SSA-3369 Work History Report

Form SSA-3369-BK (XX-XXXX) UF
Discontinue Prior Editions
SOCIAL SECURITY ADMINISTRATION

Page 1 of 14
OMB No. 0960-0578

WORK HISTORY REPORT
PLEASE READ ALL OF THIS INFORMATION BEFORE
YOU BEGIN COMPLETING THIS REPORT
The office that makes the disability decision on your case will use the information you provide in
this report to understand how your illnesses, injuries, or conditions might affect your ability to do
work for which you are qualified. This information tells us about the kinds of work that you did,
including the physical and mental requirements of each job.
IF YOU NEED HELP

WHAT YOU NEED TO COMPLETE THIS REPORT
• Information about all the jobs that you have had in the last five years.
• ANSWER EVERY QUESTION FOR EACH JOB YOU DESCRIBE unless the report indicates
otherwise. Provide as much detail as possible.
• If you cannot remember all the information about your jobs, provide what you do remember. If
you do not know an 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 want to provide
additional information.
• If you need more space to answer any questions, use Section 3 - Remarks

REMEMBER TO PROVIDE THE INFORMATION ABOUT THE PERSON
COMPLETING THIS REPORT IN SECTION 4

Work History Report -- Form SSA-3369-BK

If you need help with this report, complete as much of it as you can. Then call the phone number
provided on the letter sent with the report or the phone number of the person who asked you to
complete the report for help to finish it. If you cannot speak or understand English, we will
provide an interpreter free of charge.

Form SSA-3369-BK (XX-XXXX) UF

PAGE 2 of 14

Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 223(d), 1614(a), and 1631 of the Social Security Act, as amended, allow us to collect
this information. Furnishing us this information is voluntary. However, failing to provide all or part of
the information may prevent an accurate and timely decision on any claim filed.
We will use the information to make a determination on eligibility for benefits. We may also share your
information for the following purposes, called routine uses:
·

To contactors and other Federal agencies, as necessary, for the purpose of assisting the Social
Security Administration (SSA) in the efficient administration of its programs; and
To applicants, claimants, prospective applicants or claimants, other than the data subject, their
authorized representatives or representative payees to the extent necessary to pursue Social
Security claims and to representative payees when the information pertains to individuals for
whom they serve as representative payees, for the purpose of assisting SSA in administering its
representative payment responsibilities under the Act and assisting the representative payees in
performing their duties as payees, including receiving and accounting for benefits for individuals
for whom they serve as payees.

In addition, we may share this information in accordance with the Privacy Act and other Federal laws.
For example, where authorized, we may use and disclose this information in computer matching
programs, in which our records are compared with other records to establish or verify a person's
eligibility for Federal benefit programs and for repayment of incorrect or delinquent debts under these
programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices (SORN)
60-0089, entitled Claims Folders System, as published in the Federal Register (FR) on April 1, 2003, at
68 FR 15784, and 60-0320, entitled Electronic Disability Claim File, as published in the FR on
December 22, 2003, at 68 FR 71210. Additional information, and a full listing of all of our SORNs, is
available on our website at www.ssa.gov/privacy.
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 40 minutes 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 or any other aspects of this
collection to this address, not the completed form.

AFTER COMPLETING THIS REPORT, REMOVE THIS SHEET
AND KEEP IT FOR YOUR RECORDS

Form SSA-3369-BK (xx-xxxx) UF
Discontinue Prior Editions
SOCIAL SECURITY ADMINISTRATION
WORK HISTORY REPORT

Page 3 of 14
OMB No. 0960-0578

For SSA Use Only- Do not write in this box.
Related SSN
Number Holder

Anyone who makes or causes to be made a false statement or representation of material fact for
use in determining a payment under the Social Security Act, or knowingly conceals or fails to
disclose an event with an intent to affect an initial or continued right to payment, commits a crime
punishable under Federal law by fine, imprisonment, or both, and may be subject to
administrative sanctions.
SECTION 1 - INFORMATION ABOUT YOU
When a question refers to "you" or "your," it refers to the person who is applying for disability
benefits. If you are completing this report for someone else, provide information about them.
A. NAME (First, Middle Initial, Last, Suffix)

B. SOCIAL SECURITY NUMBER

Secondary:
(if available)

Primary:

SECTION 2 - INFORMATION ABOUT YOUR WORK
List all the jobs that you have had in the last 5 years:
• Include self-employment
• Include work in a foreign country
• List your most recent job first
Job Title
1.
2.
3.
4.
5.

