WORK HISTORY REPORT- Form SSA-3369-BK

WORK HISTORY REPORT- Form SSA-3369-BK
READ ALL OF THIS INFORMATION BEFORE YOU BEGIN COMPLETING THIS FORM
IF YOU NEED HELP
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HOW TO COMPLETE THIS FORM

Always ensure you SAVE your work if you plan to take breaks! SAVE button at bottom of page.
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.
- • 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(e1) 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.
WORK HISTORY REPORT
SECTION 1 - INFORMATION ABOUT THE DISABLED PERSON
This Work History Form is a COMPLETE list of all of my jobs over the past FIVE (5) years.
A. NAME (First, Middle Initial, Last)
Phone number
Have you been employed in at LEAST ONE job since 2019? (If NO work, select your option and scroll to the bottom of this form and click on SUBMIT - You're done! If you answer YES, continue on to complete the rest of this questionnaire entirely)
Work History Report - Form SSA-3369-BK
SECTION 2 - INFORMATION ABOUT YOUR WORK
List job history dating back ONLY FIVE (5) YEARS (2019 to Present). There are SIX available slots. Begin with MOST RECENT JOB. If you've had LESS than 6 jobs, you can leave the rest of the slots blank. SSA does NOT want to know your Employers Name, ONLY the job title and dates (example: if you delivered pizzas at 7 pizza shops, you have ONE job as a pizza delivery person).
1. Job title of last job you just had and date range (EX: Cashier 2022-2024)
2. Previous job you had and date range
3. Previous job and date range
4. Previous job and date range
5. Previous job and date range
6. Previous job and date range
By referencing the months and/or years, please explain any breaks between jobs that lasted longer than 3 months (EX: I didn't have a job in 2021-2023 because I was raising my young child):
Form SSA-3369-BK (04-2014) ef (04-2014)
In this next section, you must go into DETAIL about how each job above was performed. You will begin with JOB #1 and work your way down the list, describing all details about how you did that particular job.
Give us more information about Job No. 1 listed on Page 1. Estimate hours and pay, if you need to.
JOB #1: How much were you paid in this job?
Per (Check One)

HourMonthYear
How many hours did you work per day?
How many days did you work per week?
Describe this job. What did you do all day? (If you need more space, write in the"Remarks" section
Typical day at this job:
Use technical knowledge or skills? Do any writing, complete reports, or

YES - Use technical knowledge or skills?NOYES - Do any writing, complete reportsNOYES - Or any other duties like this?NO
In this job, how OFTEN did you do the following? Choose a number 0-8 as most shifts are typically 8 hours, but some are 12. The total number between walk, stand, sit should NOT exceed 8 or 12 hours total.
Walk?
Stand?
Sit?
Kneel? (Bend legs to rest on knees)
Crouch? (Bend legs & back down & forward)
Crawl? (Move on hands & knees)
Climb? (ladders, ropes, scaffolds)
Handle, grab, or grasp big objects?
Stoop? (Bend down and forward at waist)
Reach?
Write, type, or handle small objects?
Check the box below that best describes the HEAVIEST WEIGHT you had to lift or carry in your job (even if you only did it OCCASIONALLY!). Do the same for FREQUENTLY lifted weight of items you lifted and/or carried.

Less than 10 lbs was the heaviest I had to lift and/or carry10 lbs was the heaviest I had to lift and/or carry20 lbs was the heaviest I had to lift and/or carry50 lbs was the heaviest I had to lift and/or carry100 lbs. or more was the heaviest I had to lift and/or carryLess than 10 lbs was the amount I frequently had to lift and/or carry10 lbs was the amount I frequently had to lift and/or carry25 lbs was the amount I frequently had to lift and/or carry50 lbs or more was the amount I frequently had to lift and/or carry100 lbs or more was the amount I frequently had to lift and/or carryOther
Lifting and Carrying (Explain what you lifted, how far you carried it, and how often you did this on a typical day):
Did you supervise others at this job?

YESNO
How much of your work day was spent supervising people?
How many people did you supervise?
Did you hire and fire employees?

