Ssa 3368

DISABILITY REPORT - ADULT
SSA-3368-BK
PLEASE READ THIS INFORMATION BEFORE COMPLETING THIS REPORT
The information you give us on this report will be used by the office that makes the disability
decision on your disability claim. Completing this report accurately and completely will help us
expedite your claim. Please complete as much of the report as you can.
IF YOU NEED HELP
Note: If you are assisting someone else with this report, please answer the questions as if that
person were completing the report.
HOW TO COMPLETE THIS REPORT
Print or write clearly.

Include a ZIP or postal code with each address.
Provide complete phone numbers including area code. If a phone number is outside
the United States, also provide International Direct Dialing (IDD) code and country code.
If you cannot remember the names and addresses of your health care providers, you may
be able to get that information from the telephone book, Internet, medical bills,
prescriptions, or prescription medicine containers.
ANSWER EVERY QUESTION, unless the report indicates otherwise. If you do not know
an answer, or the answer is "none" or "does not apply," please write: "don't know," or
"none," or "does not apply."
Be sure to explain an answer if the question asks for an explanation, or if you want to give
additional information.
If you need more space to answer any question, please use Section 11 - Remarks on the
last page to finish your answer. Write the number of the question you are answering.
YOUR MEDICAL RECORDS
If you have any of your medical records, send or bring them to our office with this completed
report. Please tell us if you want to keep your records so we can return them to you. If you are
having an interview in our office, bring your medical records, your prescription medicine
containers (if available), and the completed report with you.
YOU DO NOT NEED TO ASK DOCTORS OR HOSPITALS FOR ANY MEDICAL RECORDS
THAT YOU DO NOT ALREADY HAVE. With your permission, we will request your records.
The information that you give us on this report tells us where to request your medical and
other records.
Form SSA-3368-BK (11-2014) ef (11-2014)
Disability Report- Adult-Form SSA-3368-BK
You can get help from other people, such as a friend or family member. Please do not ask
your health care provider to complete this report. If you cannot complete the report, a Social
Security Representative will assist you. If you have an appointment, please have the
completed report ready when we contact you. If we ask you to do so, please mail the
completed report to us ahead of time.
WHAT WE MEAN BY "DISABILITY"

Disability under Social Security is based on your inability to work. For purposes of this claim, we want
you to understand that disability means you are unable to work as defined by the Social Security Act.
You will be considered disabled if you are unable to do any kind of work for which you are suited and if
your disability is expected to last (or has lasted) for at least a year or is expected to result in death. So
when we ask when did you become unable to work, we are asking when you became disabled as
defined by the Social Security Act.
Privacy Act Statement
Collection and Use of Personal Information
Section 205(a), 223(d), and 1631(e)(1) of the Social Security Act, as amended, authorize us to collect this information.
We will use the information you provide to make a decision on the named claimants claim.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the information could prevent
us from making an accurate and timely decision on the named claimants claim.
We rarely use the information you supply for any purpose other than to make decisions regarding claims. We may also
disclose information to another person or to another agency in accordance with approved routine uses, which include
but are not limited to the following:
1. To enable a third party or an agency to assist Social Security in establishing rights to Social Security
benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social Security records (e.g., to the
Government Accountability Office and Department of Veterans Affairs);
3. To make determinations for eligibility in similar health and income maintenance programs at the Federal,
State, and local level; and,
4. To facilitate statistical research, audit, or investigative activities necessary to assure the integrity and
improvement of Social Security programs (e.g., to the Bureau of the Census and private concerns under
contract to Social Security).
We may also use the information you provide in computer matching programs. Matching programs compare our records
with records kept by other Federal, State, or local government agencies. Information from these matching programs can
be used to establish or verify a persons eligibility for federally-funded or administered benefit programs and for
repayment of payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in Systems of Records Notice entitled, Claims Folders
Systems, 60-0089. This notice, additional information regarding this form, and information regarding our programs and
systems, are available on-line at www.socialsecurity.gov or at your local Social Security office.
Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. 3507, as
amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we
display a valid Office of Management and Budget control number. We estimate that it will take about 60 minutes to read
the instructions, gather the facts, and answer the questions.
SEND OR BRING THE COMPLETED FORM TO THE OFFICE THAT REQUESTED IT. You can find your local
Social Security office through SSAs website at www.socialsecurity.gov. Offices are also listed under U. S.
Government agencies in your telephone directory or you may call Social Security at 1-800-772-1213 (TTY
1-800-325-0778). You may send comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD
21235-6401. Send only comments relating to our time estimate to this address, not the completed form.
AFTER COMPLETING THIS REPORT, REMOVE THIS SHEET AND