Type
Of Business

Dates Worked
From
To
(MM/YYYYY) (MM/YYYYY)

Work History Report - Form SSA-3369-BK

C. DAYTIME PHONE NUMBER(S) where we can call to speak with you or leave a message, if
needed. Include area code or IDD and country code if outside the USA or Canada.

Form SSA-3369-BK (07-2022) UF
PAGE 4 of 14
SECTION 2 - WORK HISTORY (continued)
Provide more information about Job No. 1 listed in Section 2. Estimate hours and pay, if needed.
If you need more space, use section 3.
JOB TITLE NO. 1
Rate of Pay
$

Per (Check One)

Hour

Day

Week

Month

Year

Hours per Day Days Per Week

For the job you listed in Job Title No. 1, describe in detail the tasks you did in a typical workday. Examples
of tasks include stocking shelves, greeting customers, scheduling appointments, and maintaining records.

If any of the tasks listed above involved writing or completing reports, describe the type of report you wrote
or completed and how much time you spent on it per workday or workweek.

If any of the tasks listed above involved supervising others, describe who or what you supervised and what
supervisory duties you had. Examples of supervisory duties include performance management, making
schedules, and maintaining time records.

List the machines, tools, and equipment you used regularly when doing this job, and explain what you used
them for. Examples of equipment include computer, telephone, forklift, air compressor, and meat slicer.

Tell us about the work-related skills you used in this job and the job duties you completed using these skills.
Examples of work-related skills include reading blueprints to instruct workers on how to build houses and
medical coding to determine the amounts providers should be paid.

Did your job require you to interact with coworkers, the general public, or anyone else?

YES

NO

If YES, describe who you interacted with, the purpose of the interaction, how you interacted, and how much
time you spent doing it per workday or workweek. Examples include answering customer questions on the
telephone for 5 hours per day or showing clients properties for sale in person for 4 hours per day.

Form SSA-3369-BK (07-2022) UF
PAGE 5 of 14
SECTION 2 - WORK HISTORY (continued)
Tell us how much time you spent doing the following physical activities in a typical workday. The total
hours/minutes for standing and/or walking and sitting should equal the Hours per Day. The example below shows
an 8-hour workday with 2 hours standing and/or walking and 6 hours sitting (8 hours total).
How much of
your workday?
(Hours/Minutes)

Activity
Standing and/or walking
Sitting

Example:
2 hours
6 hours
5 minutes
5 minutes
None
None
2 hours
(both hands)
1 hour
(both hands)
1 hour
(both arms)

Stooping (i.e., bending down & forward at waist)
Kneeling (i.e., bending legs to rest on knees)
Crouching (i.e., bending legs & back down & forward)
Crawling (i.e., moving on hands and knees)
Using fingers to touch, pick, or pinch (e.g., using a mouse, keyboard,
One Hand
Both Hands
turning pages, or buttoning a shirt):
Using hands to seize, hold, grasp, or turn (e.g., holding a large envelope, a
One Hand
Both Hands
small box, a hammer, or water bottle):
Reaching at or below the shoulder:

One Arm

Both Arms

Reaching overhead (above the shoulder):

One Arm

Both Arms

None

Climbing stairs or ramps
None
Climbing ladders, ropes, or scaffolds
None
Tell us about lifting and carrying in this job. Explain what you lifted, how far you carried it, and how often you
did it in a typical workday.

Select the heaviest weight lifted:
Less than 1 lb.
Less than 10 lbs.
50 lbs.
100 lbs. or more

10 lbs.
Other

20 lbs.

Select the weight frequently lifted (i.e., 1/3 to 2/3 of the workday):
Less than 1 lb.

Less than 10 lbs.

10 lbs.

25 lbs.

