYYY.
DATE last SEEN: MM/Y Y Y Y	Text	Provide the date when you were last seen by this healthcare provider. Use the format MM/YYYY.
DATE OF NEXT APPOINTMENT: (IF KNOWN) MM/Y Y Y Y	Text	If known, provide the date of your next appointment with this healthcare provider. Use the format MM/YYYY.
ADDRESS	Text	Enter the address of the medical facility or healthcare provider.
city	Text	Enter the city where the medical facility or healthcare provider is located.
State/Province	Text	Enter the state or province where the medical facility or healthcare provider is located.
ZIP/Postal Code	Text	Enter the ZIP or postal code of the medical facility or healthcare provider.
Country (If not U S Ay)	Text	If the medical facility or healthcare provider is not in the United States, enter the country.
8.Ay.2. NAME OF FACILITY OR OFFICE	Text	Enter the name of another medical facility or office where you received treatment.
NAME OF HEALTHCARE PROVIDER THAT TREATED YOU	Text	Provide the name of another healthcare provider who treated you.
What medical conditions were treated or evaluated	Text	Specify the medical conditions that were treated or evaluated at this additional facility.
DATE FIRST SEEN: MM/Y Y Y Y	Text	Enter the date (MM/YYYY) when you were first seen by this healthcare provider or facility.
DATE last SEEN: MM/Y Y Y Y	Text	Enter the date (MM/YYYY) when you were last seen by this healthcare provider or facility.
DATE OF NEXT APPOINTMENT: (IF KNOWN) MM/Y Y Y Y	Text	Enter the date (MM/YYYY) of your next appointment with this healthcare provider or facility, if known.
8.Ay.3. NAME OF FACILITY OR OFFICE	Text	Enter the name of the healthcare facility or office.
NAME OF HEALTHCARE PROVIDER THAT TREATED YOU	Text	Enter the name of the healthcare provider who treated you.
What medical conditions were treated or evaluated	Text	Describe the medical conditions that were treated or evaluated by this healthcare provider or facility.
DATE FIRST SEEN: MM/Y Y Y Y	Text	Enter the date (MM/YYYY) when you were first seen by this healthcare provider or facility.
DATE last SEEN: MM/Y Y Y Y	Text	Enter the date (MM/YYYY) when you were last seen by this healthcare provider or facility.
8.Ay.5. NAME OF FACILITY OR OFFICE	Text	Enter the name of the medical facility or office where you received treatment.
NAME OF HEALTHCARE PROVIDER THAT TREATED YOU	Text	Enter the name of the healthcare provider who treated you.
What medical conditions were treated or evaluated	Text	Describe the medical conditions that were treated or evaluated.
PHONE NUMBER	Text	Enter the phone number of the healthcare provider or facility.
DATE FIRST SEEN: MM/Y Y Y Y	Text	Enter the date when you were first seen by the healthcare provider (MM/YYYY).
DATE last SEEN: MM/Y Y Y Y	Text	Enter the date when you were last seen by the healthcare provider (MM/YYYY).
DATE OF NEXT APPOINTMENT: (IF KNOWN) MM/Y Y Y Y	Text	Enter the date of your next appointment, if known (MM/YYYY).
ADDRESS	Text	Enter the address of the healthcare provider or facility.
city	Text	Enter the city where the healthcare provider or facility is located.
State/Province	Text	Enter the state or province where the healthcare provider or facility is located.
ZIP/Postal Code	Text	Enter the ZIP or postal code of the healthcare provider or facility.
Country (If not U S Ay) If you need to list more facilities or healthcare providers, use Section 11	Text	Enter the country of the healthcare provider or facility if it is not the United States. If you need to list more facilities or healthcare providers, use Section 11.
Below is a table of 3 columns and 15 rows. Column headers are Test, Name of Healthcare Provider or Facility, and Date of Test MM/Y Y Y Y). The column of Tests is pre-filled. Row 1 Test: Blood test (not H I V). Name of Healthcare Provider or Facility	Text	Enter the name of the healthcare provider or facility where the blood test (not HIV) was conducted.
DATE OF TEST (MM/Y Y Y Y)	Text	Enter the date when the blood test (not HIV) was conducted in MM/YYYY format. Max length: 7 characters
Row 2 Test: Breathing test. Name of Healthcare Provider or Facility	Text	Enter the name of the healthcare provider or facility where the breathing test was conducted.
DATE OF TEST (MM/Y Y Y Y)	Text	Enter the date when the breathing test was conducted in MM/YYYY format. Max length: 7 characters
Row 3 Test: Cardiac catheterization. Name of Healthcare Provider or Facility	Text	Enter the name of the healthcare provider or facility where the cardiac catheterization was conducted.
DATE OF TEST (MM/Y Y Y Y)	Text	Enter the date when the cardiac catheterization was conducted in MM/YYYY format. Max length: 7 characters
Row 4 Test: E E G (brain wave test). Name of Healthcare Provider or Facility	Text	Enter the name of the healthcare provider or facility where the EEG (brain wave test) was conducted.
DATE OF TEST (MM/Y Y Y Y)	Text	Enter the date when the EEG (brain wave test) was conducted in MM/YYYY format. Max length: 7 characters
Row 5 Test: E K G (heart test). Name of Healthcare Provider or Facility	Text	Enter the name of the healthcare provider or facility where the EKG (heart test) was conducted.
DATE OF TEST (MM/Y Y Y Y)	Text	Enter the date when the EKG (heart test) was conducted in MM/YYYY format. Max length: 7 characters
Row 6 Test: Hearing test. Name of Healthcare Provider or Facility	Text	Enter the name of the healthcare provider or facility where the hearing test was conducted.
