WORK HISTORY REPORT

WORK HISTORY REPORT

SECTION 1 - INFORMATION ABOUT YOU
NAME:
SSN:
Primary Phone Number:
Format: (000) 000-0000.
Email:
You will receive confirmation email at this address.
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year

SECTION 2 - WORK HISTORY

List all the jobs you had in the 5 years before you became unable to work because of your medical conditions:

List all job titles held for each employer.
Do not include jobs you held less than 30 calendar days.
Include self-employment.
Include work in a foreign country.

After completing this list, you will be asked questions about each of these jobs.

The Start Date/End Date for each job do NOT have to be exact, but a general a guesstimate. Social Security requires the date be input in the format provided. Select the year OR month/year that fits best.

If you have no idea what general timeframe you worked, notate it in the question after the table below.

Starting with your MOST RECENT job first:

Rows	Job Title (e.g., Cashier)	Type of Business (e.g., Grocery Store)	Start Date (Month and Year)	End Date(Month and Year)
1
2
3
4
5
6
7
8
9
10

⚠️ Report all self-employment!
Are there any jobs that you have NO IDEA the timeframe you had the job?
Section 2.
Which job and WHY do you not know when you held it?

Rows	How much of your workday? (Hours/Minutes)
Standing and walking (combined)
Sitting
Stooping (bending down & forward at waist)
Kneeling (bending legs to rest on knees)
Crouching /Squatting
Crawling
Climbing stairs or ramps
Climbing ladders, ropes, or scaffolds

Rows	How much of your workday? (Hours/Minutes)
Standing and walking (combined)
Sitting
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)
Climbing stairs or ramps
Climbing ladders, ropes, or scaffolds

Rows	How much of your workday? (Hours/Minutes)
Standing and walking (combined)
Sitting
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)
Climbing stairs or ramps
Climbing ladders, ropes, or scaffolds

Rows	How much of your workday? (Hours/Minutes)
Standing and walking (combined)
Sitting
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)
Climbing stairs or ramps
Climbing ladders, ropes, or scaffolds

Rows	How much of your workday? (Hours/Minutes)
Standing and walking (combined)
Sitting
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)
Climbing stairs or ramps
Climbing ladders, ropes, or scaffolds

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 below.
Remarks

0/2500
SECTION 4 - WHO IS COMPLETING THIS REPORT
Date Report Completed:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Who is completing this report?
Your Name:
Relationship to the Claimant:
Your Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Should be Empty:

Rows	One Hand	Both Hands	How much of your workday? (Hours/Minutes)
Fine Motor: Using fingers to touch, pick, or pinch (e.g., using a mouse, keyboard, turning pages, or buttoning a shirt):
Gross Motor: Using hands to seize, hold, grasp, or turn (e.g., holding a small box, a hammer, or water bottle):

Rows	One Arm	Both Arms	How much of your workday? (Hours/Minutes)
Reaching at or below the shoulder:
Reaching overhead (above the shoulder):

Rows	One Hand	Both Hands	How much of your workday? (Hours/Minutes)
Fine Motor: Using fingers to touch, pick, or pinch (e.g., using a mouse, keyboard, turning pages, or buttoning a shirt):
Gross Motor: Using hands to seize, hold, grasp, or turn (e.g., driving, holding a hammer or water bottle):

Rows	One Arm	Both Arms	How much of your workday? (Hours/Minutes)
Reaching at or below the shoulder:
Reaching overhead (above the shoulder):

Rows	One Hand	Both Hands	How much of your workday? (Hours/Minutes)
Fine Motor:Using fingers to touch, pick, or pinch (e.g., using a keyboard, turning pages, or buttoning a shirt):
Gross Motor: Using hands to seize, hold, grasp, or turn (e.g., driving, holding a hammer or water bottle):

Job Number 1

Job Number 2

Job Number 3

Job Number 4

Job Number 5

Section 3 - Remarks

Rows	One Hand	Both Hands	How much of your workday? (Hours/Minutes)
Fine Motor:Using fingers to touch, pick, or pinch (e.g., using a mouse, keyboard, turning pages, or buttoning a shirt):
Gross Motor:Using hands to seize, hold, grasp, or turn (e.g., holding a large envelope, a small box, a hammer, or water bottle):