SSA-3033 Form PDF Details

The Social Security Administration (SSA) utilizes various forms to ensure the accurate and timely administration of benefits, with the SSA-3033 being a particularly crucial document for assessing work-related activities. Scheduled for use as indicated in its latest edition (08-2021), this form embarks on a detailed pursuit to understand the nature of an individual's employment, especially focusing on those cases where work might be subsidized or an employee's efforts deemed an unsuccessful work attempt according to Social Security regulations. Employers are approached to provide a comprehensive account of an employee's work performance, specifically if the arrangements involved are out of the ordinary, such as additional assistance provided to the employee, consideration for work completed at a level below standard expectations, or adjustments made to typical duties. This request for information underscores the importance of an employer's perspective in validating the conditions under which an individual has worked, aiming to ensure the fairness and accuracy of benefits distributed under the Retirement, Survivors and Disability Insurance and Supplemental Security Income programs. Additionally, the form includes a privacy act statement detailing the lawful basis for information collection, the purpose behind it, and the stringent privacy measures in place to protect the submitted data, aligning with the broader governmental commitment to privacy and data security. By incorporating a work activity questionnaire designed to capture nuanced details about an employee's job performance and conditions, form SSA-3033 serves as a pivotal tool in the Social Security Administration's efforts to render decisions on benefits eligibility, underscoring the intersecting roles of employers, employees, and federal agencies in the efficient and equitable provision of social security benefits.

QuestionAnswer
Form Name SSA-3033 Form
Form Length 5 pages
Fillable? No
Fillable fields 0
Avg. time to fill out 1 min 15 sec
Other names ssa 3033 bk, 3033 social security, social security disability questionnaire, social security form ssa 3033

Form Preview Example

Form SSA-3033 (08-2021) UF

 

Discontinue Prior Editions

Page 1 of 5

Social Security Administration

OMB No. 0960-0483

 

 

Social Security Administration

Retirement, Survivors and Disability Insurance

Supplemental Security Income

•

Date:

Claim Number:

Social Security Number:

Worker's

Name:

Dear Sir or Madam:

 

We are writing to you about

. This individual has indicated to us

(s)he worked for your organization, but that the work was either limited in nature, subsidized, or ultimately unsuccessful. (S)he has given us permission to reach out to you to help us determine whether his or her work activity is/was subsidized or was an unsuccessful work attempt as described in our Social Security regulations. Please assist us by completing the enclosed questionnaire. The information you provide will not be shared with other agencies and is no way a negative reflection on the employee or you as the employer.

Information About Subsidy

A subsidy exists when an employer willingly pays more in wages than the value of the actual services performed. This is usually for humanitarian reasons. A subsidy can be reflected by giving the employee:

•extra assistance,

•full wages for lower quality or quantity than standard, or

•fewer and/or easier duties than usual for that position.

Information about Unsuccessful Work Attempt

An unsuccessful work attempt may exist if the employee had frequent absences, performed unsatisfactorily, and worked for six months or less.

Form SSA-3033 (08-2021) UF

Page 2 of 5

 

 

Social Security Number:

What We Need You To Do

Please havedirect supervisor or another person having direct knowledge of

the employee's work activity complete the work activity questionnaire. We would appreciate it if you would complete, sign and return the questionnaire to this office within 7 days using the enclosed envelope. If you have any questions, or if you would rather provide this information over the phone,

please call

 

and ask for

.

 

 

 

 

 

Thank you for your time and assistance.

Manager/Adjudicator Name

Position Title

Enclosure:

Work Activity Questionnaire

Form SSA-3033 (08-2021) UF

Page 3 of 5

Social Security Number:

Privacy Act Statement

Collection and Use of Personal Information

Sections 221, 223(d), 1612(b)(4), and 1614(a)(3) of the Social Security Act, as amended, allow us to collect this information. Furnishing us this information is voluntary. However, failing to provide all or part of the information may prevent an accurate and timely decision on any claim filed.

We will use the information you provide to validate unsuccessful work attempts and subsidies, and to determine benefits eligibility. We may also share the information for the following purposes, called routine uses:

•To contractors and other Federal agencies, as necessary, for the purpose of assisting us in the efficient administration of our programs. We will disclose information under this routine use only in situations in which we may enter into a contractual or similar agreement to obtain assistance in accomplishing an SSA function relating to this system of records, and

•To claimants, prospective claimants (other than the data subject), and their authorized representatives or representative payees, to the extent necessary to pursue Social Security claims; to representative payees, when the information pertains to individuals for whom they serve as representative payees, for the purpose of assisting us in administering representative payment responsibilities under the Social Security Act; and to representative payees, for the purpose of assisting them in performing their duties as payees, including receiving and accounting for benefits for individuals for whom they as payees.