DATE OF TEST (MM/Y Y Y Y)	Text	Enter the date when the hearing test was conducted in MM/YYYY format. Max length: 7 characters
Row 7 Test: H I V test Name of Healthcare Provider or Facility	Text	Enter the name of the healthcare provider or facility where the HIV test was conducted.
Hearing test	CheckBox	Indicate if you have undergone a hearing test.
Work evaluation	CheckBox	Indicate if you have undergone a work evaluation.
Other	CheckBox	Indicate if you have undergone any other type of evaluation not listed.
If other is checked, please explain If you need to list another plan or program, use Section 11	Text	Provide details if you selected 'Other' for the type of evaluation. Use Section 11 if you need more space.
Medical Information
Section 3 - Medical Information 3.Ay. Separately list each physical and/or mental condition that limits your ability to work. If you have cancer, please include the type and stage. There is room for 5 entries. first condition	Text	List the first physical and/or mental condition that limits your ability to work. Include the type and stage if it is cancer.
second condition	Text	List the second physical and/or mental condition that limits your ability to work.
third condition	Text	List the third physical and/or mental condition that limits your ability to work.
4th condition	Text	List the fourth physical and/or mental condition that limits your ability to work.
5th condition If you need more space, go to Section 11	Text	List the fifth physical and/or mental condition that limits your ability to work. If you need more space, refer to Section 11.
3.B. What is your height? Feet	Text	Enter your height in feet.
Inches	Text	Enter your height in inches.
or centimeters	Text	Enter your height in centimeters.
3.C. What is your weight? Pounds	Text	Enter your weight in pounds.
or kilograms	Text	Enter your weight in kilograms.
IF PRESCRIBED, GIVE DOCTOR NAME (IF KNOWN)	Text	Provide the name of the doctor who prescribed the medicine, if known.
REASON FOR MEDICINE (IF KNOWN)	Text	State the reason for taking the medicine, if known.
Row 4 Name of Medicine	Text	Enter the name of the medicine listed in row 4.
IF PRESCRIBED, GIVE DOCTOR NAME (IF KNOWN)	Text	Provide the name of the doctor who prescribed the medicine, if known.
REASON FOR MEDICINE (IF KNOWN)	Text	State the reason for taking the medicine, if known.
Row 5 Name of Medicine	Text	Enter the name of the medicine listed in row 5.
IF PRESCRIBED, GIVE DOCTOR NAME (IF KNOWN)	Text	Provide the name of the doctor who prescribed the medicine, if known.
REASON FOR MEDICINE (IF KNOWN)	Text	State the reason for taking the medicine, if known.
Row 6 Name of Medicine	Text	Enter the name of the medicine listed in row 6.
IF PRESCRIBED, GIVE DOCTOR NAME (IF KNOWN)	Text	Provide the name of the doctor who prescribed the medicine, if known.
REASON FOR MEDICINE (IF KNOWN)	Text	State the reason for taking the medicine, if known.
Row 7 Name of Medicine	Text	Enter the name of the medicine listed in row 7.
IF PRESCRIBED, GIVE DOCTOR NAME (IF KNOWN)	Text	Provide the name of the doctor who prescribed the medicine, if known.
REASON FOR MEDICINE (IF KNOWN)	Text	State the reason for taking the medicine, if known.
Row 8 Name of Medicine	Text	Enter the name of the medicine listed in row 8.
IF PRESCRIBED, GIVE DOCTOR NAME (IF KNOWN)	Text	Provide the name of the doctor who prescribed the medicine, if known.
REASON FOR MEDICINE (IF KNOWN)	Text	State the reason for taking the medicine, if known.
Row 9 Name of Medicine	Text	Enter the name of the medicine listed in row 9.
IF PRESCRIBED, GIVE DOCTOR NAME (IF KNOWN)	Text	Provide the name of the doctor who prescribed the medicine listed in row 9, if known.
REASON FOR MEDICINE (IF KNOWN)	Text	State the reason for taking the medicine listed in row 9, if known.
Row 10 Name of Medicine	Text	Enter the name of the medicine listed in row 10.
IF PRESCRIBED, GIVE DOCTOR NAME (IF KNOWN)	Text	Provide the name of the doctor who prescribed the medicine listed in row 10, if known.
REASON FOR MEDICINE (IF KNOWN)	Text	State the reason for taking the medicine listed in row 10, if known.
Row 11 Name of Medicine	Text	Enter the name of the medicine listed in row 11.
IF PRESCRIBED, GIVE DOCTOR NAME (IF KNOWN)	Text	Provide the name of the doctor who prescribed the medicine listed in row 11, if known.
REASON FOR MEDICINE (IF KNOWN). If you need to list more medicines, use Section 11	Text	State the reason for taking the medicine listed in row 11, if known. If you need to list more medicines, use Section 11.
Medical Tests
Page 12 of 15 SECTION 8 - MEDICAL TREATMENT (continued) 8.B. Did any of the healthcare providers listed in 8.Ay. order any medical tests for you? Include tests already performed and scheduled in the future. NO (Go to Section 9)	CheckBox	Indicate whether any of the healthcare providers listed in Section 8.A ordered any medical tests for you. Select 'NO' if no tests were ordered.
YES (Select tests from the chart below)	CheckBox	Indicate whether any of the healthcare providers listed in Section 8.A ordered any medical tests for you. Select 'YES' if tests were ordered and choose the tests from the provided chart.
