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pdfWORK HISTORY REPORT- Form SSA-3369-BK
READ ALL OF THIS INFORMATION BEFORE
YOU BEGIN COMPLETING THIS FORM
IF YOU NEED HELP
If you need help with this form, complete as much of it as you can. Then call the phone number
provided on the letter sent with the form or the phone number of the person who asked you to
complete the form for help to finish it.
The information that you give us on this form will be used by the office that makes the disability
decision on your disability claim. You can help them by completing as much of the form as you can.
• Print or type.
• A reference to "you," "your," or "the Disabled Person," or "claimant" means
the person who is applying for disability benefits. If you are filling out the form for someone else,
provide information about him or her.
• ANSWER ALL OF THE QUESTIONS FOR EACH JOB YOU DESCRIBE. If you do not know
the 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 think you need to
explain an answer.
• If more space is needed to answer any questions, use the "REMARKS" section on Page 8, and
show the number of the question being answered.
WHY THIS INFORMATION IS IMPORTANT
The information we ask for on this form will help us understand how your illnesses, injuries, or
conditions might affect your ability to do work for which you are qualified. The information tells us
about the kinds of work you did, including the types of skills you needed and the physical and
mental requirements of each job. In Section 2, be sure to give us all of the different jobs you did in
the 15 years before you became unable to work because of your illnesses, injuries, or conditions.
There is a separate page to describe each different job.
REMEMBER TO GIVE US THE NAME AND ADDRESS OF THE PERSON
COMPLETING THIS FORM ON PAGE 8
Work History Report -- Form SSA-3369-BK
HOW TO COMPLETE THIS FORM
Privacy Act Statement
Collection and Use of Personal Information
Sections 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 determination of eligibility for Social
Security benefits.
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 any claim filed.
We rarely use the information you supply us for any purpose other than to make a determination
regarding benefits eligibility. 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); and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure 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 Records Notices 60-0089, entitled, Claims Folders Systems; and, 60-0090,
entitled, Master Beneficiary Record. Additional information about these 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 1 hour to read the instructions, gather the facts, and
answer the questions. SEND OR BRING THE COMPLETED FORM TO THE STATE AGENCY
THAT REQUESTED IT. If you have questions about how to complete the form, contact the
State Agency that requested it. If you need the address or phone number for your State
Agency, you can get it by calling 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.
PLEASE REMOVE THIS SHEET BEFORE RETURNING
THE COMPLETED FORM.
SOCIAL SECURITY ADMINISTRATION
WORK HISTORY REPORT
Form Approved
OMB No. 0960-0578
For SSA Use Only
Do not write in this box.
SECTION 1 - INFORMATION ABOUT THE DISABLED PERSON
A. NAME (First, Middle Initial, Last)
B. SOCIAL SECURITY NUMBER
(
)
-
Your Number
Message Number
None
Area Code Phone Number
SECTION 2 - INFORMATION ABOUT YOUR WORK
List all the jobs that you have had in the 15 years before you became unable to work because of
your illnesses, injuries, or conditions.
Job Title
Type of Business
Dates Worked
From
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Form SSA-3369-BK (04-2014) ef (04-2014)
PAGE 1
Destroy Prior Editions
To
Work History Report - Form SSA-3369-BK
C. DAYTIME TELEPHONE NUMBER (If you have no number where you can be reached, give us a daytime
number where we can leave a message for you.)
Give us more information about Job No. 1 listed on Page 1. Estimate hours and pay, if you
need to.
JOB TITLE NO. 1
Rate of Pay
$
Per (Check One)
Hour
Day
Hours per day Days Per Week
Month
Week
Year
Describe this job. What did you do all day? (If you need more space, write in the"Remarks" section.)
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
In this job, did you:
Use machines, tools, or equipment?
Use technical knowledge or skills?
Do any writing, complete reports, or
perform duties like this?
YES
NO
YES
NO
YES
NO
In this job, how many total hours each day did you:
Walk?
Stand?
Sit?
Climb?
Stoop? (Bend down and forward at waist)
Kneel? (Bend legs to rest on knees)
Crouch? (Bend legs & back down & forward)
Crawl? (Move on hands & knees)
Handle, grab, or grasp big objects?
Reach?
Write, type, or handle small objects?
Lifting and Carrying (Explain what you lifted, how far you carried it, and how often you did this.)
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Check the heaviest weight lifted:
Less than 10 lbs
10 lbs
20 lbs
50 lbs
100 lbs. or more
Other
Check weight you frequently lifted: (By frequently, we mean from 1/3 to 2/3 of the workday.)