50 lbs. or more

Other

Did your job expose you to any of the following? Check all that apply.
Outdoors

Extreme heat (non-weather related)

Humidity

Hazardous substances

Heavy vibrations

Loud noises

Extreme cold (non-weather related)

Moving mechanical parts

High, exposed places

Other

If one or more boxes are checked, tell us about the exposure(s) and how often you were exposed.

Explain how your medical conditions affect your ability to do this job.

Wetness

Form SSA-3369-BK (07-2022) UF
PAGE 6 of 14
SECTION 2 - WORK HISTORY (continued)
Provide more information about Job No. 2 listed in Section 2. Estimate hours and pay, if needed.
If you need more space, use section 3.
JOB TITLE NO. 2
Rate of Pay
$

Per (Check One)

Hour

Day

Week

Month

Year

Hours per Day Days Per Week

For the job you listed in Job Title No. 1, describe in detail the tasks you did in a typical workday. Examples
of tasks include stocking shelves, greeting customers, scheduling appointments, and maintaining records.

If any of the tasks listed above involved writing or completing reports, describe the type of report you wrote
or completed and how much time you spent on it per workday or workweek.

If any of the tasks listed above involved supervising others, describe who or what you supervised and what
supervisory duties you had. Examples of supervisory duties include performance management, making
schedules, and maintaining time records.

List the machines, tools, and equipment you used regularly when doing this job, and explain what you used
them for. Examples of equipment include computer, telephone, forklift, air compressor, and meat slicer.

Tell us about the work-related skills you used in this job and the job duties you completed using these skills.
Examples of work-related skills include reading blueprints to instruct workers on how to build houses and
medical coding to determine the amounts providers should be paid.

Did your job require you to interact with coworkers, the general public, or anyone else?

YES

NO

If YES, describe who you interacted with, the purpose of the interaction, how you interacted, and how much
time you spent doing it per workday or workweek. Examples include answering customer questions on the
telephone for 5 hours per day or showing clients properties for sale in person for 4 hours per day.

Form SSA-3369-BK (07-2022) UF
PAGE 7 of 14
SECTION 2 - WORK HISTORY (continued)
Tell us how much time you spent doing the following physical activities in a typical workday. The total
hours/minutes for standing and/or walking and sitting should equal the Hours per Day.
How much of
your workday?
(Hours/Minutes)

Activity
Standing and/or walking
Sitting

Example:
2 hours
6 hours
5 minutes
5 minutes
None
None
2 hours
(both hands)
1 hour
(both hands)
1 hour
(both arms)

Stooping (i.e., bending down & forward at waist)
Kneeling (i.e., bending legs to rest on knees)
Crouching (i.e., bending legs & back down & forward)
Crawling (i.e., moving on hands and knees)
Using fingers to touch, pick, or pinch (e.g., using a mouse, keyboard,
One Hand
Both Hands
turning pages, or buttoning a shirt):
Using hands to seize, hold, grasp, or turn (e.g., holding a large envelope, a
One Hand
Both Hands
small box, a hammer, or water bottle):
Reaching at or below the shoulder:

One Arm

Both Arms

Reaching overhead (above the shoulder):

One Arm

Both Arms

None

Climbing stairs or ramps
None
Climbing ladders, ropes, or scaffolds
None
Tell us about lifting and carrying in this job. Explain what you lifted, how far you carried it, and how often you
did it in a typical workday.

Select the heaviest weight lifted:
Less than 1 lb.
Less than 10 lbs.
50 lbs.
100 lbs. or more

10 lbs.
Other

20 lbs.

Select the weight frequently lifted (i.e., 1/3 to 2/3 of the workday):
Less than 1 lb.

Less than 10 lbs.

10 lbs.

25 lbs.

50 lbs. or more

Other

Did your job expose you to any of the following? Check all that apply.
Outdoors

Extreme heat (non-weather related)

Humidity

Hazardous substances

Heavy vibrations

Loud noises

Extreme cold (non-weather related)

Moving mechanical parts

High, exposed places

Other

If one or more boxes are checked, tell us about the exposure(s) and how often you were exposed.

Explain how your medical conditions affect your ability to do this job.