KEEP IT FOR YOUR RECORDS
Form SSA-3368-BK (11-2014) ef (11-2014)
Form Approved
OMB No. 0960-0579
For SSA Use Only- Do not write in this box.
SOCIAL SECURITY ADMINISTRATION
Related SSN
DISABILITY REPORT
ADULT
Number Holder
If you are filling out this report for someone else, please provide information about him or her. When a question
refers to "you" or "your," it refers to the person who is applying for disability benefits.
SECTION 1 - INFORMATION ABOUT THE DISABLED PERSON
1.A. Name (First, Middle Initial, Last)
1.B. Social Security Number
030585017
JOHN JAMES OSTIGUY
1.C. Mailing Address (Street or P O Box) Include apartment number or unit if applicable.
61 DAVID ST
City
SPRINGFIELD
State/Province
MA
Country (If not USA)
ZIP/Postal Code
01104
1.D. Email Address

[email protected]
1.E. Daytime Phone Number, including area code, and the IDD and country codes if you live outside the USA
or Canada.
Phone number 4133061887
Check this box if you do not have a phone or a number where we can leave a message .
1.F. Alternate Phone Number - another number where we may reach you, if any.
Alternate phone number
1.G. Can you speak and understand English?
Yes
No
If no, what language do you prefer?

If you cannot speak and understand English, we will provide an interpreter, free of charge.
1.H. Can you read and understand English?
Yes
No
1.I. Can you write more than your name in English?
Yes
No
1.J. Have you used any other names on your medical or educational records? Examples are maiden name, other
Yes
No
married name, or nickname.
If yes, please list them here:
SECTION 2 - CONTACTS
Give the name of someone (other than your doctors) we can contact who knows about your medical conditions, and
can help you with your claim.
2.A. Name (First, Middle Initial, Last)
2.B. Relationship to you
TARA LOPEZ
FRIEND
2.C. Daytime Phone Number (as described in 1.E. above)
4139491296
2.D. Mailing Address (Street or P O Box) Include apartment number or unit if applicable.
61 DAVID ST
City
SPRINGFIELD
State/Province
MA
2.E. Can this person speak and understand English?
Yes
If no, what language is preferred?

Form SSA-3368-BK (11-2014) ef (11-2014)
ZIP/Postal Code
01104
PAGE 1

No
2.F. Who is completing this report?
SECTION 2 - CONTACTS (continued)
The person who is applying for disability. (Go to Section 3 - Medical Conditions)
The person listed in 2.A. (Go to Section 3 - Medical Conditions)
Someone else (Complete the rest of Section 2 below)
2.G. Name (First, Middle Initial, Last)
2.H. Relationship to Person Applying
2.I. Daytime Phone Number

2.J. Mailing Address (Street or P O Box) Include apartment number or unit if applicable.
City
State/Province
ZIP/Postal Code
SECTION 3 - MEDICAL CONDITIONS

3.A. List all of the physical or mental conditions (including emotional or learning problems) that limit your ability to work.
If you have cancer, please include the stage and type. List each condition separately.
1. DEPRESSION
2. ANXIETY
3.
4.
5.
If you need more space, go to Section 11-Remarks on the last page
3.B. What is your height without shoes? 5
10
feet
3.C. What is your weight without shoes? 235
inches
pounds
OR
OR
centimeters (if outside USA)

kilograms (if outside USA)
3.D. Do your conditions cause you pain or other symptoms?

