TN 13 (09-16)
DI 10505.035 Documenting Employment Cases Using Forms SSA-821-BK (Work Activity Report - Employee) and SSA-823 (Report of SGA Determination - For SSA Use Only)
A. Purpose of the work activity report
The field office (FO) and processing center (PC) use the form SSA-821-BK (Work Activity Report - Employee) to document work activity and work incentives prior to making a substantial gainful activity (SGA) determination for initial claims, appeals, and continuing disability review (CDR) cases. To document the SGA decision and rationale, use the form SSA-823 (Report of SGA Determination – For SSA Use Only).
Consider any applicable work incentives. If work incentives are involved, request needed work incentive documentation from the beneficiary/employer (DI 13010.001) and field office (FO) tickle for 15 days payment center (PC) 35 days.
B. When to complete form SSA-821-BK
You must complete form SSA-821-BK for all work issue CDRs, EXRs, appeals, and initial applications involving employment:
after the alleged onset date (AOD);
after the potential onset date (POD) when the POD is earlier than the AOD;
after the date the claimant alleges his or her impairment(s) first began to interfere with his or her ability to work;
work activity within the CDR review period;
after the controlling date in disabled widow(er)'s benefit (DWB) claims;
any time in childhood disability benefit (CDB) claims;
after the filing date in initial Supplemental Security Income (SSI) claims (for statutory blindness cases, see DI 11005.072B.2.); and
for comparability determinations in blindness claims after age 55 (see DI 13010.135).
NOTE: You do not have to complete a form SSA-821-BK in “clearly not SGA” cases. For more information on how to evaluate and process clearly not SGA cases, see DI 10505.003.
C. How to access and save form SSA-821-BK
1. Initial claims for certified electronic folder (CEF) cases
Access form SSA-821-BK through Electronic Disability Collect System (EDCS). Use the following instructions to process CEF cases:
complete form SSA-821-BK per DI 10505.035D in this section;
store form SSA-821-BK in eView; and
check eView for legibility.
2. Initial claims for CEF exclusions
Any claim excluded from electronic processing results in a paper folder. If you are creating a form SSA-821-BK for a CEF exclusion or limitation case:
access form SSA-821-BK through UniForms;
fax form SSA-821-BK into the Non-Disability Repository for Evidentiary Document (NDRed); and
insert it into the blue section of the Modular Disability Folder (MDF).
NOTE: It is extremely important that form SSA-821-BK and any related documents are available to the DDS. Before transferring any case to the DDS, the FO must always check the certified claims file record management system (CFRMS) for any form SSA-821-BK and related documents not stored in the paper folder. If there are CFRMS forms that are not in the MDF, print and place them in the MDF prior to forwarding to the DDS.
3. Work CDR cases
Prepare form SSA-821-BK generated by eWork for all work CDR cases (unless the work is “clearly not SGA”, see Note in DI 10505.035B in this section). Initiate a work CDR by attempting telephone contact with the beneficiary. If successful, complete the SSA-821 and sign using attestation.
If unsuccessful in reaching the beneficiary by telephone, initiate a work CDR by mailing an SSA-821, and tickle the case for 15 days for field office, or 35 days for PC.
NOTE: Request only one SSA-821-BK unless the beneficiary requests a replacement SSA-821-BK.
a. Attestation for SSA-821-BK
For attestation, take these actions:
use the attestation script outlined in Alternative Signature methods - GN 00201.015F;
complete form SSA-821-BK per DI 10505.035D in this section;
enter “ATTEST” along with the office code and name of the interviewer beneath the penalty clause in the block provided for “Signature of claimant, Beneficiary or Representative;”
document the eWork development worksheet with an “ATTEST” issue and enter the receipt date;
scan form SSA-821-BK into eView or NDRed; and
give or mail the claimant a attestation cover notice generated from the document processing system (DPS) and a copy of form SSA-821-BK.
NOTE: Work CDR attestation applies only when development is done using the eWork development worksheet.
b. Wet signatures
For wet signatures, take these actions:
NOTE: If the FO receives an SSA-821-BK for a work CDR under PC jurisdiction, fax form SSA-821-BK into paperless by using the barcode OTHER-Post Entitlement, and add the remark “WCDR pending in PC jurisdiction.”. For more information on routing work CDR documentation, refer to DI 13010.026B.
D. How to complete form SSA-821-BK (Work Activity Report – Employee)
1. Cover notice
The cover notice must remain attached to form SSA-821-BK. The notice provides the public with information about:
why we are requesting work information;
when we expect the claimant to return the form; and
the employer information we have in our records.
In addition, the cover notice provides referral information and advises the claimant or beneficiary to read the mandatory enclosed pamphlet, “Working While Disabled-How We Can Help.” Be sure to include this publication when you mail or give form SSA-821-BK to the claimant or beneficiary.
2. Section: Identification - To Be Completed by SSA
Complete as follows:
enter name(s) and SSN(s) in the appropriate boxes;
check appropriate “Blind” or “Not Blind” box;
display claim number and beneficiary identification code (BIC); and
insert appropriate work development date (i.e., alleged onset date, date of onset, date of entitlement, or last determination date).
3. Section: Information - To Be Answered By Person Applying For or Receiving Benefits
Check whether there was employment income or wages. If there was no work activity since the date in the identification section, but you have reported earnings, check “no.” If you check “no”, you must answer question 2, otherwise, skip to question 3.
Capture information about income that does not represent work activity. Check the type of payment received, the name and address of the payer, and the amount paid.
Questions 3A - 3C
eWork propagates employer information for you. If the claimant or beneficiary is manually completing this form, make sure he or she provides sufficient information for you to evaluate the work activity.
