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10WORK HISTORY REPORT- Form SSA-3369-BK
READ ALL OF THIS INFORMATION BEFORE
YOU BEGIN COMPLETING THIS FORM
IF YOU NEED HELP
If you need help with this form, complete as much of it as you can. Then call the phone number
provided on the letter sent with the form or the phone number of the person who asked you to
complete the form for help to finish it.
HOW TO COMPLETE THIS FORM
The information that you give us on this form will be used by the office that makes the disability
decision on your disability claim. You can help them by completing as much of the form as you can.
• Print or type.
• A reference to "you," "your," or "the Disabled Person," or "claimant" means
the person who is applying for disability benefits. If you are filling out the form for someone else,
provide information about him or her.
• ANSWER ALL OF THE QUESTIONS FOR EACH JOB YOU DESCRIBE. If you do not know
the 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 think you need to
explain an answer.
• If more space is needed to answer any questions, use the "REMARKS" section on Page 8, and
show the number of the question being answered.
WHY THIS INFORMATION IS IMPORTANT
The information we ask for on this form will help us understand how your illnesses, injuries, or
conditions might affect your ability to do work for which you are qualified. The information tells us
about the kinds of work you did, including the types of skills you needed and the physical and
mental requirements of each job. In Section 2, be sure to give us all of the different jobs you did in
the 15 years before you became unable to work because of your illnesses, injuries, or conditions.
There is a separate page to describe each different job.
REMEMBER TO GIVE US THE NAME AND ADDRESS OF THE PERSON
COMPLETING THIS FORM ON PAGE 8
WORK HISTORY REPORT- Form SSA-3369-BK
READ ALL OF THIS INFORMATION BEFORE
YOU BEGIN COMPLETING THIS FORM
IF YOU NEED HELP
If you need help with this form, complete as much of it as you can. Then call the phone number
provided on the letter sent with the form or the phone number of the person who asked you to
complete the form for help to finish it.
HOW TO COMPLETE THIS FORM
The information that you give us on this form will be used by the office that makes the disability
decision on your disability claim. You can help them by completing as much of the form as you can.
• Print or type.
• A reference to "you," "your," or "the Disabled Person," or "claimant" means
the person who is applying for disability benefits. If you are filling out the form for someone else,
provide information about him or her.
• ANSWER ALL OF THE QUESTIONS FOR EACH JOB YOU DESCRIBE. If you do not know
the 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 think you need to
explain an answer.
• If more space is needed to answer any questions, use the "REMARKS" section on Page 8, and
show the number of the question being answered.
WHY THIS INFORMATION IS IMPORTANT
The information we ask for on this form will help us understand how your illnesses, injuries, or
conditions might affect your ability to do work for which you are qualified. The information tells us
about the kinds of work you did, including the types of skills you needed and the physical and
mental requirements of each job. In Section 2, be sure to give us all of the different jobs you did in
the 15 years before you became unable to work because of your illnesses, injuries, or conditions.
There is a separate page to describe each different job.
REMEMBER TO GIVE US THE NAME AND ADDRESS OF THE PERSON
COMPLETING THIS FORM ON PAGE 8
Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 223(d), and 1631(e)(1) of the Social Security Act, as amended, authorize us to collect
this information. We will use the information you provide to make a determination of eligibility for Social
Security benefits.
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 benefits 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 Folders Systems; and, 60-0090,
entitled, Master Beneficiary Record. 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 control
number. We estimate that it will take about 1 hour 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 to this address, not the
completed form.
PLEASE REMOVE THIS SHEET BEFORE RETURNING
THE COMPLETED FORM.
Form Approved
SOCIAL SECURITY ADMINISTRATION
OMB No. 0960-0578
WORK HISTORY REPORT
For SSA Use Only
Do not write in this box.
SECTION 1 - INFORMATION ABOUT THE DISABLED PERSON
A. NAME (First, Middle Initial, Last)
B. SOCIAL SECURITY NUMBER
C. DAYTIME TELEPHONE NUMBER
(If you have no number where you can be reached, give us a daytime
number where we can leave a message for you.)
(
)
-
Your Number
Message Number
None
Area Code Phone Number
SECTION 2 - INFORMATION ABOUT YOUR WORK
List all the jobs that you have had in the 15 years before you became unable to work because of
your illnesses, injuries, or conditions.
Job Title
Type of Business
Dates Worked
From
To
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Form SSA-3369-BK (04-2014) ef (04-2014)
PAGE 1
Destroy Prior Editions
Give us more information about Job No. 1 listed on Page 1. Estimate hours and pay, if you
need to.