4.A. Are you currently working?
Yes
No
SECTION 4 - WORK ACTIVITY
No, I have never worked (Go to question 4.B. below)

No, I have stopped working (Go to question 4.C. below)
Yes, I am currently working (Go to question 4.F. on page 3)
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)? (month/day/year) NOT SURE EXA (Go to Section 5 on page 3)
IF YOU HAVE STOPPED WORKING:
4.C. When did you stop working? (month/day/year) 4-4-2012 ABO
Why did you stop working?
Because of my condition(s).
Because of other reasons. Please explain why you stopped working (for example: laid off, early
retirement, seasonal work ended, business closed)
Even though you stopped working for other reasons, when do you believe your
condition(s) became severe enough to keep you from working? (month/day/year)
4.D. Did your condition(s) cause you to make changes in your work activity? (for example:
job duties, hours, or rate of pay)
No (Go to Section 5 - Education and Training on page 3)
Yes When did you make changes? (month/day/year)
Form SSA-3368-BK (11-2014) ef (11-2014)
Page 2
SECTION 4 - WORK ACTIVITY (continued)

4.E. Since the date in 4.D. above, have you had gross earnings greater than $1,010 in any month? Do not count sick
leave, vacation, or disability pay. (We may contact you for more information.)
No (Go to Section 5)
Yes (Go to Section 5)
IF YOU ARE CURRENTLY WORKING:
4.F. Has your condition(s) caused you to make changes in your work activity? (for example: job duties or hours)
No
When did your condition(s) first start bothering you? (month/day/year)
Yes
When did you make changes? (month/day/year)
4.G. Since your condition(s) first bothered you, have you had gross earnings greater than $1,010 in any month? Do not
count sick leave, vacation, or disability pay. (We may contact you for more information.)
No
Yes
SECTION 5 - EDUCATION AND TRAINING
5.A. Check the highest grade of school completed.

0
College:
7
10
11
12
GED
4 or more
Date completed:
5.B. Did you attend special education classes?
Yes
No (Go to 5.C.)
Name of School
City
State/Province
Dates attended special education classes:
to
from
5.C. Have you completed any type of specialized job training, trade, or vocational school?
Yes
If "Yes," what type?
No
Date completed:
If you need to list other education or training use Section 11 - Remarks on the last page.
SECTION 6 - JOB HISTORY
6.A. List the jobs (up to 5) that you have had in the 15 years before you became unable to work
because of your physical or mental conditions. List your most recent job first.
Check here and go to Section 7 on page 5 if you did not work at all in the 15 years before you became
unable to work.
Job Title
1.
2.
3.
Type of
Business
Dates Worked
From MM/
YY
To
MM/YY
Hours
Per
Day
Days
Per
Week
Rate of Pay
Amount
Frequency
CARPENTER
CONSTRUCTION
4\2000
8/2009
40
HOURLY
LABOR READY
LABOR
9\2010
1\2011
40
HOURLY
SOUTH HADLEY DUMP
SCALE OPERATOR 1\2011
4\2012
40
10
HOURLY
4.
5.
Form SSA-3368-BK (11-2014) ef (11-2014)
Page 3
SECTION 6 - JOB HISTORY (continued)

Check the box below that applies to you.
I had only one job in the last 15 years before I became unable to work. Answer the questions below.
I had more than one job in the last 15 years before I became unable to work. Do not answer the
questions on this page; go to Section 7 on page 5. (We may contact you for more information.)
Do not complete this page if you had more than one job in the last 15 years before you became unable to work.
6.B. Describe this job. What did you do all day?
BUILDING HOMES
(If you need more space, use Section 11 - Remarks on the last page.)
6.C. In this job, did you:
Use machines, tools or equipment?
Yes
No
Use technical knowledge or skills?
Yes
No
Do any writing, complete reports, or perform any duties like this?
Yes
No
6.D. In this job, how many total hours each day did you do each of the tasks listed:
Task
Walk
Hours
Task
8
Stoop (Bend down & forward at waist.)
Stand 7.5
Task
Hours
8
Handle large objects
Kneel (Bend legs to rest on knees.)
Sit
.5
Crouch (Bend legs & back down & forward.) 8
Climb
Crawl (Move on hands & knees.)
Hours
8
Write, type, or handle small objects 8
Reach
6.E. Lifting and carrying (Explain in the box below, what you lifted, how far you carried it, and how often you did
this in your job.)
LIFTING FLOOR JOIST,RAFTERS.TOOLS WALIKING BACK AND FRTH FROM PILE OF LUMBER
6.F. Check heaviest weight lifted:

