Form SSA-3033 Work Activity Questionnaire

Form SSA-3033 (XX-XXXX) UF
Discontinue Prior Editions

Page 1 of 5
OMB No. 0960-0483

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

Date:

•

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

Greetings:
The worker listed above has indicated to us that their work activity may be performed with employerprovided accommodations or under special conditions which may indicate that the work is subsidized. They
have given us permission to reach out to you to help us determine whether their work activity is subsidized
as defined by Social Security. The information you provide will not be shared with other agencies and is in
no way a negative reflection on the employee or the employer. Please assist us by completing the enclosed
questionnaire, even if the worker is no longer employed.

Information About Subsidy
When an employee’s work is subsidized, we do not consider any earnings above the reasonable value of
the work or services performed. A subsidy may exist when the employee works under any of the following
conditions:
• receives extra assistance;
• work activity is limited in nature;
• has fewer or easier duties than usual for the position;
• takes additional breaks or time off as an accommodation; or
• has other special conditions or employer accommodations.

Form SSA-3033 (XX-XXXX) UF

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Social Security Number:
What We Need You To Do

Please have someone, other than the employee, with direct knowledge of the employee's work activity
complete the work activity questionnaire. This could be a supervisor or the employee’s employment service
provider, such as a job coach, job developer, or other knowledgeable source. The information you provide
will help us determine the true value of the services performed. We would appreciate it if you would
complete and return the questionnaire to this office within 15 days, or as soon as possible. If you have any
questions, or if you would rather provide this information over the phone, please call
ask for

.

Thank you for your time and assistance.

Social Security Adminstration

Enclosure:
Work Activity Questionnaire

and

Form SSA-3033 (XX-XXXX) UF

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Privacy Act Statement
Collection and Use of Personal Information
Sections 221, 223(d), 1612(b)(4), and 1614(a)(3) 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 you provide to validate unsuccessful work attempts and subsidies, and to
determine benefits eligibility. We may also share the information for the following purposes, called routine
uses:
• To contractors and other Federal agencies, as necessary, for the purpose of assisting us in the
efficient administration of our programs. We will disclose information under this routine use only in
situations in which we may enter into a contractual or similar agreement to obtain assistance in
accomplishing an SSA function relating to this system of records, and
• To claimants, prospective claimants (other than the data subject), and their authorized
representatives or representative payees, to the extent necessary to pursue Social Security claims;
to representative payees, when the information pertains to individuals for whom they serve as
representative payees, for the purpose of assisting us in administering representative payment
responsibilities under the Social Security Act; and to representative payees, for the purpose of
assisting them in performing their duties as payees, including receiving and accounting for benefits
for individuals for whom they 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,
Claims Folders System, as published in the Federal Register (FR) on October 31, 2019, at 84 FR 58422;
60-0090, Master Beneficiary Record, as published in the FR on January 11, 2006, at 71 FR 1826; and
60-0103, Supplemental Security Income Record and Special Veterans Benefits, at 71 FR 1830. 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 (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 regarding this
burden estimate or any other aspect of this collection, including suggestions for reducing this
burden to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

Form SSA-3033 (XX-XXXX) UF
Discontinue Prior Editions
Social Security Administration

Page 4 of 5
OMB No. 0960-0483

Social Security Number:

Work Activity Questionnaire
Employee's Name:

Employee's SSN:

Business/Employer Name:
Employee's Job Title:
Date Work Started:

Date Work Ended (if applicable):

Hourly Wage/Salary:

Hours per Week:
Section 1

The following questions will help us to determine if the employer provides accommodations that support the
employee's work effort. Please answer the questions based on your direct knowledge of the employee's
work activities.
1. Does the employee require additional assistance or employer accommodation
to complete job duties? (i.e., job coach, extra help, or supervision, etc.)
• If yes, please describe in Section 2, Remarks.

Yes

No

Yes

No

Yes

No

4. Does the employer accommodate the employee by allowing them to take
additional or longer breaks, work fewer hours, extra time to complete work tasks,
or have frequent absences?

Yes

No

5. Does the employer provide any accommodations not covered above?
• If yes, please describe in Section 2, Remarks.

Yes

No

2. Is the employee assigned fewer or easier duties than typically required by
the job description?
3. Does the employee have a special relationship to the employer? (i.e., friend,
relative, long-term employee, etc.)
• If yes, please describe in Section 2, Remarks.

If the answer to any of the above is “Yes,” please proceed to Question 6.
If the answer to all the above is “No,” please proceed to Section 3.
6. Based on the answers above what is the reasonable value of the work or services performed? Please
see the following examples of how to determine a subsidy percentage:
• Example 1: The employee works 25 hours per week making $15.00 per hour. The employer allows
for extra supervision and extra time to complete tasks. The employer determines that the
reasonable value of the actual services performed is $12.00 per hour but chooses to pay the
individual $15.00 per hour. Therefore, the subsidy is $3.00 per hour or 20 %.
• Example 2: A long-term employee has held a position working 40 hours per week with a salary of
$2,850 per month. The employee can no longer perform their duties full-time. Because of the
employee’s loyalty to the company, the employer allows them to continue working, for the same
salary but at 20 hours per week . The reasonable value of the employee’s actual services
performed is $1,425 per month. Therefore, the subsidy is $1,425 per month or 50 %.
Approximately what percentage of this employee’s pay exceeds the reasonable value of the work or
services they perform? Please provide any justification in Section 2, Remarks.
10%

20%

30%

40%

60%

70%

80%

90%

100%

50%
Other

%

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Form SSA-3033 (XX-XXXX) UF

Social Security Number:
Section 2
Use the space below to let us know anything related to this employee's job, work activity or
accommodations that was not covered in the questions above and to provide additional information about
answers to those questions.
Remarks:

Section 3
Contact Information
Printed Name:

Title:

Your Organization/Employer Name:
Date:

(Telephone Number):