eSSA-821 Work Activity Report- Employee

SSA821 Online Application
Screen Package
June 25, 2021

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Contents
Application Landing Page: .................................................................................................................................................3
Email and Password Landing Page: ....................................................................................................................................4
Email Confirmation Page: ..................................................................................................................................................5
First Email: ........................................................................................................................................................................6
Password Confirmation: ..................................................................................................................................................7
SSA821 Cover Sheet: .......................................................................................................................................................8
SSA821 Adobe Form: .......................................................................................................................................................9
Adding Attachments: .....................................................................................................................................................19
Example of Conditional Requirements:........................................................................................................................20
Signature:.........................................................................................................................................................................21
Signature Completion: .............................................................................................................................................................................................22
SSA821 Adobe Form Completion Page: ................................................................................................................................................................23
Password Request Page:..........................................................................................................................................................................................24
Final Email:..................................................................................................................................................................................................................25
Password Request Page:...........................................................................................................................................................................................26
SSA821 Completed Form:.........................................................................................................................................................................................27

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Application Landing Page:

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Email and Password Landing Page:

On this page, the claimant sets the password that will be used to access the form.

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Email Confirmation Page:

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First Email:

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Password Confirmation:

The claimant must provide the password to access the form.

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SSA821 Cover Sheet:

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SSA821 Adobe Form:

Red asterisks notate a required field. Note that some required fields are conditional, based upon
how the prior question was answered. Please see page 20 for an example.

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SSA821 Adobe Form:

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SSA821 Adobe Form:

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SSA821 Adobe Form:

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SSA821 Adobe Form:

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SSA821 Adobe Form:

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SSA821 Adobe Form:

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SSA821 Adobe Form:

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SSA821 Adobe Form:

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SSA821 Adobe Form:

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Adding Attachments:

Users have the ability to add attachments to the document as they see fit. Once the file is uploaded the
user will see the file name appear in the box where the attachment field was.

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Example of Conditional Requirements:

The SSA-821's questions are based on conditional values. The example displayed above shows that
by entering an employer in question 3B, the remaining fields for 3B are yellow allowing the user to
enter information. Even though the fields for question 3B appear with an asterisk in the image to the
left, they are not required until a value is entered in the conditional field “Previous Employer’s
Name.”

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Signature:

By clicking in the Signature field the user can type their name to sign the document.

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Signature Completion:

Signature now appears on the form with the date it was signed appearing below signature. If all
required fields are completed, user can "Click to Sign".

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SSA821 Adobe Form Completion Page:

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Password Request Page:

After clicking the link on the form completion page, the user will be prompted to enter the pre-established
password to view the completed form.

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Final Email:

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Password Request Page:

After clicking the link in the final email, the user will be prompted to enter the pre-established
password to view the completed form.

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SSA821 Completed Form:

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SSA821 Completed Form:

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SSA821 Completed Form:

The green paperclip indicates that the user uploaded a document to that field.

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SSA821 Completed Form:

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SSA821 Completed Form:

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SSA821 Completed Form:

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SSA821 Completed Form:

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SSA821 Completed Form:

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SSA821 Completed Form:

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SSA821 Completed Form:

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SSA821 Completed Form:

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SSA821 Completed Form:

Any attachments that were added to the form will appear as the last pages on the form.

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