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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 and Paperwork Reduction Act Statements
The Social Security Administration is authorized to collect the information on this form under sections
205(a), 223(d) and 1631(e)(1) of the Social Security Act. The information on this form is needed by
Social Security to make a decision on the named claimant's claim. While giving us the information on this
form is voluntary, failure to provide all or part of the requested information could prevent an accurate or
timely decision on the named claimant's claim. Although the information you furnish is almost never used
for any purpose other than making a determination about the claimant's disability, such information may
be disclosed by the Social Security Administration as follows: (1) to enable a third party or 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 the Department of Veterans Affairs); and (3) to facilitate statistical research and
such activities necessary to assure the integrity and improvement of the 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 give us when we match records by computer. Matching programs
compare our records with those of other Federal, State, or local government agencies. Many agencies
may use matching programs to find or prove that a person qualifies for benefits paid by the Federal
government. The law allows us to do this even if you do not agree to it. Explanations about these and
other reasons why information you provide us may be used or given out are available in Social Security
offices.
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
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. You may send comments on our time estimate above to: SSA, 1338 Annex Building,
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.
Form Approved
OMB No. 0960-0578
SOCIAL SECURITY ADMINISTRATION
WORK HISTORY REPORT
For SSA Use Only
Do not write in this box.
SECTION 1 - INFORMATION ABOUT THE DISABLED PERSON
B. SOCIAL SECURITY NUMBER
A. Name (First, Middle Initial, Last)
-
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.)
(
)
Area Code
Your Number
-
Message Number
None
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
(Month & Year)
From
To
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Form SSA-3369-BK (1-2005)
ef (01-2005)
Use 12-2003 Edition Until Supply Is Exhausted
PAGE 1
Work History Report - Form SSA-3369-BK
-
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
Week
Hours per day Days per week
Year
Month
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 (Complete the next 3
Other
NO (Skip to the last
question on this
page.)
items.)
How many people did you supervise?
What part of your time was spent supervising people?
Did you hire and fire employees?
Were you a lead worker?
Form SSA-3369-BK (1-2005)
ef (01-2005)
YES
NO
YES
NO
PAGE 2
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
Week
Hours per day Days per week
Year
Month
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 (Complete the next 3
Other
NO (Skip to the last
question on this
page.)
items.)
How many people did you supervise?
What part of your time was spent supervising people?
Did you hire and fire employees?
Were you a lead worker?
Form SSA-3369-BK (1-2005)
ef (01-2005)
YES
NO
YES
NO
PAGE 3
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
$
Per (Check One)
Hour
Day
Week
Hours per day Days per week
Year
Month
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 (Complete the next 3
items.)
Other
NO (Skip to the last
question on this
page.)
How many people did you supervise?
What part of your time was spent supervising people?
Did you hire and fire employees?
Were you a lead worker?
Form SSA-3369-BK (1-2005)
ef (01-2005)
YES
NO
YES
NO
PAGE 4
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
$
Per (Check One)
Hour
Day
Week
Hours per day Days per week
Year
Month
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 (Complete the next 3
items.)
How many people did you supervise?
Other
NO (Skip to the last
question on this
page.)
What part of your time was spent supervising people?
Did you hire and fire employees?
Were you a lead worker?
Form SSA-3369-BK (1-2005)
ef (01-2005)
YES
NO
YES
NO
PAGE 5
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
Week
Hours per day Days per week
Year
Month
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 (Complete the next 3
items.)
How many people did you supervise?
Other
NO (Skip to the last
question on this
page.)
What part of your time was spent supervising people?
Did you hire and fire employees?
Were you a lead worker?
Form SSA-3369-BK (1-2005)
ef (01-2005)
YES
NO
YES
NO
PAGE 6
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
$
Per (Check One)
Hour
Day
Week
Hours per day Days per week
Year
Month
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?
How many people did you supervise?
50 lbs. or more
YES (Complete the next 3
items.)
Other
NO (Skip to the last
question on this
page.)
What part of your time was spent supervising people?
Did you hire and fire employees?
Were you a lead worker?
Form SSA-3369-BK (1-2005)
ef (01-2005)
YES
NO
YES
NO
PAGE 7
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 (Please print)
Date (Month, day, year)
Address (Number and Street)
Email address (optional)
City
State
Zip Code
Form SSA-3369-BK (1-2005)
ef (01-2005)
PAGE 8
| File Type | application/pdf |
| File Title | S3369.xft |
| Author | 716749 |
| File Modified | 2005-01-12 |
| File Created | 2005-01-12 |