JOB TITLE NO. 1
Rate of Pay
Per (Check One)
Hours per day
Days Per Week
$
Hour
Day
Week
Month
Year
Describe this job. What did you do all day? (If you need more space, write in the"Remarks" section.)
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
In this job, did you:
Use machines, tools, or equipment?
YES
NO
Use technical knowledge or skills?
YES
NO
Do any writing, complete reports, or
YES
NO
perform duties like this?
In this job, how many total hours each day did you:
Walk?
Kneel? (Bend legs to rest on knees)
Stand?
Crouch? (Bend legs & back down & forward)
Sit?
Crawl? (Move on hands & knees)
Climb?
Handle, grab, or grasp big objects?
Stoop? (Bend down and forward at waist)
Reach?
Write, type, or handle small objects?
Lifting and Carrying (Explain what you lifted, how far you carried it, and how often you did this.)
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Check the heaviest weight lifted:
Less than 10 lbs
10 lbs
20 lbs
50 lbs
100 lbs. or more
Other
Check weight you frequently lifted:
(By frequently, we mean from 1/3 to 2/3 of the workday.)
Less than 10 lbs
10 lbs
25 lbs
50 lbs or more
Other
(Complete the next
(Skip to the last question
Did you supervise other people in this job?
YES
NO
3 items.)
on this page.)
How many people did you supervise?
What part of your time was spent supervising people?
Did you hire and fire employees?
YES
NO
Were you a lead worker?
YES
NO
Form SSA-3369-BK (04-2014) ef (04-2014)
PAGE 2
Give us more information about Job No. 2 listed on Page 1. Estimate hours and pay, if you
need to.
JOB TITLE NO. 2
Rate of Pay
Per (Check One)
Hours per day Days per week
$
Hour
Day
Week
Month
Year
Describe this job. What did you do all day? (If you need more space, write in the"Remarks" section.)
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
In this job, did you:
Use machines, tools, or equipment?
YES
NO
Use technical knowledge or skills?
YES
NO
Do any writing, complete reports, or
YES
NO
perform duties like this?
In this job, how many total hours each day did you:
Walk?
Kneel? (Bend legs to rest on knees)
Stand?
Crouch? (Bend legs & back down & forward)
Sit?
Crawl? (Move on hands & knees)
Climb?
Handle, grab, or grasp big objects?
Stoop? (Bend down and forward at waist)
Reach?
Write, type, or handle small objects?
Lifting and Carrying (Explain what you lifted, how far you carried it, and how often you did this.)
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Check the heaviest weight lifted:
Less than 10 lbs
10 lbs
20 lbs
50 lbs
100 lbs. or more
Other
Check weight you frequently lifted: (By frequently, we mean from 1/3 to 2/3 of the workday.)
Less than 10 lbs
10 lbs
25 lbs
50 lbs or more
Other
(Complete the next
(Skip to the last
Did you supervise other people in this job?
YES
NO
3 items.)
question on this page.)
How many people did you supervise?
What part of your time was spent supervising people?
Did you hire and fire employees?
YES
NO
Were you a lead worker?
YES
NO
Form SSA-3369-BK (04-2014) ef (04-2014)
PAGE 3
Form SSA-3369-BK Instructions
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:
- Answer all the questions on the form;
- If you do not know or do not remember something, feel free to enter "do not know" or "do not remember";
- Print or type all your answers neatly;
- Make sure you have provided the necessary explanations for all the questions that required them;
- If the full answer to any question requires more space, continue in the "Remark" section;
- Do not forget to indicate the number of the question you answer if you continue explanations in the "Remark" section.
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.
How to Fill out SSA-3369-BK?
- Section 1. Information about the Disabled Person. Provide your name, Social Security number, and daytime phone number. If you do not have a phone, indicate any number where the SSA can leave a message for you if needed;
- Section 2. Information about Your Work. List all the jobs you have had in the past 15 years in chronological order. Start with the most recent job. Try to be as specific as possible regarding the month, date, and year of the beginning and end of your job. Give detailed information about your duties on each job you listed on the next six pages. The boxes on these pages are self-explanatory and designated to help you to enter all information the SSA may need to make the decision on your claim;
- Section 3. Remarks. Use it if the space provided in any of the previous boxes was not enough, or if you want to explain your answers. If you are not the person who has requested the disability benefits, print your name in the appropriate box under the "Remarks" section;
- Specify the date, mailing address, and email address (if applicable).
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.