YESNO
Form SSA-3369-BK (04-2014) ef (04-2014)
Give us more information about Job No. 2 listed on Page 1. Estimate hours and pay, if you need to.
JOB #2: How much were you paid in this job?
Per (Check One)

HourMonthYear
How many hours did you work per day?
How many days did you work per week?
Describe this job. What did you do all day? (If you need more space, write in the"Remarks" section
Typical day at this job:
Use machines, tools, or equipment?

Use technical knowledge or skills?
Do any writing, complete reports, or

YES - Use technical knowledge or skills?NOYES - Do any writing, complete reportsNOYES - Or any other duties like this?NO
In this job, how OFTEN did you do the following? Choose a number 0-8 as most shifts are typically 8 hours, but some are 12. The total number between walk, stand, sit should NOT exceed 8 or 12 hours total.
Walk?
Stand?
Sit?
Kneel? (Bend legs to rest on knees)
Crouch? (Bend legs & back down & forward)
Crawl? (Move on hands & knees)
Climb? (ladders, ropes, scaffolds)
Handle, grab, or grasp big objects?
Stoop? (Bend down and forward at waist)
Reach?
Write, type, or handle small objects?
Check the box below that best describes the HEAVIEST WEIGHT you had to lift or carry in your job (even if you only did it OCCASIONALLY!). Do the same for FREQUENTLY lifted weight of items you lifted and/or carried.

Less than 10 lbs was the heaviest I had to lift and/or carry10 lbs was the heaviest I had to lift and/or carry20 lbs was the heaviest I had to lift and/or carry50 lbs was the heaviest I had to lift and/or carry100 lbs. or more was the heaviest I had to lift and/or carryLess than 10 lbs was the amount I frequently had to lift and/or carry10 lbs was the amount I frequently had to lift and/or carry25 lbs was the amount I frequently had to lift and/or carry50 lbs or more was the amount I frequently had to lift and/or carry100 lbs or more was the amount I frequently had to lift and/or carryOther
Lifting and Carrying (Explain what you lifted, how far you carried it, and how often you did this on a typical day):
Did you supervise other people at this job?

YESNO
How much of your work day was spent supervising people?
How many people did you supervise?
Did you hire and fire employees?

YESNO
Form SSA-3369-BK (04-2014) ef (04-2014)
Give us more information about Job No. 3 listed on Page 1. Estimate hours and pay, if you need to.
JOB #3: How much were you paid in this job?
Per (Check One)

HourMonthYear
How many hours did you work per day?
How many days did you work per week?
Describe this job. What did you do all day? (If you need more space, write in the"Remarks" section
Typical day at this job:
Use machines, tools, or equipment?

Use technical knowledge or skills?

Do any writing, complete reports, or
YES - Use technical knowledge or skills?NOYES - Do any writing, complete reportsNOYES - Or any other duties like this?NO
In this job, how OFTEN did you do the following? Choose a number 0-8 as most shifts are typically 8 hours, but some are 12. The total number between walk, stand, sit should NOT exceed 8 or 12 hours total.
Walk?
Stand?
Sit?
Kneel? (Bend legs to rest on knees)
Crouch? (Bend legs & back down & forward)
Crawl? (Move on hands & knees)
Climb? (ladders, ropes, scaffolds)
Handle, grab, or grasp BIG objects?
Stoop? (Bend down and forward at waist)
Reach?
Write, type, or handle small objects?
Check the box below that best describes the HEAVIEST WEIGHT you had to lift or carry in your job (even if you only did it OCCASIONALLY!). Do the same for FREQUENTLY lifted weight of items you lifted and/or carried.

Less than 10 lbs was the heaviest I had to lift and/or carry10 lbs was the heaviest I had to lift and/or carry20 lbs was the heaviest I had to lift and/or carry50 lbs was the heaviest I had to lift and/or carry100 lbs. or more was the heaviest I had to lift and/or carryLess than 10 lbs was the amount I frequently had to lift and/or carry10 lbs was the amount I frequently had to lift and/or carry25 lbs was the amount I frequently had to lift and/or carry50 lbs or more was the amount I frequently had to lift and/or carry100 lbs or more was the amount I frequently had to lift and/or carryOther
Lifting and Carrying (Explain what you lifted, how far you carried it, and how often you did this on a typical day):
Did you supervise others? yes or no?
How much of your work day was spent supervising people?
How many people did you supervise?
Did you hire and fire employees?