DATE OF TEST (MM/Y Y Y Y)	Text	Enter the date of the HIV test in the format MM/YYYY. Max length: 7 characters
Row 8 Test: Speech/language test Name of Healthcare Provider or Facility	Text	Provide the name of the healthcare provider or facility where the speech/language test was conducted.
DATE OF TEST (MM/Y Y Y Y)	Text	Enter the date of the speech/language test in the format MM/YYYY. Max length: 7 characters
Row 9 Test: Treadmill (exercise test) Name of Healthcare Provider or Facility	Text	Provide the name of the healthcare provider or facility where the treadmill (exercise) test was conducted.
DATE OF TEST (MM/Y Y Y Y)	Text	Enter the date of the treadmill (exercise) test in the format MM/YYYY. Max length: 7 characters
Row 10 Test: Vision test Name of Healthcare Provider or Facility	Text	Provide the name of the healthcare provider or facility where the vision test was conducted.
DATE OF TEST (MM/Y Y Y Y)	Text	Enter the date of the vision test in the format MM/YYYY. Max length: 7 characters
Row 11 Test: Psychological/I Q test Name of Healthcare Provider or Facility	Text	Provide the name of the healthcare provider or facility where the psychological/IQ test was conducted.
DATE OF TEST (MM/Y Y Y Y)	Text	Enter the date of the psychological/IQ test in the format MM/YYYY. Max length: 7 characters
Row 12 Test Biopsy (list body part)	Text	List the body part that was biopsied.
Name of Healthcare Provider or Facility	Text	Provide the name of the healthcare provider or facility where the biopsy was conducted.
DATE OF TEST (MM/Y Y Y Y)	Text	Enter the date of the biopsy in the format MM/YYYY. Max length: 7 characters
Row 13 Test M R I/C T scan (list body part)	Text	List the body part that was scanned in the MRI/CT scan.
Name of Healthcare Provider or Facility	Text	Provide the name of the healthcare provider or facility where the MRI/CT scan was conducted.
DATE OF TEST (MM/Y Y Y Y)	Text	Enter the date of the test in MM/YYYY format. Max length: 7 characters
Row 14 Test X-ray (list body part)	Text	Specify the body part that was X-rayed.
Name of Healthcare Provider or Facility	Text	Provide the name of the healthcare provider or facility where the X-ray was performed.
DATE OF TEST (MM/Y Y Y Y)	Text	Enter the date of the X-ray test in MM/YYYY format. Max length: 7 characters
Row 15 Test Other - please specify	Text	Specify the type of other test performed.
Name of Healthcare Provider or Facility	Text	Provide the name of the healthcare provider or facility where the other test was performed.
DATE OF TEST (MM/Y Y Y Y) If you need to list more tests, use Section 11	Text	Enter the date of the other test in MM/YYYY format. If you need to list more tests, use Section 11. Max length: 7 characters
Medical Treatment
Page 10 of 15 SECTION 8 - MEDICAL TREATMENT 8.Ay. Have you seen or received treatment from a healthcare provider (doctor, hospital, clinic, psychiatrist, nurse practitioner, therapist, physical therapist, or other medical professional), or do you have a future appointment scheduled? NO (Go to Section 9)	CheckBox	Indicate if you have seen or received treatment from a healthcare provider or have a future appointment scheduled. Select 'NO' if you have not and proceed to Section 9.
YES (Complete the chart(s) below)	CheckBox	Indicate if you have seen or received treatment from a healthcare provider or have a future appointment scheduled. Select 'YES' and complete the chart(s) below if applicable.
Page 11 of 15 SECTION 8 - MEDICAL TREATMENT (continued) 8.Ay.4. NAME OF FACILITY OR OFFICE	Text	Provide the name of the medical facility or office where you received treatment.
NAME OF HEALTHCARE PROVIDER THAT TREATED YOU	Text	Enter the name of the healthcare provider who treated you.
What medical conditions were treated or evaluated	Text	Describe the medical conditions that were treated or evaluated.
8.Ay.6. NAME OF FACILITY OR OFFICE	Text	Enter the name of the facility or office where you received medical treatment.
NAME OF HEALTHCARE PROVIDER THAT TREATED YOU	Text	Provide the name of the healthcare provider who treated you.
What medical conditions were treated or evaluated	Text	List the medical conditions that were treated or evaluated by the healthcare provider.
PHONE NUMBER	Text	Enter the phone number of the facility or healthcare provider.
DATE FIRST SEEN: MM/Y Y Y Y	Text	Enter the date when you were first seen by the healthcare provider in MM/YYYY format.
DATE last SEEN: MM/Y Y Y Y	Text	Enter the date when you were last seen by the healthcare provider in MM/YYYY format.
DATE OF NEXT APPOINTMENT: (IF KNOWN) MM/Y Y Y Y	Text	Enter the date of your next appointment with the healthcare provider, if known, in MM/YYYY format.
ADDRESS	Text	Provide the address of the facility or healthcare provider.
city	Text	Enter the city where the facility or healthcare provider is located.
State/Province	Text	Enter the state or province where the facility or healthcare provider is located.
ZIP/Postal Code	Text	Enter the ZIP or postal code of the facility or healthcare provider.
Country (If not U S Ay) If you need to list more facilities or healthcare providers, use Section 11	Text	Enter the country where the facility or healthcare provider is located, if it is not in the USA.
Medicines
SECTION 7 - MEDICINES 7. Are you currently taking any prescription or non-prescription medicine(s)? NO (Go to Section 8)	CheckBox	Check this box if you are not currently taking any prescription or non-prescription medicines.