Less than 10 lbs.
10 lbs.
20 lbs.
50 lbs.
100 lbs. or more
Other
6.G. Check weight frequently lifted: (by frequently, we mean from 1/3 to 2/3 of the workday.)
Less than 10 lbs.
10 lbs.
25 lbs.
6.H. Did you supervise other people in this job?
50 lbs. or more
Yes (Complete items below.)
2
How many people did you supervise?
What part of your time did you spend supervising people?
Did you hire and fire employees?
6.I. Were you a lead worker?
Form SSA-3368-BK (11-2014) ef (11-2014)
Other
Yes
No
Yes
No
Page 4
HALF THE DAY
No (if No, go to 6.I.)
SECTION 7 - MEDICINES
7. Are you taking any medicines (prescription or non-prescription)?
Yes
(Give the information requested below. You may need to look at your medicine containers.)
No
(Go to Section 8-Medical Treatment.)

If prescribed, give name of
doctor
Name of Medicine
Reason for medicine
BUSIPRONE
JASON LUSCZ
ANXIETY
PROZAC
JASON LUSCZ
DEPRESSION
If you need to list other medicines, go to Section 11 - Remarks on the last page.
SECTION 8 - MEDICAL TREATMENT
Have you seen a doctor or other health care professional or received treatment at a hospital or clinic, or do you have a
future appointment scheduled?
8.A. For any physical condition(s)?
Yes
No
8.B. For any mental condition(s) (including emotional or learning problems)?

Yes
No
If you answered "No" to both 8.A. and 8.B., go to Section 9 - Other Medical Information on page 11.
Form SSA-3368-BK (11-2014) ef (11-2014)
PAGE 5
SECTION 8 - MEDICAL TREATMENT (continued)

Tell us who may have medical records about any of your physical and/or mental condition(s) (including emotional or
learning problems) that limit your ability to work. This includes doctors' offices, hospitals (including emergency room
visits), clinics, and other health care facilities. Tell us about your next appointment, if you have one scheduled.
8.C. Name of Facility or Office
BAYSTATE HEALTH
Name of health care professional who treated you
ALL OF THE QUESTIONS ON THIS PAGE REFER TO THE HEALTH CARE PROVIDER ABOVE.
Phone Number
Patient ID# (if known)
413794000
Mailing Address
759 CHESTNUT ST
City
SPRINGFIELD
Dates of Treatment
1. Office, Clinic or
Outpatient visits
First Visit
Last Visit
State/Province
MA
ZIP/Postal Code
01199
2. Emergency Room visits

3. Overnight hospital stays
List the most recent date first
A.
A. Date in
Date out
2012
B.
2011 NUMEROUS
Next scheduled appointment (if any) C.

2010-09
B. Date in
Date out
C. Date in
Date out
What medical conditions were treated or evaluated?
PANIC ATTACKS ANXIETY

What treatment did you receive for the above conditions? (Do not describe medicines or tests in this box.)
PRESCRIPTIONS AND REFERREL

Check the boxes below for any tests this provider performed or sent you to, or has scheduled you to take. Please give
the dates for past and future tests. If you need to list more tests, use Section 11-Remarks on the last page.
Check this box if no tests by this provider or at this facility.
Kind of Test
Dates of Tests
Kind of Test
EKG (heart test)
EEG (brain wave test)
Treadmill (exercise test)
HIV Test
Cardiac Catheterization
Blood Test (not HIV)
Biopsy (list body part)
X-Ray (list body part)
Hearing Test
MRI/CT Scan (list body part)
Dates of Tests
Speech/Language Test
Other (please describe)
Vision Test
Breathing Test
If you do not have any more doctors or hospitals to describe, go to Section 9 on page 11.
Form SSA-3368-BK (11-2014) ef (11-2014)
PAGE 6

8.D. Name of Facility or Office
NORTHGATE MEDICAL
Phone Number
4137399955
Mailing Address
1985 MAIN ST
City
SPRINGFIELD
Dates of Treatment
Outpatient visits
First Visit
2010
State/Province
MA
ZIP/Postal Code
01103