YESNO
Form SSA-3369-BK (04-2014) ef (04-2014)
Give us more information about Job No. 4 listed on Page 1. Estimate hours and pay, if you need to.
JOB #4: How much were you paid in this job?
Per (Check One)

HourMonthYear
How many hours did you work per day?
How many days did you work per week?
Describe this job. What did you do all day? (If you need more space, write in the"Remarks" section
Typical day at this job:
Use machines, tools, or equipment?

Use technical knowledge or skills?
Do any writing, complete reports, or

YES - Use technical knowledge or skills?NOYES - Do any writing, complete reportsNOYES - Or any other duties like this?NO
In this job, how OFTEN did you do the following? Choose a number 0-8 as most shifts are typically 8 hours, but some are 12. The total number between walk, stand, sit should NOT exceed 8 or 12 hours total.
Walk?
Stand?
Sit?
Kneel? (Bend legs to rest on knees)
Crouch? (Bend legs & back down & forward)
Crawl? (Move on hands & knees)
Climb? (ladders, ropes, scaffolds)
Handle, grab, or grasp big objects?
Stoop? (Bend down and forward at waist)
Reach?
Write, type, or handle small objects?
Check the HEAVIEST weight you lifted and then the weight you most frequently lifted in the workday: By frequently, we mean from 1/3 to 2/3 of the workday
Check the box below that best describes the HEAVIEST WEIGHT you had to lift or carry in your job (even if you only did it OCCASIONALLY!). Do the same for FREQUENTLY lifted weight of items you lifted and/or carried.

Less than 10 lbs was the heaviest I had to lift and/or carry10 lbs was the heaviest I had to lift and/or carry20 lbs was the heaviest I had to lift and/or carry50 lbs was the heaviest I had to lift and/or carry100 lbs. or more was the heaviest I had to lift and/or carryLess than 10 lbs was the amount I frequently had to lift and/or carry10 lbs was the amount I frequently had to lift and/or carry25 lbs was the amount I frequently had to lift and/or carry50 lbs or more was the amount I frequently had to lift and/or carry100 lbs or more was the amount I frequently had to lift and/or carryOther
Lifting and Carrying (Explain what you lifted, how far you carried it, and how often you did this on a typical day):
Did you supervise other employees, yes or no?
How much of your work day was spent supervising people?
How many people did you supervise?
Did you hire and fire employees?

YESNO
Form SSA-3369-BK (04-2014) ef (04-2014)PAGE 5
Give us more information about Job No. 5 listed on Page 1. Estimate hours and pay, if you need to.
JOB #5: How much were you paid in this job?
Per (Check One)

HourMonthYear
How many hours did you work per day?
How many days did you work per week?
Describe this job. What did you do all day? (If you need more space, write in the"Remarks" section
Typical day at this job:
Use machines, tools, or equipment?

Use technical knowledge or skills?
Do any writing, complete reports, or

YES - Use technical knowledge or skills?NOYES - Do any writing, complete reportsNOYES - Or any other duties like this?NO
In this job, how OFTEN did you do the following? Choose a number 0-8 as most shifts are typically 8 hours, but some are 12. The total number between walk, stand, sit should NOT exceed 8 or 12 hours total.
Walk?
Stand?
Sit?
Kneel? (Bend legs to rest on knees)
Crouch? (Bend legs & back down & forward)
Crawl? (Move on hands & knees)
Climb? (ladders, ropes, scaffolds)
Handle, grab, or grasp big objects?
Stoop? (Bend down and forward at waist)
Reach?
Write, type, or handle small objects?
Check the box below that best describes the HEAVIEST WEIGHT you had to lift or carry in your job (even if you only did it OCCASIONALLY!). Do the same for FREQUENTLY lifted weight of items you lifted and/or carried.