YES (Complete the information below. You may need to look at your medicine containers.)	CheckBox	Check this box if you are currently taking any prescription or non-prescription medicines. You may need to refer to your medicine containers for details.
This is a table of 3 columns and 11 rows. Column Headers are Name of Medicine, IF PRESCRIBED, GIVE DOCTOR NAME (IF KNOWN), and REASON FOR MEDICINE (IF KNOWN). There are no row headers. Row 1 Name of Medicine	Text	Enter the name of the medicine you are taking in this row.
IF PRESCRIBED, GIVE DOCTOR NAME (IF KNOWN)	Text	If the medicine is prescribed, provide the name of the doctor who prescribed it, if known.
REASON FOR MEDICINE (IF KNOWN)	Text	Provide the reason for taking the medicine, if known.
Row 2 Name of Medicine	Text	Enter the name of the medicine you are taking in this row.
IF PRESCRIBED, GIVE DOCTOR NAME (IF KNOWN)	Text	If the medicine is prescribed, provide the name of the doctor who prescribed it, if known.
REASON FOR MEDICINE (IF KNOWN)	Text	Provide the reason for taking the medicine, if known.
Row 3 Name of Medicine	Text	Enter the name of the medicine you are taking in this row.
Other Medical Information
Page 13 of 15 SECTION 9 - OTHER MEDICAL INFORMATION 9. Does anyone else (other than your healthcare providers) have your medical information? Examples include Department of Veterans Affairs, social service agencies, vocational rehabilitation agencies, welfare agencies, attorneys, prisons, workers' compensation, and insurance companies who have paid you disability benefits. NO (Go to Section 10 if you are receiving Supplemental Security Income (SSI) and have been asked to complete this report; if not, go to Section 11.)	CheckBox	Check this box if no one else (other than your healthcare providers) has your medical information.
YES (Complete the information below)	CheckBox	Check this box if someone else (other than your healthcare providers) has your medical information and complete the information below.
Name of Organization	Text	Provide the name of the organization that has your medical information.
Phone Number	Text	Provide the phone number of the organization that has your medical information.
address	Text	Provide the address of the organization that has your medical information.
City	Text	Provide the city of the organization that has your medical information.
State/Province	Text	Provide the state or province of the organization that has your medical information.
Personal Information
Page 3 of 15 DISABILITY REPORT ADULT For S S Ay Use Only - Do not write in this box. Related S S N Number Holder. End of For SSA Use only. Anyone who makes or causes to be made a false statement or representation of material fact for use in determining a payment under the Social Security Act, or knowingly conceals or fails to disclose an event with an intent to affect an initial or continued right to payment, commits a crime punishable under Federal law by fine, imprisonment, or both, and may be subject to administrative sanctions. SECTION 1 - INFORMATION ABOUT YOU When a question refers to "you" or "your," it refers to the person who is applying for disability benefits. If you are completing this report for someone else, provide information about them. 1.Ay. Name (First, Middle Initial, Last, Suffix)	Text	Enter the full name of the person applying for disability benefits, including first name, middle initial, last name, and any suffix.
1.B. Social Security Number	Text	Enter the Social Security Number of the person applying for disability benefits.
1.C. Have you used any other names on your medical or educational records? Examples include maiden name, other married names, other names, or nickname. Yes	CheckBox	Indicate if you have used any other names on your medical or educational records, such as a maiden name or nickname. Check 'Yes' if applicable.
NO	CheckBox	Indicate if you have not used any other names on your medical or educational records. Check 'No' if applicable.
If YES, please list names used	Text	If you answered 'Yes' to using other names, list all the names you have used on your medical or educational records.
State/Province	Text	Enter the state or province where you currently reside.
ZIP/Postal Code	Text	Enter your ZIP or postal code.
Country (If not U S Ay)	Text	Enter your country if it is not the United States.
State/Province	Text	Enter the state or province where you reside.
ZIP/Postal Code	Text	Enter your ZIP or postal code.
Country (If not U S Ay)	Text	Enter your country if it is not the United States.
Claim number (if any)	Text	Enter your claim number if you have one.
Physical Abilities
Row 10 Reaching overhead (above the shoulder): One Arm	CheckBox	Indicate if you can reach overhead (above the shoulder) with one arm.
Both Arms	CheckBox	Indicate if you can reach overhead (above the shoulder) with both arms.
How much of your workday? (Hours/Minutes) Example: None	Text	Specify how much of your workday involves reaching overhead (above the shoulder). Provide the duration in hours and minutes, or indicate 'None' if not applicable.
Row 11: Climbing stairs or ramps How much of your workday? Example None	Text	Specify how much of your workday involves climbing stairs or ramps. Provide the duration in hours and minutes, or indicate 'None' if not applicable.
Row 11: Climbing ladders, ropes, or scaffolds How much of your workday? Example None If you need more space, use Section 11	Text	Specify how much of your workday involves climbing ladders, ropes, or scaffolds. Provide the duration in hours and minutes, or indicate 'None' if not applicable. Use Section 11 if you need more space.
Physical and Environmental Requirements
Page 8 of 15 SECTION 6 - WORK HISTORY (continued) 6.C. Physical and environmental requirements of your work Tell us how much time you spent doing the following physical activities in a typical workday. The total hours/minutes for standing, walking, and sitting should equal the Hours per Day reported in 6.Ay. The example below shows an 8-hour workday with 2 hours standing and walking and 6 hours sitting (8 hours total). Below is a table with 3 columns and 12 rows. The first and third columns have pre-filled data. Column headers are Activity, How much of your workday? (Hours/Minutes), and Example. Row 1: Standing and walking (combined) How much of your workday? Example 2 hours	Text	Indicate how much time you spent standing and walking (combined) in a typical workday for the job listed in section 6.A. The total hours/minutes for standing, walking, and sitting should equal the Hours per Day reported in section 6.A.