A.
A. Date in
Date out
B.
B. Date in
Date out
C. Date in
Date out
Last Visit
2012
BACK ISSUES PANIC ATTACKS ANXIETY DEPRESSION

PESCRIPTIONS
Tell us about any tests this provider performed or sent you to, or has scheduled you to take. Please give the dates for
past and future tests. If you need to list more tests, use Section 11 - Remarks on the last page.
Kind of Test
Dates of Tests
Kind of Test
EKG (heart test)
HIV Test
2012
2011
Hearing Test
2011
Vision Test
Breathing Test
Dates of Tests
2011
Form SSA-3368-BK (11-2014) ef (11-2014)
PAGE 7

8.E. Name of Facility or Office
RIVERBEND MEDICAL
Phone Number
413-533-2900
Mailing Address
395 SOUTHHAMPTON RD
City
WESTFIELD
Dates of Treatment
Outpatient visits
First Visit
2008
State/Province
MA
ZIP/Postal Code
01085

A.
A. Date in
Date out
B.
B. Date in
Date out
C. Date in
Date out
Last Visit
2010
GENERAL MEDICINE// DEPRESSION ANXIETY PANIC ATTACKS

PRESCRIPTIONS
Kind of Test
Dates of Tests
Kind of Test
EKG (heart test)
HIV Test
Hearing Test
Dates of Tests
UNSURE
Vision Test
Breathing Test
UNSURE
Form SSA-3368-BK (11-2014) ef (11-2014)
PAGE 8

8.F. Name of Facility or Office
BHN
Phone Number
413-736-3668
Mailing Address
417 LIBERTY ST.
City
SPRINGFIELD
Dates of Treatment
Outpatient visits
First Visit
2013
State/Province
MA
ZIP/Postal Code
01104

A.
A. Date in
Date out
2013 STAYED 10 DA 2013
B.
B. Date in
Date out
C. Date in
Date out
Last Visit
2013
DEPRESSION ANXIETY
THERAPY PRESCRIPTIONS
Kind of Test
Dates of Tests
Kind of Test
EKG (heart test)
HIV Test
Hearing Test
Dates of Tests
2013
Vision Test
Breathing Test
2013
Form SSA-3368-BK (11-2014) ef (11-2014)
PAGE 9

8.G. Name of Facility or Office
Phone Number
Mailing Address
City
State/Province
ZIP/Postal Code
Dates of Treatment
Outpatient visits
First Visit

A.
A. Date in
Date out
Last Visit
B.
B. Date in
Date out
C. Date in
Date out
Kind of Test
Dates of Tests
Kind of Test
EKG (heart test)
HIV Test
Hearing Test
Dates of Tests
Vision Test
Breathing Test
If you have been treated by more than five doctors or hospitals, use Section 11 - Remarks on
the last page and give the same detailed information as above for each healthcare provider.
Form SSA-3368-BK (11-2014) ef (11-2014)
PAGE 10
SECTION 9 - OTHER MEDICAL INFORMATION

9. Does anyone else have medical information about your physical and/or mental condition(s) (including emotional and
learning problems), or are you scheduled to see anyone else? (This may include places such as workers'
compensation, vocational rehabilitation, insurance companies who have paid you disability benefits, prisons, attorneys,
social service agencies and welfare.)
Yes (Please complete the information below.)
No (If you are receiving Supplemental Security Income (SSI) and have been asked to complete this report,
go to Section 10 - Vocational Rehabilitation; if not, go to Section 11 on the last page.)
Name of Organization
Phone Number
Mailing Address
City
State/Province
Name of Contact Person

Date of First Contact
ZIP/Postal Code
Claim or ID number (if any)

Date of Last Contact
Date of Next Contact (if any)
Reasons for Contacts
If you need to list other people or organizations use Section 11 - Remarks on the last page and give the same
detailed information as above for each one you list.
COMPLETE THIS SECTION ONLY IF YOU ARE ALREADY RECEIVING SSI.
SECTION 10 - VOCATIONAL REHABILITATION, EMPLOYMENT, OR OTHER SUPPORT SERVICES
10.A. Have you participated, or are you participating in:
An individual work plan with an employment network under the Ticket to Work Program;
An individualized plan for employment with a vocational rehabilitation agency or any other organization;
A Plan to Achieve Self-Support (PASS);
An Individualized Education Program (IEP) through a school (if a student age 18-21); or
Any program providing vocational rehabilitation, employment services, or other support services to help
you go to work?
Yes (Complete the following information)
No (Go to Section 11)
10.B. Name of Organization or School

