DI 11005.045: Completing the SSA-3367 (Disability Report – Field Office)
Effective Dates: 06/05/2017 - Present TN 48 (05-16)
- DI 11005.045 Completing the SSA-3367 (Disability Report – Field Office)
The field office (FO) is responsible for completing Form SSA-3367 (or the Electronic Disability Collect System (EDCS) 3367 Disability Report) before transferring jurisdiction of a claim to the disability determination services (DDS). The SSA-3367 or EDCS 3367 entries provide the DDS information about the: * current filing including the potential onset date (POD), work after the alleged onset date (AOD), and blind date last insured (DLI), if applicable;
- * prior filings;
- * presumptive disability and presumptive blindness (Title XVI only); and
* observations made by the interviewer. This information alerts the DDS to non-medical factors that could affect entitlement and helps guide DDS case development. The FO completes the SSA-3367 or EDCS 3367 for initial claims, reconsiderations of the initial claim and escalated claims, and continuing disability reviews (CDRs), including expedited reinstatements (EXR). REMINDER: Claims excluded from EDCS make up a small number of disability claims and you rarely need a paper form SSA-3367. A. Completing the SSA-3367 For multiple or concurrent EDCS exclusion claims, fill out one complete paper form SSA-3367 and duplicate copies of page 1, items 1 through 6, for each additional claim.
- 1. IDENTIFYING INFORMATION (items 1-5)
Complete the following information.
- a. Item 1: Name, Social Security number, gender, date of birth
Enter the full name and social security number (SSN) of the number holder (NH). Enter the full name, gender, date of birth, and SSN of the claimant, if different from the NH. For auxiliary or survivor claims (e.g., a disabled widow(er) beneficiary (DWB) filing on the deceased spouse’s record, or a disabled minor child (DMC) filing on a parent’s record), enter the claimant’s name and SSN.
- b. Item 2: Claimant’s Alleged Onset Date (AOD)
Enter the AOD. The AOD is the date the claimant says that he or she became unable to work because of his or her medical condition (see DI 25501.210). If the AOD conflicts anywhere in the file (e.g., the AOD is different on the application from what is recorded on the SSA-3368-BK (Disability Report - Adult)), resolve the conflict with the claimant, enter the date selected by the claimant, and explain it in the remarks section on the SSA-3367. NOTE: Even if the claimant never worked, enter the date when he or she believes the condition(s) became severe enough to keep him or her from working. (Refer to the work activity section on the SSA-3368-BK.) c. Item 3: Potential Onset Date (POD) For detailed instructions on completing items 3 through 6 for specific claim types, refer to DI 11005.045B in this section. The POD alerts the DDS examiner of work issues, insured status, and other non-medical factors that may affect the EOD. The POD is claim specific. For Title II disability insurance benefit (DIB) claims, the POD is the earliest possible date that we can establish onset based on non-medical factors. The POD may be the same as, earlier, or later than the AOD. Enter the POD for each disability claim at the initial and reconsideration levels, including escalated claims, after the claimant meets all non-medical requirements. For both FO and DDS instructions for determining the POD, see DI 25501.220. Enter the POD for Title XVI cases if it is different from the protective filing date or the filing date if there is no protective filing. For instructions on how to enter the POD in Title II cases, see the chart in DI 25501.220C.1.b. For concurrent cases, consider the POD separately for each disability claim type (see DI 25501.220A.3.). NOTE: Be aware that the POD may be in a previously adjudicated period; including a period decided by an administrative law judge (ALJ). If the FO sets a POD in a previously adjudicated period, the DDS must consider whether reopening and revising a prior determination or decision is appropriate (see DI 27501.005).
- d. Item 4: Reason for Potential Onset Date
Complete this item if you entered a POD in item 3 in DI 11005.045A.1.c. in this section.
- Check the appropriate block for the reason for the POD.
* Supplemental Security Insurance (SSI) application date
- * Date last insured
- * Date first insured
- * Controlling date
* Work before or after the AOD (check appropriate reason): * UWA (unsuccessful work attempt); * SGA (substantial gainful activity);
- * Not SGA;
* SSA-823 (Report of SGA Determination – For SSA Use Only) in file. (For EDCS claims, when you select the “823 in file” option, you must also select if work is UWA, SGA or Not SGA. This will allow for the transfer of the claim to the DDS; see MSS15-083 EDCS.) * Other – explain in item 5. IMPORTANT: You must complete the Form SSA-823 (Report of SGA Determination- For SSA Use Only) in all initial claims that require an SSA-820-BK (Work Activity Report - Self-Employment) or SSA-821-BK (Work Activity Report - Employee). Do not complete an SSA-821-BK or SSA-823 if the work is clearly not SGA; see DI 10505.003. For more detailed information on work activity reports, (SSA-820-BK and SSA-821-BK), see DI 10510.025 and DI 10505.035.
