Form SSA-3369-BK, Work History Report is a form used for providing the Social Security Administration (SSA) with detailed information about all jobs you performed in the past 15 years. The latest version of the form - also known as the SSA Form 3369-BK - was released by the SSA on April 1, 2014. The previous editions of this document are obsolete. A Form SSA-3369-BK fillable version is available for download below.
The SSA Work History Report is an important part of your application for Social Security disability benefits. It helps the SSA to obtain detailed information about any employment you had had in the last 15 years before you became unable to work due to an injury, illness, or a particular condition. This document informs the SSA about the type of job you held, specific skills and experience you gained, and mental and physical requirements each of the positions demanded. The agency needs these details to make sure that you can no longer perform the duties you performed on your previous jobs, and have no skills or knowledge to find work in any other area.
The information you provide via this form is used to make a decision on your disability request. Follow all the instructions to prevent protracting your disability claim decision:
You can find detailed SSA Form 3369-BK instructions on the first two pages of the form. Read them carefully, detach, and keep for references. If you need help when completing the form, fill out as much as you can and call a phone number sent you with the form. You can also ask your lawyer or attorney to help you.
Return the filled-out Form SSA-3369-BK to the state agency that requested it. If you cannot find the envelope with your state agency address, call the SSA at the phone number indicated on the second page of the form.
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