WORK HISTORY REPORT- Form SSA-****-BK

READ ALL OF THIS INFORMATION BEFORE

YOU BEGIN COMPLETING THIS FORM

IF YOU NEED HELP

If you need help with this form, complete as much of it as you can. Then call the phone number provided on the letter sent with the form or the phone number of the person who asked you to complete the form for help to finish it.

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.

• Print or type.

• 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

Work History Report -- Form SSA-3369-BK

Privacy Act Statement

Collection and Use of Personal Information

Sections 205(a), 223(d), and 1631(e)(1) 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. PLEASE REMOVE THIS SHEET BEFORE RETURNING

THE COMPLETED FORM.

- 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 control number. We estimate that it will take about 1 hour to read the instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO THE STATE AGENCY THAT REQUESTED IT. If you have questions about how to complete the form, contact the State Agency that requested it. If you need the address or phone number for your State Agency, you can get it by calling Social Security at 1-800-***-**** (TTY 1-800-***-****). You may send comments on our time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.

Paperwork Reduction Act Statement

Work History Report - Form SSA-3369-BK

Form SSA-3369-BK (04-2014) ef (04-2014)

Destroy Prior Editions

SOCIAL SECURITY ADMINISTRATION

WORK HISTORY REPORT

Form Approved

OMB No. 0960-0578

PAGE 1

For SSA Use Only

Do not write in this box.

SECTION 1 - INFORMATION ABOUT THE DISABLED PERSON

A. NAME (First, Middle Initial, Last) B. SOCIAL SECURITY NUMBER C. 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 Number Message Number None

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 Dates Worked

From To

1.

2.

3.

4.

5.

6.

7.

8.

9.

10. -

Area Code Phone Number

PAGE 2

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

JOB TITLE NO. 1

Rate of Pay

$

Per (Check One)

Hour Day Week Month Year

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? YES NO

Use technical knowledge or skills? YES NO

Do any writing, complete reports, or

perform duties like this?

YES NO

In this job, how many total hours each day did you: Walk?

Stand?

Sit?

Climb?

Stoop? (Bend down and forward at waist)

Kneel? (Bend legs to rest on knees)

Crouch? (Bend legs & back down & forward)

Crawl? (Move on hands & knees)

Handle, grab, or grasp big objects?

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 lbs 10 lbs 20 lbs 50 lbs 100 lbs. or more Other Check weight you frequently lifted: (By frequently, we mean from 1/3 to 2/3 of the workday.) Less than 10 lbs 10 lbs 25 lbs 50 lbs or more Other Did you supervise other people in this job? YES

(Complete the next

3 items.)

NO

(Skip to the last question

on this page.)

How many people did you supervise?

What part of your time was spent supervising people? Did you hire and fire employees? YES NO

Were you a lead worker? YES NO

Form SSA-3369-BK (04-2014) ef (04-2014)

Hours per day

PAGE 3

Give us more information about Job No. 2 listed on Page 1. Estimate hours and pay, if you need to.

JOB TITLE NO. 2

Rate of Pay

$

Per (Check One)

Hour Day Week Month Year

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? YES NO

Use technical knowledge or skills? YES NO

Do any writing, complete reports, or

perform duties like this?

YES NO

In this job, how many total hours each day did you: Walk?

Stand?

Sit?

Climb?

Stoop? (Bend down and forward at waist)

Kneel? (Bend legs to rest on knees)

Crouch? (Bend legs & back down & forward)

Crawl? (Move on hands & knees)

Handle, grab, or grasp big objects?

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 lbs 10 lbs 20 lbs 50 lbs 100 lbs. or more Other Check weight you frequently lifted: (By frequently, we mean from 1/3 to 2/3 of the workday.) Less than 10 lbs 10 lbs 25 lbs 50 lbs or more Other Did you supervise other people in this job? YES

(Complete the next

3 items.)

NO

(Skip to the last

question on this page.)

How many people did you supervise?

What part of your time was spent supervising people? Did you hire and fire employees? YES NO

Were you a lead worker? YES NO

Form SSA-3369-BK (04-2014) ef (04-2014)

PAGE 4

Give us more information about Job No. 3 listed on Page 1. Estimate hours and pay, if you need to.

JOB TITLE NO. 3

Rate of Pay

$

Per (Check One)

Hour Day Week Month Year

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? YES NO

Use technical knowledge or skills? YES NO

Do any writing, complete reports, or

perform duties like this?

YES NO

In this job, how many total hours each day did you: Walk?

Stand?

Sit?

Climb?

Stoop? (Bend down and forward at waist)

Kneel? (Bend legs to rest on knees)

Crouch? (Bend legs & back down & forward)

Crawl? (Move on hands & knees)

Handle, grab, or grasp big objects?