Determine if the claimant or beneficiary received any other payment(s) or benefit(s), in addition to his or her regular pay from the employer. If you check “no,” go to Question 5. If “yes,” check all that apply.
Capture information about possible subsidy. Check for any additional help or special conditions that may apply. For more information on subsidy, see DI 10505.010.
Questions 6A - 6B
Check for any possibility of an (UWA). For more information on UWA, see DI 11010.145.
Capture information on possible impairment-related work expenses (IRWE). Describe any items or services that the claimant or beneficiary spent his or her money on that relates to his or her physical or mental conditions. For more information on IRWE, see DI 10520.001.
4. Section: Remarks
Document any additional information that the claimant or beneficiary did not have space for in other parts of form SSA-821-BK. Do not use this section to document your SGA rationale.
5. Section: Signature
Take the following actions:
Inform the claimant or beneficiary that by attesting this form they are authorizing any employer, agency, or other organization to disclose information about their physical and mental conditions, or their work to SSA, or the State Agency that may determine their entitlement to disability benefits;
You may take a signature proxy on form SSA-821-BK during an initial claim or when completing a work CDR using the eWork development worksheet. For more information on alternative signature requirements, see GN 00201.015 or DI 81010.120; and
If a third party refuses to sign, document the form with “Refused to sign.” Also note the source of the information, and if possible, the reason for the refusal.
E. Diary to control the return of form SSA-821-BK
1. FO instructions
a. Initial Claims:
Document a 15-day diary issue date on the development worksheet (DW01) in the Modernized Claims System (MCS) or Modernized Supplemental Security Income Claims System (MSSICS) for initial SSI disability claims.
b. Post Entitlement (PE):
eWork establishes a 15-day diary issue date on the eWork development worksheet. If you cannot use eWork, establish the issue on the CDR development worksheet (CDRW) of the Disability Control File (DCF).
NOTE: Request only one SSA-821-BK unless the beneficiary requests a replacement SSA-821-BK. You cannot use The Work Number unless you have a recently signed/attested SSA-821-BK (12 months or less) or a signed form SSA-8510. The SSA-8240 and the response captured in Wage and Employment Authorization (WEIA) are not approved authorizations for The Work Number.
2. PC instructions
Route the paperless action control record (ACR) to the paperless diary-holding file (DHF) with a 35-day follow-up date.
NOTE: If the beneficiary is homeless, alleges a mental impairment, or the evidence suggests a mental impairment, try to identify a third party that can assist, if possible.
F. When the claimant or beneficiary returns form SSA-821-BK
1. Updating diary controls
FOs and PCs take these actions:
FOs: Receipt in and update any outstanding diary controls in MCS/MSSICS, the DCF, or eWork, as appropriate; and
PCs: Cancel any outstanding follow-up controls in paperless, the DCF, and eWork.
2. SSA-821-BK review
Review form SSA-821-BK to make sure the claimant answered all pertinent questions.
Determine if verification of monthly earnings is needed. If so, or if the beneficiary does not return form SSA-821-BK, follow the development steps outlined in DI 10505.005C for post entitlement and DI 10505.005D for initial claims, which ever one applies.
Determine if verification of work incentive information is needed. If so, follow DI 10505.010 and DI 10520.025 to verify and document subsidies and IRWE. Follow procedure in DI 10505.005.
G. When to complete form SSA-823 (Report of SGA Determination - For SSA Use Only)
You must complete form SSA-823 in all initial claim determinations that require an SSA-820-BK or SSA-821-BK. Complete the forms prior to sending to DDS. In PE situations, you may complete the form if a rationale is necessary to document your decision considering subsidy, IRWE, or UWA issues. If eWork sufficiently documents all issues, you are not required to complete form SSA-823. If you are not using eWork, completion of the SSA-823 is mandatory. You are not required to complete form SSA-823 for work activity that is “clearly not SGA”. For information on documenting clearly not SGA cases, see DI 10505.003.
NOTE: For initial claims with an allegation of statutory blindness, see DI 11010.170.
H. How to complete form SSA-823 (Report of SGA Determination - For SSA Use Only)
1. Section: Identification
Take the following actions:
complete the name of the claimant or beneficiary, and his or her own SSN;
determine if blindness applies, and check the appropriate box; and
complete the claim number and the beneficiary identification code (BIC).
2. Section: Instructions
Read the instructions carefully, and make the appropriate determination based on case circumstances.
3. Section: Initial Claim
Check any initial claims considerations that apply to either a Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) claim. If any considerations apply, explain your rationale in 2.C. on form SSA-823.
Make the SGA determination by marking either “A” or “B”. If you developed for subsidies, special conditions, UWAs, or IRWEs, mark “C,” and explain your rationale. Otherwise, you do not have to complete “C.”
4. Section: Continuing Disability Review/Post-Entitlement (CDR/PE)
Check any continuing disability considerations that apply to the SSDI claim. If any considerations apply, explain your rationale in 2C.
Make the SGA determination, completing A or B, if subsidies, special conditions, UWA, or IRWE exist, and explain your rationale in C.
5. Section: Signature and Date
Mark the basis of the SGA determination in the appropriate check box. Sign, date, and write your component code and telephone number.
DI 10505.000 Evaluation and Development of Employment - Table of Contents
DI 13010.025 Field Office (FO) Responsibilities in Work Continuing Disability Reviews (CDRs)
DI 81010.090 Faxing Documents into the Certified Electronic Folder (CEF) Using Barcodes
DI 81010.120 Using Form Attestation for Work Activity Reports
DI 81010.140 Processing Field Office (FO) Determinations
GN 00201.015 Alternative Signature Methods
SM 00344.001 Detail Earnings Query (DEQY) Overview
OS 15025.010 SSA-821-BK, Work Activity Report – Employee