Row 2: Sitting How much of your workday? Example 6 hours	Text	Indicate how much time you spent sitting in a typical workday for the job listed in section 6.A. The total hours/minutes for standing, walking, and sitting should equal the Hours per Day reported in section 6.A.
Privacy Information
Privacy Act Statement Section Marker	Text	Section marker indicating the start of the 'Privacy Act Statement: Collection and Use of Personal Information' section for internal SSA use.
Program Information
TYPE OF PROGRAM	Text	Specify the type of program you are enrolled in or associated with.
Date Completed (or scheduled to be completed) MM/Y Y Y Y	Text	Enter the date when the program was completed or is scheduled to be completed in MM/YYYY format.
Report Completion
SECTION 12 - WHO IS COMPLETING THIS REPORT Date Report Completed (MM/DD/YYYY)	Text	Enter the date when this report was completed in MM/DD/YYYY format.
Who is completing this report? The person listed in 1.Ay	CheckBox	Indicate if the person listed in section 1.Ay is completing this report.
The person listed in 2.Ay	CheckBox	Indicate if the person listed in section 2.Ay is completing this report.
The person listed in 2.F	CheckBox	Indicate if the person listed in section 2.F is completing this report.
Someone else (Complete the information below)	CheckBox	Indicate if someone else is completing this report. Provide their information below.
NAME (First, Middle Initial, Last)	Text	Enter the name (First, Middle Initial, Last) of the person completing this report.
Relationship to the Person in 1.Ay	Text	Specify the relationship of the person completing this report to the individual listed in section 1.Ay.
MAILING ADDRESS (Street or P O Box) Include the apartment number, if applicable	Text	Provide the mailing address (Street or P.O. Box) of the person completing this report. Include the apartment number if applicable.
Submission Instructions
How to Submit Section Marker	Text	Section marker indicating the start of the 'How to Submit This Report' section for internal SSA use.
Support Services
COMPLETE THIS SECTION ONLY IF YOU ARE ALREADY RECEIVING SSI. SECTION 10 - SUPPORT SERVICES Provide information about your participation in support services, if applicable. Examples of support services can include: • An Individualized Education Program (I E P) through a school (if a student aged 18-21) • An individual work plan with an employment network under the Ticket to Work Program • A Plan to Achieve Self-Support (P Ay S S) • An individualized plan for employment with a vocational rehabilitation agency or any other organization 10.Ay. Have you participated or are you participating in any support services mentioned above or any other vocational rehabilitation, employment services, or other support services to help you to go to work? YES (Complete the information below)	CheckBox	Check this box if you are already receiving SSI and have participated or are participating in any support services mentioned.
No (Go to Section 11)	CheckBox	Check this box if you are not participating in any support services and proceed to Section 11.
10.B. FACILITY OR ORGANIZATION NAME	Text	Provide the name of the facility or organization where you are receiving support services.
Phone Number	Text	Enter the phone number of the facility or organization where you are receiving support services.
COUNSELOR, INSTRUCTOR, OR JOB COACH NAME	Text	Provide the name of your counselor, instructor, or job coach at the facility or organization.
Page 14 of 15 SECTION 10 - SUPPORT SERVICES (continued) 10.C. Are you still participating in the plan or program? (Select answer below) Yes	CheckBox	Indicate whether you are still participating in the plan or program by selecting 'Yes'.
If yes is checked, Date began: MM/ Y Y Y Y	Text	If you are still participating in the plan or program, enter the date you began (MM/YYYY).
Expected completion date: MM/Y Y Y Y	Text	Enter the expected completion date of the plan or program (MM/YYYY).
No	CheckBox	Indicate whether you are no longer participating in the plan or program by selecting 'No'.
If no is checked, Date began: MM/ Y Y Y Y	Text	If you are no longer participating in the plan or program, enter the date you began (MM/YYYY).
Date stopped: MM/ Y Y Y Y	Text	Enter the date you stopped participating in the plan or program (MM/YYYY).
Reason stopped	Text	Provide the reason why you stopped participating in the plan or program.
10.D. What types of services, tests, or evaluation were provided? Select all that apply: Vision test	CheckBox	Select this checkbox if you received a vision test as part of the services, tests, or evaluations provided.
Psychological/I Q test	CheckBox	Select this checkbox if you received a psychological or IQ test as part of the services, tests, or evaluations provided.
Work classes	CheckBox	Select this checkbox if you attended work classes as part of the services, tests, or evaluations provided.
Training and Vocational History
Page 6 of 15 SECTION 5 - EDUCATION, TRAINING, AND LITERACY (continued) 5.C. Have you received any type of training (specialized job, trade, or vocational training)? NO (Go to 5.D.)	CheckBox	Check this box if you have not received any type of specialized job, trade, or vocational training.
YES (Complete the table below.)	CheckBox	Check this box if you have received any type of specialized job, trade, or vocational training. Complete the table below if checked.
Name of Training Facility	Text	Enter the name of the training facility where you received specialized job, trade, or vocational training.
Phone Number	Text	Enter the phone number of the training facility where you received specialized job, trade, or vocational training.
Address	Text	Enter the address of the training facility where you received specialized job, trade, or vocational training.
city	Text	Enter the city where the training facility is located.