Wetness

Form SSA-3369-BK (07-2022) UF
PAGE 8 of 14
SECTION 2 - WORK HISTORY (continued)
Provide more information about Job No. 3 listed in Section 2. Estimate hours and pay, if needed.
If you need more space, use section 3.
JOB TITLE NO. 3
Rate of Pay
$

Per (Check One)

Hour

Day

Week

Month

Year

Hours per Day Days Per Week

For the job you listed in Job Title No. 1, describe in detail the tasks you did in a typical workday. Examples
of tasks include stocking shelves, greeting customers, scheduling appointments, and maintaining records.

If any of the tasks listed above involved writing or completing reports, describe the type of report you wrote
or completed and how much time you spent on it per workday or workweek.

If any of the tasks listed above involved supervising others, describe who or what you supervised and what
supervisory duties you had. Examples of supervisory duties include performance management, making
schedules, and maintaining time records.

List the machines, tools, and equipment you used regularly when doing this job, and explain what you used
them for. Examples of equipment include computer, telephone, forklift, air compressor, and meat slicer.

Tell us about the work-related skills you used in this job and the job duties you completed using these skills.
Examples of work-related skills include reading blueprints to instruct workers on how to build houses and
medical coding to determine the amounts providers should be paid.

Did your job require you to interact with coworkers, the general public, or anyone else?

YES

NO

If YES, describe who you interacted with, the purpose of the interaction, how you interacted, and how much
time you spent doing it per workday or workweek. Examples include answering customer questions on the
telephone for 5 hours per day or showing clients properties for sale in person for 4 hours per day.

Form SSA-3369-BK (07-2022) UF
PAGE 9 of 14
SECTION 2 - WORK HISTORY (continued)
Tell us how much time you spent doing the following physical activities in a typical workday. The total
hours/minutes for standing and/or walking and sitting should equal the Hours per Day.
How much of
your workday?
(Hours/Minutes)

Activity
Standing and/or walking
Sitting

Example:
2 hours
6 hours
5 minutes
5 minutes
None
None
2 hours
(both hands)
1 hour
(both hands)
1 hour
(both arms)

Stooping (i.e., bending down & forward at waist)
Kneeling (i.e., bending legs to rest on knees)
Crouching (i.e., bending legs & back down & forward)
Crawling (i.e., moving on hands and knees)
Using fingers to touch, pick, or pinch (e.g., using a mouse, keyboard,
One Hand
Both Hands
turning pages, or buttoning a shirt):
Using hands to seize, hold, grasp, or turn (e.g., holding a large envelope, a
One Hand
Both Hands
small box, a hammer, or water bottle):
Reaching at or below the shoulder:

One Arm

Both Arms

Reaching overhead (above the shoulder):

One Arm

Both Arms

None

Climbing stairs or ramps
None
Climbing ladders, ropes, or scaffolds
None
Tell us about lifting and carrying in this job. Explain what you lifted, how far you carried it, and how often you
did it in a typical workday.

Select the heaviest weight lifted:
Less than 1 lb.
Less than 10 lbs.
50 lbs.
100 lbs. or more

10 lbs.
Other

20 lbs.

Select the weight frequently lifted (i.e., 1/3 to 2/3 of the workday):
Less than 1 lb.

Less than 10 lbs.

10 lbs.

25 lbs.

50 lbs. or more

Other

Did your job expose you to any of the following? Check all that apply.
Outdoors

Extreme heat (non-weather related)

Humidity

Hazardous substances

Heavy vibrations

Loud noises

Extreme cold (non-weather related)

Moving mechanical parts

High, exposed places

Other

If one or more boxes are checked, tell us about the exposure(s) and how often you were exposed.

Explain how your medical conditions affect your ability to do this job.

Wetness

Form SSA-3369-BK (07-2022) UF
PAGE 10 of 14
SECTION 2 - WORK HISTORY (continued)
Provide more information about Job No. 4 listed in Section 2. Estimate hours and pay, if needed.
If you need more space, use section 3.
JOB TITLE NO. 4
Rate of Pay
$

Per (Check One)

Hour

Day

Week

Month

Year

Hours per Day Days Per Week

For the job you listed in Job Title No. 1, describe in detail the tasks you did in a typical workday. Examples
of tasks include stocking shelves, greeting customers, scheduling appointments, and maintaining records.

