TN 11 (06-04)
DI 11005.025 Completing the SSA-3369
The SSA-3369 is used to supplement the SSA-3368 with detailed information about jobs that the claimant has performed in addition to the usual job.
1. When to Complete
The FO must complete an SSA-3369 only for someone who:
Is homeless; or
Will be difficult to contact by telephone; or
Will be unavailable for contact (e.g., may be on an extended trip).
2. When Not to Complete
The FO does not complete the SSA-3369 when:
SSA-3368 curtailment is applicable (see DI 11005.020).
The claimant had only one job in the 15-year period before becoming unable to work because of his or her illnesses, injuries, or conditions.
1. Section 1 -- Information About The Disabled Person
Record basic identifying information about the claimant (his/her name, Social Security Number).
Indicate the telephone number where the claimant can be reached, or the number where a message can be left.
2. Section 2 -- Information About Your Work
List information about all the jobs the claimant had in the last 15 years before becoming unable to work because of his or her illnesses, injuries, or conditions. Record the type job performed (job title), not the individual employers the claimant had. For example, if the claimant was a waiter at three different restaurants from 1990 to 1993, only one entry in Section 2 is necessary for that job title (if the job duties and physical/mental requirements were the same).
If the claimant had a marginal education (i.e., sixth grade or less) and performed only arduous, unskilled physical labor for 35 years or more, list all the jobs the claimant has had since beginning to work.
Enter specific information from the claimant about the jobs listed in Section 2 (Information About Your Work). Include information about:
The use of machines, tools, or other equipment.
How much bending, sitting, walking, or related activity was required.
Whether the claimant had to do any writing.
Basic job duties.
Other descriptive data providing a complete picture of the nature and duties of the job performed.
3. Section 3 --Remarks
Use Section 3 for the claimant to continue the work history or give any other information about past relevant work.
NOTE: If there is insufficient space on the form to include all jobs, use an additional SSA-3369(s). When more than one form is used, complete ONLY the claimant's name and SSN on the front page of all additional forms. Mark “Supplementary” at the top of the additional form(s). Draw a line through any section of the form that is not being completed