Form Ssa 3369 Bk – Fill Out and Use This PDF

When a question refers to "you" or "your," it refers to the person who is applying for disability benefits.

If you are completing this report for someone else, provide information about them.

Daytime phone number(s) to call to speak with you or leave a message, if needed. Include area code or IDD and country code if outside the USA or Canada. Primary: Secondary: (if available)

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

List your most recent job first. List all job titles even if they were for the same employer. Do not include jobs you held less than 30 calendar days. Include self-employment (e.g., rideshare driver, hair stylist). Include work in a foreign country.

Estimate hours and pay, if needed: Hours per Day and Days per Week.

Per (Check One) Hour Day Week Month Year

For the job you listed in Job Title No. 1, describe in detail the tasks you did in a typical workday.

Examples of tasks include stocking shelves, greeting customers, scheduling appointments, or maintaining records.

If any of the tasks you listed involved writing or completing reports, describe the type of report you wrote or completed and how much time you spent on it per workday or workweek.

If any of the tasks you listed involved supervising others, describe who or what you supervised and what supervisory duties you had.

Examples of supervisory duties include evaluating employee job performance, making schedules, or maintaining time records.

List the machines, tools, and equipment you used regularly when doing this job, and explain what you used them for.

Examples of equipment include computer, telephone, forklift, air compressor, or meat slicer.

Did this job require you to interact with coworkers, the general public, or anyone else?

If YES, describe who you interacted with, the purpose of the interaction, how you interacted, and how much time you spent doing it per workday or workweek.

Examples include answering customer questions on the telephone for 5 hours per day or showing clients properties for sale in person for 4 hours per day.

The total hours/minutes for standing, walking, and sitting should equal the Hours per Day.

Select the heaviest weight lifted: Less than 1 lb. Less than 10 lbs. 10 lbs. 20 lbs. 50 lbs. 100 lbs. or more Other

Select the weight frequently lifted (i.e., 1/3 to 2/3 of the workday): Less than 1 lb. Less than 10 lbs. 10 lbs. 25 lbs. 50 lbs. or more Other

Explain what you lifted, how far you carried it, and how often you did it in a typical workday.

Did this job expose you to any of the following? Check all that apply.

Outdoors Extreme heat (non-weather related) Extreme cold (non-weather related) Wetness Humidity Hazardous substances Moving mechanical parts High, exposed places Heavy vibrations Loud noises Other

Explain how your medical conditions would affect your ability to do this job.

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 on a separate sheet of paper(s).

• If you need more space to answer any questions, use Section 3 - Remarks.

Who is completing this report? The person listed in 1.A. Someone else (Complete the information)

MAILING ADDRESS (Street or PO Box) Include the apartment number, if applicable.

Remember to provide the information about the person completing this report in Section 4.

Form SSA-3369-BK, the Work History Report, tells the office that makes the disability decision how your illnesses, injuries, or conditions might affect your ability to do work. This information tells about the kinds of work that you did, including the physical and mental requirements of each job.

SEND OR BRING THE COMPLETED FORM TO THE STATE AGENCY THAT REQUESTED IT.

Anyone who makes or causes to be made a false statement or representation of material fact for use in determining a payment under the Social Security Act, or knowingly conceals or fails to disclose an event with an intent to affect an initial or continued right to payment, commits a crime punishable under Federal law by fine, imprisonment, or both, and may be subject to administrative sanctions.