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 lbs 10 lbs 20 lbs 50 lbs 100 lbs. or more Other Check weight you frequently lifted: (By frequently, we mean from 1/3 to 2/3 of the workday.) Less than 10 lbs 10 lbs 25 lbs 50 lbs or more Other Did you supervise other people in this job? YES

(Complete the next

3 items.)

NO

(Skip to the last question on

this page.)

How many people did you supervise?

What part of your time was spent supervising people? Did you hire and fire employees? YES NO

Were you a lead worker? YES NO

Form SSA-3369-BK (04-2014) ef (04-2014)

PAGE 5

Give us more information about Job No. 4 listed on Page 1. Estimate hours and pay, if you need to.

JOB TITLE NO. 4

Rate of Pay

$

Per (Check One)

Hour Day Week Month Year

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? YES NO

Use technical knowledge or skills? YES NO

Do any writing, complete reports, or

perform duties like this?

YES NO

In this job, how many total hours each day did you: Walk?

Stand?

Sit?

Climb?

Stoop? (Bend down and forward at waist)

Kneel? (Bend legs to rest on knees)

Crouch? (Bend legs & back down & forward)

Crawl? (Move on hands & knees)

Handle, grab, or grasp big objects?

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 lbs 10 lbs 20 lbs 50 lbs 100 lbs. or more Other Check weight you frequently lifted: (By frequently, we mean from 1/3 to 2/3 of the workday.) Less than 10 lbs 10 lbs 25 lbs 50 lbs or more Other Did you supervise other people in this job? YES (Complete the next 3 items.)

NO (Skip to the last

question on this page.)

How many people did you supervise?

What part of your time was spent supervising people? Did you hire and fire employees? YES NO

Were you a lead worker? YES NO

Form SSA-3369-BK (04-2014) ef (04-2014)

PAGE 6

Give us more information about Job No. 5 listed on Page 1. Estimate hours and pay, if you need to.

JOB TITLE NO. 5

Rate of Pay

$

Per (Check One)

Hour Day Week Month Year

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? YES NO

Use technical knowledge or skills? YES NO

Do any writing, complete reports, or

perform duties like this?

YES NO

In this job, how many total hours each day did you: Walk?

Stand?

Sit?

Climb?

Stoop? (Bend down and forward at waist)

Kneel? (Bend legs to rest on knees)

Crouch? (Bend legs & back down & forward)

Crawl? (Move on hands & knees)

Handle, grab, or grasp big objects?

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 lbs 10 lbs 20 lbs 50 lbs 100 lbs. or more Other Check weight you frequently lifted: (By frequently, we mean from 1/3 to 2/3 of the workday.) Less than 10 lbs 10 lbs 25 lbs 50 lbs or more Other Did you supervise other people in this job? YES (Complete the next 3 items.)

NO (Skip to the last

question on this page.)

How many people did you supervise?

What part of your time was spent supervising people? Did you hire and fire employees? YES NO

Were you a lead worker? YES NO

Form SSA-3369-BK (04-2014) ef (04-2014)

PAGE 7

Give us more information about Job No. 6 listed on Page 1. Estimate hours and pay, if you need to.

JOB TITLE NO. 6

Rate of Pay

$

Per (Check One)

Hour Day Week Month Year

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? YES NO

Use technical knowledge or skills? YES NO

Do any writing, complete reports, or

perform duties like this?

YES NO

In this job, how many total hours each day did you: Walk?

Stand?

Sit?

Climb?

Stoop? (Bend down and forward at waist)

Kneel? (Bend legs to rest on knees)

Crouch? (Bend legs & back down & forward)

Crawl? (Move on hands & knees)

Handle, grab, or grasp big objects?

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 lbs 10 lbs 20 lbs 50 lbs 100 lbs. or more Other Check weight you frequently lifted: (By frequently, we mean from 1/3 to 2/3 of the workday.) Less than 10 lbs 10 lbs 25 lbs 50 lbs or more Other Did you supervise other people in this job? YES (Complete the next 3 items.)

NO (Skip to the last

question on this page.)

How many people did you supervise?

What part of your time was spent supervising people? Did you hire and fire employees? YES NO

Were you a lead worker? YES NO

Form SSA-3369-BK (04-2014) ef (04-2014)

PAGE 8

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.

BE SURE TO COMPLETE THE BOTTOM OF THIS PAGE.

Name of person completing this form if other than the disabled person

(Please print)

Date (Month, day, year)

Address (Number and Street) Email address (optional) City State ZIP Code

Form SSA-3369-BK (04-2014) ef (04-2014)

Contact this candidate