Medical And Job Form Worksheet PDF Details

Navigating the process of applying for Social Security disability benefits can be complex and requires careful preparation. The Medical and Job Worksheet - Adult, a critical tool in this process, is designed to help applicants compile and organize important information needed for their disability claim. While it is not the application itself, this worksheet serves as a comprehensive guide to prepare for either an in-person or telephone appointment, or when filing a claim online through the Social Security Administration's website. Applicants are advised against mailing this worksheet to their local office but are encouraged to start the application process online for efficiency. The worksheet comprises several sections including medical conditions detailing any physical, mental, emotional, or learning problems; employment history focusing on jobs held in the 15 years prior to the onset of disability; medical sources such as doctors and hospitals visited; medications prescribed, including the prescribing doctor; and any medical tests conducted or planned. Completing this worksheet is a crucial step in ensuring all relevant information is ready and available, helping to streamline the disability benefits application process. Importantly, applicants are reminded to proceed with filing their application even if they don't have all the information immediately at hand, as the Social Security Administration can assist in gathering any missing details.

QuestionAnswer
Form NameMedical And Job Form Worksheet
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesssa 3381, form 3381, ssa 3381 fillable form, medical and job worksheet

Form Preview Example

MEDICAL AND JOB WORKSHEET - ADULT

Please do not mail this worksheet to your local office.

Did you know that you can start the application process online?

Visit www.socialsecurity.gov/applyfordisability for more information!

Complete this worksheet to get ready for the appointment or when filing online. This worksheet is not the application for Social Security disability benefits. You should bring this worksheet to your appointment or have it with you if your appointment is by telephone.

A.Medical Conditions

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.

CONDITIONS

1.

2.

3.

4.

5.

B.If you are not working, when did you stop working?

C. Height without shoes:_______feet_____inches Weight without shoes: _____ pounds

D.Medical Sources

Please list any doctors, hospitals, clinics, therapists, or emergency rooms you have visited because of your conditions.

NAME

ADDRESS

PHONE NUMBER (with area code)

DATE FIRST

DATE LAST

SEEN OR

SEEN OR

ADMISSION

DISCHARGE

DATE

DATE

 

 

Form SSA-3381 (12-2009) Destroy prior editions

OVER

E.Medicines

Please list any medicines you take and why you take them. If prescribed, please provide the doctor’s name.

NAME OF MEDICINE

WHY YOU TAKE IT

PRESCRIBED BY

F.Medical Tests

Please list any medical tests you had or are going to have in the future.

NAME OF TEST

PROVIDER WHO SENT YOU

DATE(S)

G.Job History

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.

JOB TITLE (e.g., cook)

TYPE OF BUSINESS

(e.g., restaurant)

DATES WORKED

FROM

TO

Mo/Yr

Mo/Yr

 

 

HOURS

PER DAY

DAYS PER

WEEK

RATE OF PAY

Amount Frequency

Bring this worksheet to your appointment or have it with you if your appointment is by telephone. Do not delay filing your application, even if you do not have all of the information. We will help you get any missing information.

Form SSA-3381 (12-2009) Destroy prior editions

How to Edit Medical And Job Form Worksheet Online for Free

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With regards to the fields of this precise document, this is what you want to do:

1. The fillable form ssa 3381 needs certain information to be typed in. Ensure that the subsequent blank fields are complete:

Filling in segment 1 of ssa form worksheet

2. Soon after finishing the last step, go on to the next part and fill out all required details in these fields - PHONE NUMBER with area code, ADMISSION, DATE, DISCHARGE, DATE, Form SSA Destroy prior editions, and OVER.

Step number 2 for completing ssa form worksheet

3. This 3rd segment is normally quite easy, NAME OF MEDICINE, WHY YOU TAKE IT, PRESCRIBED BY, F Medical Tests, Please list any medical tests you, NAME OF TEST, PROVIDER WHO SENT YOU, and DATES - these fields must be filled in here.

NAME OF MEDICINE, Please list any medical tests you, and WHY YOU TAKE IT of ssa form worksheet

4. The next subsection will require your details in the following areas: G Job History, List the jobs up to that you have, JOB TITLE eg cook, TYPE OF BUSINESS, eg restaurant, DATES WORKED, FROM MoYr, MoYr, HOURS PER DAY, DAYS PER, WEEK, RATE OF PAY, and Amount Frequency. Make certain you fill in all required details to go forward.

Stage number 4 in filling in ssa form worksheet

Lots of people generally make errors when completing eg restaurant in this section. Remember to re-examine what you type in right here.

Step 3: Prior to addressing the next step, it's a good idea to ensure that all blanks have been filled out the right way. Once you are satisfied with it, click on “Done." Obtain your fillable form ssa 3381 once you register here for a 7-day free trial. Easily view the form from your personal account page, together with any modifications and adjustments all preserved! We don't share or sell any details you type in whenever working with documents at our website.