Work Activities
Row 3: Stooping (i.e., bending down & forward at waist) How much of your workday? Example 15 minutes	Text	Specify how much of your workday involves stooping (bending down and forward at the waist). Provide an example such as '15 minutes'.
Row 4: Kneeling (i.e., bending legs to rest on knees) How much of your workday? Example 15 minutes	Text	Specify how much of your workday involves kneeling (bending legs to rest on knees). Provide an example such as '15 minutes'.
Row 5: Crouching (i.e., bending legs & back down & forward) How much of your workday? Example None	Text	Specify how much of your workday involves crouching (bending legs and back down and forward). Provide an example such as 'None'.
Row 6: Crawling (i.e., moving on hands and knees) How much of your workday? Example None	Text	Specify how much of your workday involves crawling (moving on hands and knees). Provide an example such as 'None'.
Row 7 Using fingers to touch, pick, or pinch (e.g., using a mouse, keyboard, turning pages, or buttoning a shirt): One Hand	CheckBox	Indicate if you use one hand for activities involving fingers to touch, pick, or pinch (e.g., using a mouse, keyboard, turning pages, or buttoning a shirt).
Both Hands	CheckBox	Indicate if you use both hands for activities involving fingers to touch, pick, or pinch (e.g., using a mouse, keyboard, turning pages, or buttoning a shirt).
How much of your workday? (Hours/Minutes) Example: 2 hours (both hands)	Text	Specify how much of your workday involves using fingers to touch, pick, or pinch. Provide the duration in hours or minutes, for example, '2 hours (both hands)'.
Row 8 Using hands to seize, hold, grasp, or turn (e.g., holding a large envelope, a small box, a hammer, or water bottle): One Hand	CheckBox	Indicate if you use one hand for activities involving seizing, holding, grasping, or turning (e.g., holding a large envelope, a small box, a hammer, or water bottle).
Both Hands	CheckBox	Indicate if you use both hands for activities involving seizing, holding, grasping, or turning (e.g., holding a large envelope, a small box, a hammer, or water bottle).
How much of your workday? (Hours/Minutes) Example: 1 hour (both hands)	Text	Specify how much of your workday involves using hands to seize, hold, grasp, or turn. Provide the duration in hours or minutes, for example, '1 hour (both hands)'.
Row 9 Reaching at or below the shoulder: One Arm	CheckBox	Indicate if you use one arm for reaching at or below the shoulder.
Both Arms	CheckBox	Indicate if you use both arms for reaching at or below the shoulder.
How much of your workday? (Hours/Minutes) Example: 1 hour (both arms)	Text	Specify how much of your workday involves reaching at or below the shoulder. Provide the duration in hours or minutes, for example, '1 hour (both arms)'.
Work Activity
SECTION 4 - WORK ACTIVITY 4.Ay. Are you currently working? No, I have never worked (Go to question 4.B.)	CheckBox	Check this box if you are not currently working and have never worked. Proceed to question 4.B.
No, I have stopped working (Go to question 4.C. )	CheckBox	Check this box if you are not currently working and have stopped working. Proceed to question 4.C.
Yes, I am currently working (Go to question 4.F. )	CheckBox	Check this box if you are currently working. If checked, proceed to question 4.F.
IF YOU HAVE NEVER WORKED: 4.B. When do you believe your condition(s) became severe enough to keep you from working (even though you have never worked)? (MM/DD/Y Y Y Y) Go to Section 5	Text	Enter the date when you believe your condition(s) became severe enough to keep you from working, even if you have never worked before. Use the format MM/DD/YYYY.
IF YOU HAVE STOPPED WORKING: 4.C. When did you stop working? (MM?DD?Y Y Y Y)	Text	Enter the date when you stopped working. Use the format MM/DD/YYYY.
Why did you stop working? Because of my condition(s)	CheckBox	Check this box if you stopped working because of your condition(s).
Because of other reasons	CheckBox	Check this box if you stopped working for reasons other than your condition(s).
Please explain why you stopped working examples include laid off, early retirement, seasonal work ended, business closed	Text	Provide an explanation for why you stopped working. Examples include being laid off, early retirement, seasonal work ending, or business closure.
Even though you stopped working for other reasons, when do you believe your condition(s) became severe enough to keep you from working? (MM/DD/Y Y Y Y)	Text	If you stopped working for reasons other than your condition(s), enter the date when you believe your condition(s) became severe enough to keep you from working. Use the format MM/DD/YYYY.
Page 5 of 15 Section4 - Work Activity (continued) 4.D. Did your condition(s) cause you or your employer to make changes in your work activity? Examples include job duties, hours, or rate of pay. No, (Go to Section 5)	CheckBox	Check this box if your condition(s) did not cause you or your employer to make changes in your work activity. If checked, proceed to Section 5.
Yes	CheckBox	Check this box if your condition(s) caused you or your employer to make changes in your work activity.
If Yes is checked When did the changes start? (MM/DD/Y Y Y Y)	Text	If you checked 'Yes' to the previous question, enter the date when the changes in your work activity started. Use the format MM/DD/YYYY.
4.E. Since the date in 4.D. above, have you had earnings greater than 1,550 dollars before tax in any month? Do not count sick leave, vacation, or disability pay. (We may contact you for more information.) Yes (Go to Section 5)	CheckBox	Check this box if you have had earnings greater than $1,550 before tax in any month since the date in question 4.D. Do not count sick leave, vacation, or disability pay. If checked, proceed to Section 5.
NO (Go to Section 5)	CheckBox	Check this box if you have not had earnings greater than $1,550 before tax in any month since the date in question 4.D. Do not count sick leave, vacation, or disability pay. If checked, proceed to Section 5.