Less than 10 lbs was the heaviest I had to lift and/or carry10 lbs was the heaviest I had to lift and/or carry20 lbs was the heaviest I had to lift and/or carry50 lbs was the heaviest I had to lift and/or carry100 lbs. or more was the heaviest I had to lift and/or carryLess than 10 lbs was the amount I frequently had to lift and/or carry10 lbs was the amount I frequently had to lift and/or carry25 lbs was the amount I frequently had to lift and/or carry50 lbs or more was the amount I frequently had to lift and/or carry100 lbs or more was the amount I frequently had to lift and/or carryOther
Lifting and Carrying (Explain what you lifted, how far you carried it, and how often you did this on a typical day):
Did you supervise other people at this job? Yes or NO?
How much of your work day was spent supervising people?
How many people did you supervise?
Did you hire and fire employees?

YESNO
Form SSA-3369-BK (04-2014) ef (04-2014)
Give us more information about Job No. 6 listed on Page 1. Estimate hours and pay, if you need to.
JOB #6: How much were you paid in this job?
Per (Check One)

HourMonthYear
How many hours did you work per day?
How many days did you work per week?
Describe this job. What did you do all day? (If you need more space, write in the"Remarks" section
Typical day at this job:
Use machines, tools, or equipment?

Use technical knowledge or skills?
Do any writing, complete reports, or

YES - Use technical knowledge or skills?NOYES - Do any writing, complete reportsNOYES - Or any other duties like this?NO
In this job, how OFTEN did you do the following? Choose a number 0-8 as most shifts are typically 8 hours, but some are 12. The total number between walk, stand, sit should NOT exceed 8 or 12 hours total.
Walk?
Stand?
Sit?
Kneel? (Bend legs to rest on knees)
Crouch? (Bend legs & back down & forward)
Crawl? (Move on hands & knees)
Climb? (ladders, ropes, scaffolds)
Handle, grab, or grasp big objects?
Stoop? (Bend down and forward at waist)
Reach?
Write, type, or handle small objects?
Check the box below that best describes the HEAVIEST WEIGHT you had to lift or carry in your job (even if you only did it OCCASIONALLY!). Do the same for FREQUENTLY lifted weight of items you lifted and/or carried.

Less than 10 lbs was the heaviest I lifted10 lbs was the heaviest I lifted20 lbs was the heaviest I lifted50 lbs was the heaviest I lifted100 lbs. or more was the heaviest I liftedLess than 10 lbs was the amount I frequently had to lift and/or carry10 lbs was the amount I frequently had to lift and/or carry25 lbs was the amount I frequently had to lift and/or carry50 lbs or more was the amount I frequently had to lift and/or carry100 lbs or more was the amount I frequently had to lift and/or carryOther
Lifting and Carrying (Explain what you lifted, how far you carried it, and how often you did this on a typical day):
Did you supervise other people in this job? Yes or NO
How much of your work day was spent supervising people?
How many people did you supervise?
Did you hire and fire employees?

YESNO
Did you hire or fire employees

YESNO
DO YOU NEED MORE SPACE?

No, this form was enough for me.Yes, I had more than 6 job titles since 2007 (please list additional job titles below).
(OPTIONAL) If you have more than 6 past jobs since 2007, list them down below:
SECTION 3 - REMARKS
NEED MORE SPACE? TYPE HERE
Use this section to add any information you did not have space for in other parts of the form. Show the page number of the part
Name of person completing this form if other than the disabled person
Date

MonthDayYear
Date
Address of Applicant

Mailing Address

Street Address Line 2

CityState

ZIP Code
Email address of Applicant (required for copy of report)
example@example.com
Form SSA-3369-BK (04-2014) ef (04-2014)
Should be Empty:

WORK HISTORY REPORT- Form SSA-3369-BK

READ ALL OF THIS INFORMATION BEFORE YOU BEGIN COMPLETING THIS FORM

IF YOU NEED HELP

HOW TO COMPLETE THIS FORM

WHY THIS INFORMATION IS IMPORTANT

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

WORK HISTORY REPORT

SECTION 1 - INFORMATION ABOUT THE DISABLED PERSON

This Work History Form is a COMPLETE list of all of my jobs over the past FIVE (5) years.

Work History Report - Form SSA-3369-BK

SECTION 2 - INFORMATION ABOUT YOUR WORK

In this next section, you must go into DETAIL about how each job above was performed. You will begin with JOB #1 and work your way down the list, describing all details about how you did that particular job.

SECTION 3 - REMARKS