In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where authorized, we may use and disclose this information in computer matching programs, in which our records are compared with other records to establish or verify a person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent debts under these programs.

A list of additional routine uses is available in our Privacy Act System of Records Notices (SORN) 60-0089, Claims Folders System, as published in the Federal Register (FR) on October 31, 2019, at 84 FR 58422; 60-0090, Master Beneficiary Record, as published in the FR on January 11, 2006, at 71 FR 1826; and

60-0103, Supplemental Security Income Record and Special Veterans Benefits, at 71 FR 1830. Additional information, and a full listing of all of our SORNs, is available on our website at www.ssa.gov/privacy.

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 (OMB) control number. We estimate that it will take about 15 minutes to read the instructions, gather the facts, and answer the questions. Send only comments regarding this burden estimate or any other aspect of this collection, including suggestions for reducing this burden to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

Form SSA-3033 (08-2021) UF

Discontinue Prior Editions

Social Security Administration

Social Security Number:

Page 4 of 5 OMB No. 0960-0483

Work Activity Questionnaire

Business Name:

Employee's

Job Title:

Hourly Wage:

Hours per Week:

Date Work Started:

Date Work Stopped:

Section 1

1.

Does the employee complete all the usual duties required for his/her position?

Yes

No

 

 

 

 

2.

Is the employee able to complete all of the job duties without special assistance?

Yes

No

 

 

 

 

3.

Does the employee regularly report for work as scheduled?

Yes

No

 

 

 

 

4.

On average, does the employee complete his/her work in the same amount of

Yes

No

 

time as employees in similar positions?

 

 

 

 

 

 

 

5.Please indicate the type(s) of special assistance, if any, the employee receives on the job that is not regularly given to other employees. (Check all that apply)

Fewer or easier duties

Irregular hours

Special transportation

Less hours

More breaks/rest periods

Frequent absences

Lower production standards

Extra help/supervision

Lower quality standards

Special equipment

6.Based on the information above, approximately how would you rate the productivity of the employee compared to other employees in similar positions and similar pay rates?

50% or less of other employees' productivity

80% of other employees' productivity

60% or less of other employees' productivity

90% of other employees' productivity

70% or less of other employees' productivity

100% of other employees' productivity

7.Are you paying the employee more per hour than you would another employee in a similar position?

Yes

No

If Yes, what would you pay another employee in a similar position per hour?

Form SSA-3033 (08-2021) UF

Page 5 of 5

Social Security Number:

Section 2

Unsuccessful Work Attempt

1.

Was the person frequently absent from work?

Yes

No

 

 

 

 

2.

Did the person do the work under special conditions such as with extra help/

Yes

No

 

supervision, fewer/easier duties, frequent rest periods, or lower production?

 

 

 

 

 

 

 

3.

Does the employee regularly report for work as scheduled?

Yes

No

 

 

 

 

Section 3

Signature and Title

Date:

(Telephone Number):

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1. Fill out your social security work report with a selection of necessary blank fields. Consider all the information you need and make certain not a single thing neglected!

Completing section 1 of social work questionnaire

2. Just after the prior section is done, proceed to enter the applicable details in all these: Form SSA UF, Page of, Social Security Number, What We Need You To Do, Please have direct supervisor or, the employees work activity, complete sign and return the, have any questions or if you would, please call and ask for, Thank you for your time and, Enclosure, and ManagerAdjudicator Name Position.

What We Need You To Do, the employees work activity, and have any questions or if you would of social work questionnaire

3. This stage is usually straightforward - complete all of the empty fields in Form SSA UF, Page of, Social Security Number, Privacy Act Statement, Collection and Use of Personal, Sections d b and a of the Social, To contractors and other Federal, efficient administration of our, and To claimants prospective in order to complete this part.

Filling out part 3 in social work questionnaire

4. This next section requires some additional information. Ensure you complete all the necessary fields - Form SSA UF Discontinue Prior, Social Security Number, Page of OMB No, Work Activity Questionnaire, Business Name, Employees Job Title, Hourly Wage, Hours per Week, Date Work Started, Date Work Stopped, Section, Does the employee complete all, Is the employee able to complete, Yes, and Yes - to proceed further in your process!

Step no. 4 in completing social work questionnaire

5. Lastly, the following last part is precisely what you'll want to complete prior to submitting the form. The blank fields at issue include the next: Does the employee regularly, On average does the employee, time as employees in similar, Yes, Yes, Please indicate the types of, regularly given to other employees, Fewer or easier duties, Irregular hours, Special transportation, Less hours, More breaksrest periods, Frequent absences, Lower production standards, and Extra helpsupervision.

time as employees in similar, Extra helpsupervision, and Yes of social work questionnaire

Concerning time as employees in similar and Extra helpsupervision, make sure you take another look in this section. Both these are the most significant fields in this form.

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