- e. Item 5: Explanation for Potential Onset Date, when applicable
If you check “Other” in item 4, explain the reason for the POD. Provide an explanation if: * The POD and the AOD are inconsistent. (The FO must resolve and explain any inconsistencies in work activity or other non-medical factors that may affect the onset date.) * The claimant’s work is clearly not SGA (see DI 10505.003). * The date first insured (DFI) is indicated as a reason for the POD, then enter the DFI. * In blindness and visual impairment paper claims, enter the following statement on the SSA-3367 in item 5, Explanation for Potential Onset Date, when applicable: “If claimant is found statutorily blind, the blind DFI is MM/DD/YYYY and the blind DLI is MM/DD/YYYY.” For EDCS claims, see DI 11005.045A.9.g.
- 2. Item 6: MISCELLANEOUS INFORMATION
- Provide the following information:
* Enter the protective filing date. * For DIB and Freeze claims, enter the non-blind date last insured (DLI). * For DWB claims, enter the prescribed period and controlling date. For detailed guidance, see DI 11005.050. * Enter the blind DLI, if applicable. For EDCS claims, see DI 11005.045A.9.g. * Check “yes” or “no” for a closed period of disability case. For more information on closed periods, see DI 25510.001, DI 25510.010, and DI 25510.015. NOTE: For instructions on cases involving potential blindness, see DI 11005.045B.1. in this section. 3. Item 7: PRIOR FILING INFORMATION
- Indicate whether the claimant has a prior filing(s).
If yes, provide the following: * Claim type(s);
- * SSN(s) of prior claim(s);
* Date of last decision (MM/DD/YYYY); * Level of last decision (initial, reconsideration, etc.); * Outcome of last decision (allowance or denial);
- * Location of prior folder; and
- * Prior folder requested; if “yes” include the date requested or “no.”
IMPORTANT: List ALL prior filings with a medical decision and SGA denials on the SSA-3367 (or the EDCS 3367). The DDS does not need filing information for technical denials (e.g., N13, N04, N18, 090).
- For instructions on prior filings, see Prior Claims Activity in DI 11005.085.
- 4. Item 8: PRESUMPTIVE
Check the block(s) for any presumptive disability (PD) or presumptive blindness (PB) criteria that apply in SSI (Title XVI) claims. For detailed FO procedures on processing PD and PB cases, see DI 11055.240.
- 5. Item 9: OBSERVATIONS/PERCEPTIONS
Observations are very valuable because DDS examiners do not have face-to-face contact with claimants. Record the following information: * type of interview (teleclaim, face-to-face, or no contact with the claimant); * difficulties with any of the activities listed (check “yes,” “no,” or “not observed”); * explanation or comments about your observations in the space provided; and * description of the claimant’s behavior, appearance, grooming, or degree of limitations in the space provided.
- 6. Item 10: FO DEVELOPMENT
Completely document any development initiated by the FO. For information on FO development of medical evidence, see DI 11010.485 through DI 11010.495. For information on FO development of other non-medical evidence, see DI 22501.002B. 7. Item 11: MEDICAL EVIDENCE Indicate if the claimant submitted medical evidence of record (MER) to the FO. 8. Item 12: CAPABILITY DEVELOPMENT If you cannot make a capability determination, but capability is questionable (e.g., allegation of mental disorder(s) or noticeable abnormal behavior of the claimant), request the DDS to give an opinion on the issue of capability and explain in the remarks section on the SSA-3367. NOTE: While the DDS may provide an opinion regarding the evidence of capability, the FO is responsible for the final determination of capability. For policy about FO requests for DDS capability development, see DI 11055.215A. 9. REMARKS SECTION Use the remarks section to add explanations, descriptions, or expansion of the answers to questions. Use this area to record other pertinent information about the claim for the DDS. See the following examples of when to use the remarks section. a. Medicare for Qualified Government Employment (MQGE) cases
- Enter the following information:
* When applicable, enter a remark to advise the DDS that the claimant filed an application with the Office of Personnel Management for an annuity based on disability, or is receiving an annuity based on disability. Include the Civil Service annuity claim number; * When forwarding MQGE cases to the DDS for a disability determination, annotate the remarks section “MQGE claim for Medicare entitlement only;” * When developing disability for MQGE claims and there are differences in the DLI or the prescribed period for MQGE and cash benefits, annotate the remarks section to notify the DDS to avoid unnecessary development; and * If a claimant is potentially entitled to both MQGE and DIB benefits with different DFIs, DLIs, and PODs, the FO must indicate this in the remarks section to alert the DDS to develop evidence based on multiple onset dates. For more information on MQGE policy and procedures, see DI 11035.001, DI 11035.005, and DI 25501.365.
- b. Consultative examination (CE) appointment
If the claimant expects difficulties in keeping a possible CE appointment (e.g., lack of transportation, home confinement due to disability, inability to read, no telephone where claimant can be reached, or homelessness), document the reason in the remarks section. c. Prisoner cases For applicable remarks to document prisoner cases, refer to Field Offices Identifying and Documenting Prisoner Status for Title II Disability Benefits in DI 10105.094B.2.
