Work History Report (current version)

WORK 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 on this form to make a decision on the
named claimant's claim.
Completion of this form is voluntary; however, failure to provide all or part of the requested
information could prevent an accurate or timely decision on the named claimant's claim.
We rarely use the information you supply for any purpose other than for determining continuing
eligibility. However, we may use it for the administration and integrity of Social Security programs.
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.
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 person's 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 are available in our System of Records Notices
entitled, Claims Folders Systems (60-0089) and the Master Beneficiary Record (60-0090). These
notices, additional information regarding this form, routine uses of information, and 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 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.

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
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

To

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Form SSA-3369-BK (04-2011) ef (04-2011) Destroy Prior Editions

PAGE 1

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
$

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

(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 (04-2011) ef (04-2011)

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
$

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

(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 (04-2011) ef (04-2011)

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
$

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

(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 (04-2011) ef (04-2011)

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
$

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

(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 (04-2011) ef (04-2011)

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
$

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:
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?

50 lbs or more

YES

How many people did you supervise?

Other

(Complete the next 3
items.)

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 (04-2011) ef (04-2011)

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
$

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

(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 (04-2011) ef (04-2011)

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 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 (04-2011) ef (04-2011)

ZIP Code

PAGE 8