Form HA-4633 Claimant's Work Background

Form Approved
OMB No.0960-0300

SOCIAL SECURITY ADMINISTRATION
Office of Disability Adjudication and Review

CLAIMANT’S WORK BACKGROUND
A. To be completed by Hearing Office
(Claimant and Social Security Number)

(Wage Earner and Social Security Number) The last time we brought your case
(Leave blank if same as claimant)
up-to-date was:

B. To be completed by the claimant

PLEASE PRINT
Start with your most recent job, and list that and any work performed within the past 15 years.
DATE OF EMPLOYMENT
NAME OF EMPLOYER AND
DUTIES PERFORMED
(APPROXIMATELY)
LOCATION OF EMPLOYMENT
FROM
TO

FROM
TO

FROM
TO

FROM
TO

Form HA-4633 (3-1994) ef (6-2009)
Issue Old Stock

If more space is needed,
use additional sheets.

Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 702, 1631 (e)(1)(A) and (B) and 1869(b)(1)(C) of the Social Security Act, as
appropriate, authorize us to collect the information on this form. The information you provide will
help us to determine your potential eligibility for benefit payments and/or help us to decide if
additional information is needed. Your response is voluntary. However, failure to provide the
requested information may prevent an accurate and timely decision on any claim filed, or could
result in the loss of benefits. See Revised Privacy Act Statement Attached
We rarely use the information provided on this form for any purpose other than for determining
entitlement to benefit payments. In accordance with 5 U.S.C. § 552a(b) of the Privacy Act, however,
we may disclose the information provided on this form 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 make determinations for eligibility in similar health and income maintenance
programs at the Federal, state and local level;

3.

To comply with Federal laws requiring the disclosure of the information from our
records; and

4.

To facilitate statistical research, audit or investigative activities necessary to assure the
integrity of SSA programs.

We may also use the information you provide when we match records by computer. Computer
matching programs compare our records with those of other Federal, state or local government
agencies. Information from these matching programs can be used to establish or verify a person’s
eligibility for Federally funded or administered benefit programs and for repayment of payments or
delinquent debts under these programs. The law allows us to do this even if you do not agree to it.
Additional information regarding this form, routine uses of information, and other Social Security
programs are available from our Internet website 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 itSee
will Revised
take aboutPRA
15 minutes
to read
the instructions, gather the facts, and
Statement
Attached
answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL
SOCIAL SECURITY OFFICE. The office listed under U. S. Government agencies in your
telephone directory or you may call Social Security at 1-800-772-1213. You may send comments
on our time estimate above to: SSA, 6401Security Blvd, Baltimore, MD 21235-6401. Send only
comments relating to our time estimate to this address, not the completed form.
Form HA-4633 (3-1994) ef (6-2009)

SSA will insert the following revised Privacy Act and PRA Statements into the form at its next
scheduled reprinting:
Privacy Statement
Collection and Use of Personal Information

Sections 205(a), 702, 1631(1)(A) and (B) and 1869(b)(1)(C) of the Social Security Act authorize
us to collect the information on this form. We will use the information you provide to determine
your potential eligibility for receiving benefits and/or to determine if we need additional
information to support your claim.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may prevent an accurate and timely decision on your claim.
We rarely use the information you supply us for any purpose other than for the reasons explained
above. However, we may use the information for the administration of our programs including
sharing information:
1. To comply with Federal laws requiring the release of information from our records
(e.g., to the Government Accountability Office and Department of Veterans Affairs);
2. To facilitate statistical research, audit, or investigative activities necessary to assure
the integrity and improvement of our programs (e.g., to the Bureau of the Census and
to private entities under contract with us).
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Record Notice entitled, Claims Folders System,
(60-0089). Additional information about this and other system of records notices and our
programs are available online at www.socialsecurity.gov or at your local Social Security office.
We may share the information you provide to other health agencies through computer matching
programs. Matching programs compare our records with records kept by other Federal, State or
local government agencies. We use the information from these programs to establish or verify a
person’s eligibility for federally funded or administered benefit programs and for repayment of
incorrect payments or delinquent debts under these programs.
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 15 minutes to read the instructions, gather
the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO
YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your local Social Security
office through SSA’s 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.