If any of the tasks listed above involved writing or completing reports, describe the type of report you wrote
or completed and how much time you spent on it per workday or workweek.

If any of the tasks listed above involved supervising others, describe who or what you supervised and what
supervisory duties you had. Examples of supervisory duties include performance management, making
schedules, and maintaining time records.

List the machines, tools, and equipment you used regularly when doing this job, and explain what you used
them for. Examples of equipment include computer, telephone, forklift, air compressor, and meat slicer.

Tell us about the work-related skills you used in this job and the job duties you completed using these skills.
Examples of work-related skills include reading blueprints to instruct workers on how to build houses and
medical coding to determine the amounts providers should be paid.

Did your job require you to interact with coworkers, the general public, or anyone else?

YES

NO

If YES, describe who you interacted with, the purpose of the interaction, how you interacted, and how much
time you spent doing it per workday or workweek. Examples include answering customer questions on the
telephone for 5 hours per day or showing clients properties for sale in person for 4 hours per day.

Form SSA-3369-BK (07-2022) UF
PAGE11 of 14
SECTION 2 - WORK HISTORY (continued)
Tell us how much time you spent doing the following physical activities in a typical workday. The total
hours/minutes for standing and/or walking and sitting should equal the Hours per Day.
How much of
your workday?
(Hours/Minutes)

Activity
Standing and/or walking
Sitting

Example:
2 hours
6 hours
5 minutes
5 minutes
None
None
2 hours
(both hands)
1 hour
(both hands)
1 hour
(both arms)

Stooping (i.e., bending down & forward at waist)
Kneeling (i.e., bending legs to rest on knees)
Crouching (i.e., bending legs & back down & forward)
Crawling (i.e., moving on hands and knees)
Using fingers to touch, pick, or pinch (e.g., using a mouse, keyboard,
One Hand
Both Hands
turning pages, or buttoning a shirt):
Using hands to seize, hold, grasp, or turn (e.g., holding a large envelope, a
One Hand
Both Hands
small box, a hammer, or water bottle):
Reaching at or below the shoulder:

One Arm

Both Arms

Reaching overhead (above the shoulder):

One Arm

Both Arms

None

Climbing stairs or ramps
None
Climbing ladders, ropes, or scaffolds
None
Tell us about lifting and carrying in this job. Explain what you lifted, how far you carried it, and how often you
did it in a typical workday.

Select the heaviest weight lifted:
Less than 1 lb.
Less than 10 lbs.
50 lbs.
100 lbs. or more

10 lbs.
Other

20 lbs.

Select the weight frequently lifted (i.e., 1/3 to 2/3 of the workday):
Less than 1 lb.

Less than 10 lbs.

10 lbs.

25 lbs.

50 lbs. or more

Other

Did your job expose you to any of the following? Check all that apply.
Outdoors

Extreme heat (non-weather related)

Humidity

Hazardous substances

Heavy vibrations

Loud noises

Extreme cold (non-weather related)

Moving mechanical parts

High, exposed places

Other

If one or more boxes are checked, tell us about the exposure(s) and how often you were exposed.

Explain how your medical conditions affect your ability to do this job.

Wetness

Form SSA-3369-BK (07-2022) UF
PAGE 12 of 14
SECTION 2 - WORK HISTORY (continued)
Provide more information about Job No. 5 listed in Section 2. Estimate hours and pay, if needed.
If you need more space, use section 3.
JOB TITLE NO. 5
Rate of Pay
$

Per (Check One)

Hour

Day

Week

Month

Year

Hours per Day Days Per Week

For the job you listed in Job Title No. 1, describe in detail the tasks you did in a typical workday. Examples
of tasks include stocking shelves, greeting customers, scheduling appointments, and maintaining records.

If any of the tasks listed above involved writing or completing reports, describe the type of report you wrote
or completed and how much time you spent on it per workday or workweek.