Work Activity Changes
IF YOU ARE CURRENTLY WORKING: 4.F. Has your condition(s) caused you or your employer to make changes in your work activity? Examples include job duties, hours, or rate of pay. YES	CheckBox	Indicate if your medical condition has caused you or your employer to make changes in your work activity, such as job duties, hours, or rate of pay.
If yes is checked When did the changes start? (MM/DD/Y Y Y Y)	Text	If you answered 'Yes' to changes in your work activity, specify the date when these changes started (MM/DD/YYYY).
NO	CheckBox	Indicate if your medical condition has not caused any changes in your work activity.
If no is checked When did your condition(s) first start bothering you? (MM/DD/Y Y Y Y)	Text	If you answered 'No' to changes in your work activity, specify the date when your condition first started bothering you (MM/DD/YYYY).
Work History
SECTION 6 - WORK HISTORY (If you need more space, use Section 11) 6.A. Did you have a job in the 5 years before you became unable to work because of your medical conditions? NO (Go to Section 7)	CheckBox	Indicate if you had a job in the 5 years before you became unable to work due to your medical conditions. Select 'NO' if you did not have a job and proceed to Section 7.
YES (Complete the table below.)	CheckBox	Indicate if you had a job in the 5 years before you became unable to work due to your medical conditions. Select 'YES' and complete the table below if you had a job.
List all the jobs you had in the 5 years before you became unable to work because of your medical conditions: • List your most recent job first • List all job titles even if they were for the same employer • Do not include jobs you held less than 30 calendar days • Include self-employment (e.g., ride share driver, hair stylist) • Include work in a foreign country Below is a table of 8 columns and 5 rows. The columns are labeled Job Title (e.g., Cashier), Type of Business (e.g., Grocery Store), Date Worked From MM/Y Y Y Y Date Worked To MM/Y Y Y Y, Hours Per Day, Days Per Week, Rate of Pay Amount, and Rate of Pay Frequency (per) hour, day, week, month, or year. 1. Job title (e.g., Cashier)	Text	Enter the title of the job you held most recently before you became unable to work due to your medical conditions. Include all job titles even if they were for the same employer, and do not include jobs held for less than 30 days. Include self-employment and work in a foreign country.
Type of Business (e.g., Grocery Store)	Text	Specify the type of business for the job you listed, such as 'Grocery Store' or 'Construction'.
dates worked from M M/Y Y Y Y	Text	Enter the month and year (MM/YYYY) when you started working at the job you listed. Max length: 7 characters
To M M/Y Y Y Y	Text	Enter the month and year (MM/YYYY) when you stopped working at the job you listed. Max length: 7 characters
Hours per day	Text	Enter the number of hours you worked per day at the job you listed.
Days per week	Text	Enter the number of days you worked per week at the job you listed.
Rate of pay Amount	Text	Enter the amount you were paid for the job you listed.
Rate of Pay Frequency (per) hour, day, week, month, or year	Text	Specify the frequency of your pay for the job you listed, such as per hour, day, week, month, or year.
2. Job Title	Text	Enter the title of the second most recent job you held before you became unable to work due to your medical conditions.
Type of Business	Text	Specify the type of business for the second job you listed, such as 'Grocery Store' or 'Construction'.
dates worked from M M/Y Y Y Y	Text	Enter the month and year (MM/YYYY) when you started working at the second job you listed. Max length: 7 characters
To M M/Y Y Y Y	Text	Enter the month and year (MM/YYYY) when you stopped working at the second job you listed. Max length: 7 characters
Hours per day	Text	Enter the number of hours you worked per day in your most recent job.
Days per week	Text	Enter the number of days you worked per week in your most recent job.
Rate of pay Amount	Text	Enter the amount you were paid for your most recent job.
Rate of Pay Frequency	Text	Specify the frequency of your pay (e.g., weekly, bi-weekly, monthly) for your most recent job.
3. Job title	Text	Enter the job title of your third most recent job.
type of business	Text	Specify the type of business for your third most recent job.
dates worked from M M/Y Y Y Y	Text	Enter the start date (MM/YYYY) for your third most recent job. Max length: 7 characters
To M M/Y Y Y Y	Text	Enter the end date (MM/YYYY) for your third most recent job. Max length: 7 characters
Hours per day	Text	Enter the number of hours you worked per day in your third most recent job.
Days per week	Text	Enter the number of days you worked per week in your third most recent job.
Rate of pay Amount	Text	Enter the amount you were paid for your third most recent job.
Rate of Pay Frequency	Text	Specify the frequency of your pay (e.g., weekly, bi-weekly, monthly) for your third most recent job.
4. Job title	Text	Enter the job title of your fourth most recent job.
type of business	Text	Specify the type of business for your fourth most recent job.
dates worked from M M/Y Y Y Y	Text	Enter the start date (MM/YYYY) for your fourth most recent job. Max length: 7 characters
To M M/Y Y Y Y	Text	Enter the end date (MM/YYYY) for your fourth most recent job. Max length: 7 characters
Hours per day	Text	Enter the number of hours you worked per day in this job.
Days per week	Text	Enter the number of days you worked per week in this job.
Rate of pay Amount	Text	Enter the amount you were paid for this job.
Rate of Pay Frequency	Text	Specify how often you were paid (e.g., weekly, bi-weekly, monthly) for this job.
