WORK HISTORY REPORT- Form SSA-3369-BK/Impact Disability Law

WORK HISTORY REPORT- Form SSA-3369-BK
READ ALL OF THIS INFORMATION BEFORE
YOU BEGIN COMPLETING THIS FORM
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.
- 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.
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.
WORK HISTORY REPORT
SECTION 1 - INFORMATION ABOUT THE DISABLED PERSON
A. NAME

First NameMiddle NameLast Name
B. SOCIAL SECURITY NUMBER
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 NumberMessage NumberNone
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	From: Date	To: Date
1
2
3
4
5
6
7
8
9
10

Give us more information about Job No. 1 listed above. Estimate hours and pay, if you need to.
JOB NO. 1
TITLE
Rate of Pay
Per (Check One)

HourDayWeekMonthYear
Hours per day
Days Per Week
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?

YesNo
Use technical knowledge or skills?

YesNo
Do any writing, complete reports, or perform duties like this?

YesNo
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 lbs10 lbs20 lbs50 lbs100 lbs. or moreOther
Check weight you frequently lifted: (By frequently, we mean from 1/3 to 2/3 of the workday.)

Less than 10 lbs10 lbs25 lbs50 lbsOther
Did you supervise other people in this job?

YesNo
How many people did you supervise?
What part of your time was spent supervising people?
Did you hire and fire employees?

YesNo
Were you a lead worker?

YesNo
Give us more information about Job No. 2 listed above. Estimate hours and pay, if you need to.
JOB NO. 2
TITLE
Rate of Pay
Per (Check One)

HourDayWeekMonthYear
Hours per day
Days Per Week
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?

YesNo
Use technical knowledge or skills?

YesNo
Do any writing, complete reports, or perform duties like this?

YesNo
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 lbs10 lbs20 lbs50 lbs100 lbs. or moreOther
Check weight you frequently lifted: (By frequently, we mean from 1/3 to 2/3 of the workday.)

Less than 10 lbs10 lbs25 lbs50 lbsOther
Did you supervise other people in this job?

YesNo
How many people did you supervise?
What part of your time was spent supervising people?
Did you hire and fire employees?

YesNo
Were you a lead worker?

YesNo
Give us more information about Job No. 3 listed above. Estimate hours and pay, if you need to.
JOB NO. 3
TITLE
Rate of Pay
Per (Check One)

HourDayWeekMonthYear
Hours per day
Days Per Week
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?

YesNo
Use technical knowledge or skills?

YesNo
Do any writing, complete reports, or perform duties like this?

YesNo
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 lbs10 lbs20 lbs50 lbs100 lbs. or moreOther
Check weight you frequently lifted: (By frequently, we mean from 1/3 to 2/3 of the workday.)

Less than 10 lbs10 lbs25 lbs50 lbsOther
Did you supervise other people in this job?

YesNo
How many people did you supervise?
What part of your time was spent supervising people?
Did you hire and fire employees?

YesNo
Were you a lead worker?

YesNo
Give us more information about Job No. 4 listed above. Estimate hours and pay, if you need to.
JOB NO. 4
TITLE
Rate of Pay
Per (Check One)

HourDayWeekMonthYear
Hours per day
Days Per Week
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?

YesNo
Use technical knowledge or skills?

YesNo
Do any writing, complete reports, or perform duties like this?

YesNo
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 lbs10 lbs20 lbs50 lbs100 lbs. or moreOther
Check weight you frequently lifted: (By frequently, we mean from 1/3 to 2/3 of the workday.)

Less than 10 lbs10 lbs25 lbs50 lbsOther
Did you supervise other people in this job?

YesNo
How many people did you supervise?
What part of your time was spent supervising people?
Did you hire and fire employees?

YesNo
Were you a lead worker?

YesNo
Give us more information about Job No. 5 listed above. Estimate hours and pay, if you need to.
JOB NO. 5
TITLE
Rate of Pay
Per (Check One)

HourDayWeekMonthYear
Hours per day
Days Per Week
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?

YesNo
Use technical knowledge or skills?

YesNo
Do any writing, complete reports, or perform duties like this?

YesNo
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 lbs10 lbs20 lbs50 lbs100 lbs. or moreOther
Check weight you frequently lifted: (By frequently, we mean from 1/3 to 2/3 of the workday.)

Less than 10 lbs10 lbs25 lbs50 lbsOther
Did you supervise other people in this job?

YesNo
How many people did you supervise?
What part of your time was spent supervising people?
Did you hire and fire employees?

YesNo
Were you a lead worker?

YesNo
Give us more information about Job No. 6 listed above. Estimate hours and pay, if you need to.
JOB NO. 6
TITLE
Rate of Pay
Per (Check One)

HourDayWeekMonthYear
Hours per day
Days Per Week
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?

YesNo
Use technical knowledge or skills?

YesNo
Do any writing, complete reports, or perform duties like this?

YesNo
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 lbs10 lbs20 lbs50 lbs100 lbs. or moreOther
Check weight you frequently lifted: (By frequently, we mean from 1/3 to 2/3 of the workday.)

Less than 10 lbs10 lbs25 lbs50 lbsOther
Did you supervise other people in this job?

YesNo
How many people did you supervise?
What part of your time was spent supervising people?
Did you hire and fire employees?

YesNo
Were you a lead worker?

YesNo
SECTION 3 - REMARKS
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 you are continuing.
Name of person completing this form if other than the disabled person

First NameLast Name
Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Should be Empty:

WORK HISTORY REPORT- Form SSA-3369-BK

WORK HISTORY REPORT

SECTION 1 - INFORMATION ABOUT THE DISABLED PERSON

SECTION 2 - INFORMATION ABOUT YOUR WORK

Give us more information about Job No. 1 listed above. Estimate hours and pay, if you need to.

JOB NO. 1

In this job, did you:

Give us more information about Job No. 2 listed above. Estimate hours and pay, if you need to.

JOB NO. 2

In this job, did you:

Give us more information about Job No. 3 listed above. Estimate hours and pay, if you need to.

JOB NO. 3

In this job, did you:

Give us more information about Job No. 4 listed above. Estimate hours and pay, if you need to.

JOB NO. 4

In this job, did you:

Give us more information about Job No. 5 listed above. Estimate hours and pay, if you need to.

JOB NO. 5

In this job, did you:

Give us more information about Job No. 6 listed above. Estimate hours and pay, if you need to.

JOB NO. 6

In this job, did you:

SECTION 3 - REMARKS