If any of the tasks listed above involved supervising others, describe who or what you supervised and what
supervisory duties you had. Examples of supervisory duties include performance management, making
schedules, and maintaining time records.

List the machines, tools, and equipment you used regularly when doing this job, and explain what you used
them for. Examples of equipment include computer, telephone, forklift, air compressor, and meat slicer.

Tell us about the work-related skills you used in this job and the job duties you completed using these skills.
Examples of work-related skills include reading blueprints to instruct workers on how to build houses and
medical coding to determine the amounts providers should be paid.

Did your job require you to interact with coworkers, the general public, or anyone else?

YES

NO

If YES, describe who you interacted with, the purpose of the interaction, how you interacted, and how much
time you spent doing it per workday or workweek. Examples include answering customer questions on the
telephone for 5 hours per day or showing clients properties for sale in person for 4 hours per day.

Form SSA-3369-BK (07-2022) UF
PAGE 13 of 14
SECTION 2 - WORK HISTORY (continued)
Tell us how much time you spent doing the following physical activities in a typical workday. The total
hours/minutes for standing and/or walking and sitting should equal the Hours per Day.
How much of
your workday?
(Hours/Minutes)

Activity
Standing and/or walking
Sitting

Example:
2 hours
6 hours
5 minutes
5 minutes
None
None
2 hours
(both hands)
1 hour
(both hands)
1 hour
(both arms)

Stooping (i.e., bending down & forward at waist)
Kneeling (i.e., bending legs to rest on knees)
Crouching (i.e., bending legs & back down & forward)
Crawling (i.e., moving on hands and knees)
Using fingers to touch, pick, or pinch (e.g., using a mouse, keyboard,
One Hand
Both Hands
turning pages, or buttoning a shirt):
Using hands to seize, hold, grasp, or turn (e.g., holding a large envelope, a
One Hand
Both Hands
small box, a hammer, or water bottle):
Reaching at or below the shoulder:

One Arm

Both Arms

Reaching overhead (above the shoulder):

One Arm

Both Arms

None

Climbing stairs or ramps
None
Climbing ladders, ropes, or scaffolds
None
Tell us about lifting and carrying in this job. Explain what you lifted, how far you carried it, and how often you
did it in a typical workday.

Select the heaviest weight lifted:
Less than 1 lb.
Less than 10 lbs.
50 lbs.
100 lbs. or more

10 lbs.
Other

20 lbs.

Select the weight frequently lifted (i.e., 1/3 to 2/3 of the workday):
Less than 1 lb.

Less than 10 lbs.

10 lbs.

25 lbs.

50 lbs. or more

Other

Did your job expose you to any of the following? Check all that apply.
Outdoors

Extreme heat (non-weather related)

Humidity

Hazardous substances

Heavy vibrations

Loud noises

Extreme cold (non-weather related)

Moving mechanical parts

High, exposed places

Other

If one or more boxes are checked, tell us about the exposure(s) and how often you were exposed.

Explain how your medical conditions affect your ability to do this job.

Wetness

Form SSA-3369-BK (07-2022) UF

PAGE 14 of 14
SECTION 3 - REMARKS

Please provide any additional information you did not give in earlier parts of this report. If you did not have enough space in the
prior sections of this report to provide the requested information, please use this space to provide the additional information
requested in those sections. Be sure to include the job title number and question to which you are referring. If you add more jobs
than the 5 jobs listed, please provide the same information as you did for job titles numbers 1-5 on a separate sheet of paper(s).
BE SURE TO COMPLETE THE BOTTOM OF THIS PAGE.

SECTION 4 - WHO IS COMPLETING THIS REPORT
Date Report Completed (MM/DD/YYYY)
Who is completing this report?
The person listed in 1.A.
Someone else (Complete the following section below)
NAME (First, Middle Initial, Last)

Relationship to the Person in 1.A.

MAILING ADDRESS (Street or PO Box) Include the apartment number, if applicable.
CITY

STATE/Province

ZIP/Postal Code

COUNTRY (if not USA)

DAYTIME PHONE NUMBER where we may reach you or leave a message, if needed. Include the area
code or IDD and country code if outside the USA or Canada.