- d. Recontacting the claimant
If re-contact with the claimant is difficult (e.g., when the claimant is homeless, will be difficult to contact by telephone, or will be on an extended trip and unavailable for contact), document the reason in the remarks section. For more information, see DI 11005.001A.2.
- e. Curtailing completion of Form SSA-3368-BK (Disability Report – Adult) or SSA-3820-BK (Disability Report – Child)
If you curtail completion of the SSA-3368-BK or SSA-3820-BK, explain why in the remarks section. See details in DI 11005.020. f. Earnings that are clearly not SGA Document the monthly earnings allegations and write “clearly not SGA” in the remarks section per DI 10505.003B.1.a. g. Blindness claims (EDCS 3367 only) In blindness and visual impairment claims, enter the following statement: “If claimant is found statutorily blind, the blind DFI is MM/DD/YYYY and the blind DLI is MM/DD/YYYY.” h. Potential parent’s benefits claims If the DIB claimant alleges providing half support to a parent at the time of onset, enter the following statement: Potential Parent’s Benefits - Do not use the DIB expedient when establishing the EOD.” (See DI 25501.300.) 10. INTERVIEWER INFORMATION Print the interviewer’s name or the name of the person completing the form (if different from interviewer), the interviewer’s area code and phone number, and date the form. B. Supplemental instructions for Form SSA-3367 for specific claim types You need supplemental claim information regarding insured status, prescribed period or controlling date, or both, for the claim types described in DI 11005.045B in this section. If you fail to document this information properly, it could affect the claimant’s entitlement to benefits. 1. DIB and freeze cases with a non-blind DLI prior to the filing date and an allegation of blindness, vision problems, or low vision When an applicant alleges blindness, vision problems, or low vision, the blind date first insured (DFI) and the blind date last insured (DLI) could be material to the established onset date for blindness. Provide the blind DLI when the non-blind DLI is in the past or is likely to expire before DDS or the Office of Disability Adjudication and Review (ODAR) renders a decision (e.g., will expire within six months of the filing date or the date of appeal). In these cases: * In item 3, Potential Onset Date, check the “OTHER” block. Enter NONE and explain in Item 5 (no disability entitlement, blindness entitlement only) in the space provided. * In item 5, Explanation for Potential Onset Date, when applicable, enter the following statement for paper claims: “If claimant is found statutorily blind; the blind DFI is MM/DD/YYYY. * In item 6, Miscellaneous Information, “Date last insured (DIB/Freeze case)” field, enter the non-blind DLI in the space provided. * In item 6, Miscellaneous Information, enter the blind DLI in the “Blind date last insured (if applicable)” field. NOTE: For EDCS blindness claims, see DI 11005.045A.9.g. in this section. 2. MQGE cases There may be a second, more recent DLI for Medicare purposes when the claimant meets insured status. For MQGE cases: * In item 4, Reason for Potential Onset Date, check the “Date Last Insured” block. * In item 5, Explanation for Potential Onset Date, when applicable, enter the following statement: “Possible later DLI for Medicare purposes only due to claimant being a Medicare Qualified Government Employee”. * In item 6, Miscellaneous Information, “Non-blind date last insured (DIB/Freeze case)” field, enter the DLI (the non-blind DLI). For further instructions for MQGE cases, refer to DI 11005.045A.9.a. in this section. 3. DWB cases For DWB cases, provide the following information: * In item 6, Miscellaneous Information, always enter the protective filing date. * In item 6, Miscellaneous Information, enter the beginning and ending dates of the prescribed period and the controlling date. To determine these dates, see the guide in DI 11005.050C. * In item 6, Miscellaneous Information, in a Medicare-only claim filed by a mother or father beneficiary, enter “Not yet started” in the line for “End of Prescribed Period,” because the prescribed period has not yet begun; see DI 11005.050B.1.
- C. References
* DI 10505.003 Evaluating and Developing Earnings that Clearly are or are not Substantial Gainful Activity (SGA) * DI 10505.035 Documenting Employment Cases Using Forms SSA-821-BK (Work Activity Report-Employee) and SSA-823 (Report of SGA Determination-For SSA Use Only) * DI 10510.025 Documenting Self-Employment Cases Using the SSA-820-BK (Work Activity Report-Self-Employment) and the SSA-823 (Report of SGA Determination- For SSA Use Only)
- * DI 10515.000 Evaluation of Work Activity in Title II Blindness Cases – Table of Contents
* DI 25501.220 Potential Onset Date (POD)
- * DI 25501.380 Establishing the Established Onset Date (EOD) of Statutory Blindness in Title II Disability Insurance Benefits (DIB) Claims
- * DI 27500.000 Reopenings, Adoptions and Refilings – Table of Contents
* DI 81010.025 Completing Electronic Disability Collect System (EDCS) Forms for Initial Claims
- * DI 81010.150 Processing Claims Appeals of Medical Decisions in Electronic Disability Collect System (EDCS)
* AM–14047 REV Potential Erroneous DLI Propagation in EDCS
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