BASIC (04-00)

DI 22515.005 Use of Form SSA-3369-BK (Work History Report)

A. Procedure - Development

1. Development by Telephone or Direct Contact

If the DDS decides that detailed vocational information (in addition to that shown on Form SSA-3368-BK for the claimant's usual job) is needed, proceed as follows:

  1. If vocational information is obtained by phone or in person and documentation of the claimant's usual job supports a finding of ability to perform past relevant work, do not document other past work.

  2. If documentation of other past work is necessary, fully develop each successive job until a relevant job is identified that the claimant can perform.

2. Development by Mail

If the DDS mails the SSA-3369-BK to be completed by the claimant, ask the claimant to completely document each job held during the 15 years before becoming unable to work because of his or her illnesses, injuries or conditions. For title II claims with a date last insured or prescribed period in the past, ask the claimant to completely document each job held during the 15 years prior to the date last insured or the end of the prescribed period.

B. Description of Form

1. Section 1 (Information About the Disabled Person)

The SSA-3369-BK includes space for identifying information. (Get this information from the SSA-3368-BK or other form in file.)

NOTE: The identifying information is to be completed by the DDS (or FO) in every case in which completion of the SSA-3369-BK is required.

2. Section 2 (Information About Your Work)

Page 1 of Section 2 provides space to list all the jobs the claimant had in the 15 years before becoming unable to work because of his or her illnesses, injuries, or conditions. It also provides space for the dates worked (month and year).

NOTE: If the claimant had a marginal education or less, and performed only arduous labor for 35 years or more, or the claimant could meet the visual profile in

DI 25020.005A.10. or the mental profile in DI 25020.010A.3.b., all the jobs the claimant has had since beginning to work are to be listed.

3. Section 2, Pages 2-7

Pages 2-7 contain identical subsections. Each subsection asks specific information about the jobs listed on page 1 of Section 2 of the SSA-3369-BK, or Section 6 of the SSA-3368-BK. The SSA-3369-BK has subsections for describing up to 6 past jobs.

Each subsection asks for information about:

  1. the rate of pay and hours of work per day and per week.

  2. the use of machines, tools or other equipment.

  3. amount of bending, sitting, walking, or related activity.

  4. whether the claimant had to do any writing.

  5. basic job duties.

  6. other descriptive data providing a complete picture of the nature and duties of the job performed.

4. Section 3 (Remarks)

Section 3 provides space for the claimant to continue his/her history or to give any other information about his/her past relevant work.

NOTE: The signature and witness sections have been removed from the SSA-3369-BK as a step toward the paperless process. In place of the signature section, the SSA-3369 provides space for the claimant or the person who completes the form for the claimant to print his or her name, address, date, and Email address (optional).

C. Procedure — DDS

1. DDS Processing of Form

a. Section 1

Complete parts A, B, and C. This information should be available from the  SSA-3368-BK or other file documents.

b. Section 2, Page 1

Do not ask the claimant to complete the work history chart on page 1 of section 2 if Section 6.A of the SSA-3368-BK has been adequately completed.

If the SSA-3369-BK must be mailed to the claimant for completion, include a photocopy of the completed Section 6.A of the SSA-3368-BK to avoid unnecessary duplication of the work history report. (If using this procedure, include an explanatory statement to the claimant that the work history chart on page 1 of the SSA-3369-BK need not be completed.)

c. Section 2, Pages 2-7

Obtain this information for every job other than the claimant's usual job (provided that the claimant's usual job is adequately described on the SSA-3368-BK).

If there is insufficient space on the form to do this, use one or more additional

SSA-3369-BKs.

NOTE: If more than one SSA-3369-BK is used, complete Section 1, and as much of Section 2 as is necessary. Mark the second form “Supplementary” at the top.

2. DDS Review

Review the SSA-3369-BK by checking that all items and questions requiring a response are completed. (Even if the claimant is unable to give more than a nonspecific answer, such as, “I don't know” or “unknown” to a particular question or item involved, this assures that an item or question has not been overlooked or omitted.)

After reviewing the SSA-3369-BK, telephone the claimant for further information, if needed.

If the SSA-3369-BK in file is unsigned, obtain the necessary additional information, and include it in the file without further review by the claimant.

If a signed SSA-3369-BK is in file, record any additional information on an SSA-5002 for inclusion in the file without further review by the claimant. Include a cross reference to the SSA-5002 by date for identification on the SSA-3369-BK. Indicate which item or question number(s) is being modified or supplemented.

3. Person Completing the Form

Request that the claimant or the person completing the form for the claimant print his or her name, address, date and email address (optional) in the spaces provided in Section 3 of the form.

4. Followup Procedure

See DI 23007.004 and DI 23007.005 for instructions.


To Link to this section - Use this URL:
http://policy.ssa.gov/poms.nsf/lnx/0422515005
DI 22515.005 - Use of Form SSA-3369-BK (Work History Report) - 02/27/2013
Batch run: 02/27/2013
Rev:02/27/2013