Less than 10 lbs
10 lbs
25 lbs
Did you supervise other people in this job?
50 lbs or more
YES
How many people did you supervise?
(Complete the next
3 items.)
Other
NO
What part of your time was spent supervising people?
Did you hire and fire employees?
YES
NO
Were you a lead worker?
YES
NO
Form SSA-3369-BK (04-2014) ef (04-2014)
PAGE 2
(Skip to the last question
on this page.)
Give us more information about Job No. 2 listed on Page 1. Estimate hours and pay, if you
need to.
JOB TITLE NO. 2
Rate of Pay
$
Per (Check One)
Hour
Day
Hours per day Days per week
Week
Month
Year
Describe this job. What did you do all day? (If you need more space, write in the"Remarks" section.)
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
In this job, did you:
Use machines, tools, or equipment?
YES
NO
Use technical knowledge or skills?
Do any writing, complete reports, or
perform duties like this?
YES
NO
YES
NO
In this job, how many total hours each day did you:
Walk?
Stand?
Sit?
Climb?
Stoop? (Bend down and forward at waist)
Kneel? (Bend legs to rest on knees)
Crouch? (Bend legs & back down & forward)
Crawl? (Move on hands & knees)
Handle, grab, or grasp big objects?
Reach?
Write, type, or handle small objects?
Lifting and Carrying (Explain what you lifted, how far you carried it, and how often you did this.)
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Check the heaviest weight lifted:
Less than 10 lbs
10 lbs
20 lbs
50 lbs
100 lbs. or more
Other
Check weight you frequently lifted: (By frequently, we mean from 1/3 to 2/3 of the workday.)
Less than 10 lbs
10 lbs
25 lbs
Did you supervise other people in this job?
50 lbs or more
YES
How many people did you supervise?
Other
(Complete the next
3 items.)
NO
What part of your time was spent supervising people?
Did you hire and fire employees?
YES
NO
Were you a lead worker?
YES
NO
Form SSA-3369-BK (04-2014) ef (04-2014)
PAGE 3
(Skip to the last
question on this page.)
Give us more information about Job No. 3 listed on Page 1. Estimate hours and pay, if you
need to.
JOB TITLE NO. 3
Rate of Pay
$
Hours per day Days per week
Per (Check One)
Hour
Day
Week
Month
Year
Describe this job. What did you do all day? (If you need more space, write in the"Remarks" section.)
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
In this job, did you:
Use machines, tools, or equipment?
YES
NO
Use technical knowledge or skills?
Do any writing, complete reports, or
perform duties like this?
YES
NO
YES
NO
In this job, how many total hours each day did you:
Walk?
Stand?
Sit?
Climb?
Stoop? (Bend down and forward at waist)
Kneel? (Bend legs to rest on knees)
Crouch? (Bend legs & back down & forward)
Crawl? (Move on hands & knees)
Handle, grab, or grasp big objects?
Reach?
Write, type, or handle small objects?
Lifting and Carrying (Explain what you lifted, how far you carried it, and how often you did this.)
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Check the heaviest weight lifted:
Less than 10 lbs
10 lbs
20 lbs
50 lbs
100 lbs. or more
Other
Check weight you frequently lifted: (By frequently, we mean from 1/3 to 2/3 of the workday.)
Less than 10 lbs
10 lbs
25 lbs
Did you supervise other people in this job?
50 lbs or more
YES
How many people did you supervise?
Other
(Complete the next
3 items.)
What part of your time was spent supervising people?
Did you hire and fire employees?
YES
NO
Were you a lead worker?
YES
NO
Form SSA-3369-BK (04-2014) ef (04-2014)
PAGE 4
NO
(Skip to the last question on
this page.)
Give us more information about Job No. 4 listed on Page 1. Estimate hours and pay, if you
need to.
JOB TITLE NO. 4
Rate of Pay
$
Hours per day Days per week
Per (Check One)
Hour
Day
Week
Month
Year
Describe this job. What did you do all day? (If you need more space, write in the"Remarks" section.)
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
In this job, did you:
Use machines, tools, or equipment?
YES
NO
Use technical knowledge or skills?
Do any writing, complete reports, or
perform duties like this?
YES
NO
YES
NO
In this job, how many total hours each day did you:
Walk?
Stand?
Sit?
Climb?
Stoop? (Bend down and forward at waist)
Kneel? (Bend legs to rest on knees)
Crouch? (Bend legs & back down & forward)
Crawl? (Move on hands & knees)
Handle, grab, or grasp big objects?
Reach?
Write, type, or handle small objects?
Lifting and Carrying (Explain what you lifted, how far you carried it, and how often you did this.)