5. Job title	Text	Enter the job title you held in this position.
type of business	Text	Specify the type of business or industry for this job.
dates worked from M M/Y Y Y Y	Text	Enter the month and year you started working in this job (MM/YYYY). Max length: 7 characters
To M M/Y Y Y Y	Text	Enter the month and year you stopped working in this job (MM/YYYY). Max length: 7 characters
Hours per day	Text	Enter the number of hours you worked per day in this job.
Days per week	Text	Enter the number of days you worked per week in this job.
Rate of pay Amount	Text	Enter the amount you were paid for this job.
Rate of Pay Frequency	Text	Specify how often you were paid (e.g., weekly, bi-weekly, monthly) for this job.
Page 7 of 15 SECTION 6 - WORK HISTORY (continued) Check the box below that applies to you. I had more than one job. (If you had more than one job, we may contact you for more information. Do not answer the questions in Section 6.B through 6.D. Go to Section 7.)	CheckBox	Check this box if you had more than one job. If checked, you do not need to answer the questions in Section 6.B through 6.D and should proceed to Section 7.
I had only one job. (If you had only one job, complete the questions in 6.B. through 6.D.)	CheckBox	Check this box if you had only one job. If checked, complete the questions in Section 6.B through 6.D.
6.B. Information about your work 6.B.1. For the job you listed in 6.Ay., describe in detail the tasks you did in a typical workday. Examples of tasks include stocking shelves, greeting customers, scheduling appointments, or maintaining records	Text	Describe in detail the tasks you performed in a typical workday for the job listed in section 6.A. Examples of tasks include stocking shelves, greeting customers, scheduling appointments, or maintaining records.
6.B.2. If any of the tasks listed above involved writing or completing reports, describe the type of report you wrote or completed and how much time you spent on it per workday or workweek	Text	If any of the tasks listed in section 6.B.1 involved writing or completing reports, describe the type of report you wrote or completed and how much time you spent on it per workday or workweek.
6.B.3. If any of the tasks listed above involved supervising others, describe who or what you supervised and what supervisory duties you had. Examples of supervisory duties include evaluating employee job performance, making schedules, or maintaining time records	Text	If any of the tasks listed in section 6.B.1 involved supervising others, describe who or what you supervised and what supervisory duties you had. Examples of supervisory duties include evaluating employee job performance, making schedules, or maintaining time records.
6.B.4. List the machines, tools, and equipment you used regularly when doing this job and explain what you used them for. Examples of equipment include computer, telephone, forklift, air compressor, or meat slicer	Text	List the machines, tools, and equipment you used regularly when doing the job listed in section 6.A and explain what you used them for. Examples of equipment include computer, telephone, forklift, air compressor, or meat slicer.
6.B.5. Did this job require you to interact with coworkers, the general public, or anyone else? Yes	CheckBox	Indicate if the job listed in section 6.A required you to interact with coworkers, the general public, or anyone else. Select 'Yes' if it did.
No	CheckBox	Indicate if the job listed in section 6.A did not require you to interact with coworkers, the general public, or anyone else. Select 'No' if it did not.
If YES, describe who you interacted with, the purpose of the interaction, how you interacted, and how much time you spent doing it per workday or workweek. Examples include answering customer questions on the telephone for 5 hours per day or showing clients sale properties in person for 4 hours per day	Text	If you selected 'Yes' in section 6.B.5, describe who you interacted with, the purpose of the interaction, how you interacted, and how much time you spent doing it per workday or workweek. Examples include answering customer questions on the telephone for 5 hours per day or showing clients sale properties in person for 4 hours per day.
Select the weight frequently lifted (i.e., one third to two thirds of the workday): Less than 1 pound	CheckBox	Select this option if you frequently lifted less than 1 pound during your workday.
Less than 10 pounds	CheckBox	Select this option if you frequently lifted less than 10 pounds during your workday.
10 pounds	CheckBox	Select this option if you frequently lifted 10 pounds during your workday.
25 pounds	CheckBox	Select this option if you frequently lifted 25 pounds during your workday.
50 pounds or more	CheckBox	Select this option if you frequently lifted 50 pounds or more during your workday.
Other	CheckBox	Select this option if you frequently lifted a weight not listed here during your workday.
If other is checked enter weight	Text	Enter the weight you frequently lifted if you selected 'Other' in the previous question.
Did this job expose you to any of the following? Check all that apply. Outdoors	CheckBox	Select this option if your job exposed you to outdoor conditions.
Extreme heat (non-weather related)	CheckBox	Select this option if your job exposed you to extreme heat that is not weather-related.
Extreme cold (non-weather related)	CheckBox	Select this option if your job exposed you to extreme cold that is not weather-related.
Wetness	CheckBox	Select this option if your job exposed you to wet conditions.
Humidity	CheckBox	Select this option if your job exposed you to high humidity.
Hazardous substances	CheckBox	Select this option if your job exposed you to hazardous substances.
Moving mechanical parts	CheckBox	Select this option if your job exposed you to moving mechanical parts.
High, exposed places	CheckBox	Select this option if your job exposed you to high, exposed places.
Heavy vibrations	CheckBox	Select this option if your job exposed you to heavy vibrations.
Loud noise	CheckBox	Check this box if your job exposed you to loud noise.
Other	CheckBox	Check this box if your job exposed you to other hazardous conditions not listed.
If one or more boxes are checked, tell us about the exposure(s) and how often you were exposed	Text	If you checked any of the exposure boxes, describe the type of exposure and how often you were exposed.
Page 9 of 15 Section 6 - Work History (continued) 6.D. Explain how your medical conditions would affect your ability to do this job	Text	Explain how your medical conditions affect your ability to perform your job duties.

Form SSA-3368-BK, Disability Report - Adult Instructions