Form SSA-3033 Work Activity Questionnaire

Social Security Administration
Retirement, Survivors and Disability Insurance
Supplemental Security Income

•

Date:
Claim Number:
Social Security Number:
Worker's Name:

Dear Sir or Madam:
We are writing to you about
. Please assist us
by completing the enclosed questionnaire. We are requesting this information in order
to determine whether
work activity is/was subsidized or was
an unsuccessful work attempt under the Social Security rules. The information you
provide will not be shared with other agencies and is in no way a negative reflection on
the employee, or you as the employer.
Information About Subsidy
A subsidy exists when an employer willingly pays more in wages than the value of the
actual services performed. This is usually for humanitarian reasons. A subsidy can be
reflected by giving the employee:
• extra assistance,
• full wages for lower quality or quantity than standard, or
• fewer and/or easier duties than usual for that position.
Information about Unsuccessful Work Attempt
An unsuccessful work attempt may exist if the employee had frequent absences,
performed unsatisfactorily, and worked for six months or less.

Form SSA-3033 (01-2016) UF (01-2016)

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Social Security Number:

What We Need You To Do
Please have
direct supervisor or another person having direct
knowledge of the employee's work activity complete the work activity questionnaire. We
would appreciate it if you would complete, sign and return the questionnaire to this
office within 7 days using the enclosed envelope. If you have any questions, or if you
would rather provide this information over the telephone, please call
and ask for
.
Thank you for your time and assistance.

Manager/Adjudicator Name
Position Title
Enclosure:
Work Activity Questionnaire

Form SSA-3033 (01-2016) UF (01-2016)

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Social Security Number:
Privacy Act Statement
Collection and Use of Personal Information
Sections 221, 223(d)(4), 1612(b)(4)(B), and 1614(a)(3)(D) of the Social Security Act, as
amended, authorize us to collect this information. We will use the information you
provide to determine whether the employee's work activity was an unsuccessful work
attempt or whether it is/was subsidized.
See Revised Privacy Act Statement Attached
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 benefit 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
Folder System and 60-0103, entitled, Supplemental Security Income Record and
Special Veterans Benefits. 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 (OMB) control number. We estimate that it will
take about 15 minutes to read the instructions, gather the facts, and answer the
questions. Send only comments relating to our time estimate above to: SSA, 6401
Security Blvd, Baltimore, MD 21235-6401.
Form SSA-3033 (01-2016) UF (01-2016)

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Social Security Number:
Form Approved
OMB No. 0960-0483

Social Security Administration

WORK ACTIVITY QUESTIONNAIRE
Business Name:
Job Title:
Hourly Wage

Hours per Week

Date Work Started

Date Work Stopped
Section 1

1. Does the employee complete all the usual duties required for
his/her position?

Yes

No

2. Is the employee able to complete all of the job duties without
special assistance?

Yes

No

3. Does the employee regularly report for work as scheduled?

Yes

No

4. On average, does the employee complete his/her
work in the same amount of time as employees in
similar positions?

Yes

No

5. Please indicate the type(s) of special assistance, if any, the employee receives on the job
that is not regularly given to other employees. (Check all that apply)

Fewer or easier duties
Irregular hours
Special transportation
Less hours
More breaks/rest periods

Form SSA-3033 (01-2016) UF (01-2016)

Frequent absences
Lower production standards
Extra help/supervision
Lower quality standards
Special equipment

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Social Security Number:
6. Based on the information above, approximately how would you rate the productivity of the
employee compared to other employees in similar positions and similar pay rates?

50% or less of other employees' productivity
60% of other employees' productivity
70% of other employees' productivity
80% of other employees' productivity
90% of other employees' productivity
100% of other employees' productivity
7. Are you paying the employee more per hour than you would
another employee in a similar position?

Yes

No

1. Was the person frequently absent from work?

Yes

No

2. Did the person do the work under special conditions such as
with extra help/supervision, fewer/easier duties, frequent rest
periods, or lower production?

Yes

No

3. Was the person's work satisfactory when compared to
another employee who worked in a similar position?

Yes

No

If Yes, what would you pay another employee in a similar
position per hour?

Section 2
Unsuccessful Work Attempt

Section 3
Signature
and Title
Date

Form SSA-3033 (01-2016) UF (01-2016)

(Telephone Number)

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