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Check the heaviest weight lifted:
Less than 10 lbs
10 lbs
20 lbs
100 lbs. or more
50 lbs
Other
Check weight you frequently lifted: (By frequently, we mean from 1/3 to 2/3 of the workday.)
Less than 10 lbs
10 lbs
25 lbs
Did you supervise other people in this job?
50 lbs or more
YES
How many people did you supervise?
Other
(Complete the next
3 items.)
NO
What part of your time was spent supervising people?
Did you hire and fire employees?
YES
NO
Were you a lead worker?
YES
NO
Form SSA-3369-BK (04-2014) ef (04-2014) PAGE 5
(Skip to the last
question on this page.)
Give us more information about Job No. 5 listed on Page 1. Estimate hours and pay, if you
need to.
JOB TITLE NO. 5
Rate of Pay
$
Per (Check One)
Hour
Day
Hours per day Days per week
Week
Month
Year
Describe this job. What did you do all day? (If you need more space, write in the"Remarks" section.)
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
In this job, did you:
Use machines, tools, or equipment?
YES
NO
Use technical knowledge or skills?
Do any writing, complete reports, or
perform duties like this?
YES
NO
YES
NO
In this job, how many total hours each day did you:
Kneel? (Bend legs to rest on knees)
Crouch? (Bend legs & back down & forward)
Crawl? (Move on hands & knees)
Handle, grab, or grasp big objects?
Reach?
Write, type, or handle small objects?
Walk?
Stand?
Sit?
Climb?
Stoop? (Bend down and forward at waist)
Lifting and Carrying (Explain what you lifted, how far you carried it, and how often you did this.)
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Check the heaviest weight lifted:
Less than 10 lbs
10 lbs
20 lbs
50 lbs
100 lbs. or more
Other
Check weight you frequently lifted: (By frequently, we mean from 1/3 to 2/3 of the workday.)
Less than 10 lbs
10 lbs
25 lbs
Did you supervise other people in this job?
How many people did you supervise?
50 lbs or more
Other
YES (Complete the next
3 items.)
NO
What part of your time was spent supervising people?
Did you hire and fire employees?
YES
NO
Were you a lead worker?
YES
NO
Form SSA-3369-BK (04-2014) ef (04-2014)
PAGE 6
(Skip to the last
question on this page.)
Give us more information about Job No. 6 listed on Page 1. Estimate hours and pay, if you need
to.
JOB TITLE NO. 6
Rate of Pay
$
Hours per day Days per week
Per (Check One)
Hour
Day
Week
Month
Year
Describe this job. What did you do all day? (If you need more space, write in the"Remarks" section.)
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
In this job, did you:
Use machines, tools, or equipment?
YES
NO
Use technical knowledge or skills?
Do any writing, complete reports, or
perform duties like this?
YES
NO
YES
NO
In this job, how many total hours each day did you:
Walk?
Stand?
Sit?
Climb?
Stoop? (Bend down and forward at waist)
Kneel? (Bend legs to rest on knees)
Crouch? (Bend legs & back down & forward)
Crawl? (Move on hands & knees)
Handle, grab, or grasp big objects?
Reach?
Write, type, or handle small objects?
Lifting and Carrying (Explain what you lifted, how far you carried it, and how often you did this.)
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Check the heaviest weight lifted:
Less than 10 lbs
10 lbs
20 lbs
50 lbs
100 lbs. or more
Other
Check weight you frequently lifted: (By frequently, we mean from 1/3 to 2/3 of the workday.)
Less than 10 lbs
10 lbs
25 lbs
Did you supervise other people in this job?
50 lbs or more
YES
How many people did you supervise?
Other
(Complete the
next 3 items.)
NO
What part of your time was spent supervising people?
Did you hire and fire employees?
YES
NO
Were you a lead worker?
YES
NO
Form SSA-3369-BK (04-2014) ef (04-2014)
PAGE 7
(Skip to the last
question on this page.)
SECTION 3 - REMARKS
Use this section to add any information you did not have space for in other parts of the form. Show the page number of the part
you are continuing.
BE SURE TO COMPLETE THE BOTTOM OF THIS PAGE.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Name of person completing this form if other than the disabled person
(Please print)
Date (Month, day, year)
Address (Number and Street)
Email address (optional)
City
State
Form SSA-3369-BK (04-2014) ef (04-2014)
PAGE 8
ZIP Code
| File Type | application/pdf |
| File Title | Work History Report |
| Subject | SSA-3369-BK, 3369, work history |
| Author | SSA |
| File Modified | 2014-12-05 |
| File Created | 2014-09-15 |