Name of Counselor, Instructor, or Job Coach
Phone Number
Mailing Address
City
State/Province
10.C. When did you start participating in the plan or program?
Form SSA-3368-BK (11-2014) ef (11-2014)
PAGE 11
ZIP/Postal Code
SECTION 10 - VOCATIONAL REHABILITATION, EMPLOYMENT, OR OTHER SUPPORT SERVICES

(continued)
10.D. Are you still participating in the plan or program?
Yes, I am scheduled to complete the plan or program on:
No. I completed the plan or program on:
No. I stopped participating in the plan or program before completing it because:
10.E. List the types of services, tests, or evaluations that you received (for example: intelligence or psychological
testing, vision or hearing test, physical exam, work evaluations, or classes).
If you need to list another plan or program use Section 11 Remarks and give the same detailed information as above.
SECTION 11 - REMARKS
Please write 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 write the requested information, please use this space to tell us the additional information
requested in those sections. Be sure to show the section to which you are referring.
IN 2013 I STAYED IN A INHOUSE PROGRAM AT BEHAVIORAL HEALTH FOR ABOUT 10 DAYS OR SO FOR
DEPRESSION
Date Report Completed
06-11-2015
Form SSA-3368-BK (11-2014) ef (11-2014)
month, day, year

PAGE 12

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DISABILITY REPORT - ADULT

Print or write clearly.

Disability Report- Adult-Form SSA-3368-BK

WHAT WE MEAN BY "DISABILITY"

AFTER COMPLETING THIS REPORT, REMOVE THIS SHEET AND

Form SSA-3368-BK (11-2014) ef (11-2014)

SOCIAL SECURITY ADMINISTRATION

Country (If not USA)

1.D. Email Address

1.G. Can you speak and understand English?

If no, what language do you prefer?

1.I. Can you write more than your name in English?

2.E. Can this person speak and understand English?

If no, what language is preferred?

Country (If not USA)

2.F. Who is completing this report?

SECTION 2 - CONTACTS (continued)

2.G. Name (First, Middle Initial, Last)

2.H. Relationship to Person Applying

2.I. Daytime Phone Number

Country (If not USA)

SECTION 3 - MEDICAL CONDITIONS

centimeters (if outside USA)

3.D. Do your conditions cause you pain or other symptoms?

SECTION 4 - WORK ACTIVITY

No, I have never worked (Go to question 4.B. below)

IF YOU HAVE NEVER WORKED:

Form SSA-3368-BK (11-2014) ef (11-2014)

SECTION 4 - WORK ACTIVITY (continued)

When did your condition(s) first start bothering you? (month/day/year)

When did you make changes? (month/day/year)

5.A. Check the highest grade of school completed.

Dates attended special education classes:

Country (If not USA)

SOUTH HADLEY DUMP

SCALE OPERATOR 1\2011

SECTION 6 - JOB HISTORY (continued)

Use technical knowledge or skills?

Do any writing, complete reports, or perform any duties like this?

Kneel (Bend legs to rest on knees.)

Crouch (Bend legs & back down & forward.) 8

Crawl (Move on hands & knees.)

Write, type, or handle small objects 8

6.F. Check heaviest weight lifted:

100 lbs. or more

6.H. Did you supervise other people in this job?

Yes (Complete items below.)

HALF THE DAY

No (if No, go to 6.I.)

(Go to Section 8-Medical Treatment.)

Reason for medicine

8.B. For any mental condition(s) (including emotional or learning problems)?

Form SSA-3368-BK (11-2014) ef (11-2014)

SECTION 8 - MEDICAL TREATMENT (continued)

Name of health care professional who treated you

Country (If not USA)

2. Emergency Room visits

Next scheduled appointment (if any) C.

What medical conditions were treated or evaluated?