TN 2 (08-17)
DI 22515.030 Use of Form SSA-3369-BK (Work History Report)
A. Vocational Development
1. Development by Telephone or Direct Contact
If you decide you need to obtain detailed vocational information (in addition to that shown on Form SSA-3368-BK (Disability Report – Adult) for the claimant's usual job), proceed as follows:
If you obtain vocational information 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.
If documentation of other past work is necessary, fully develop each successive job until you identify a relevant job the claimant can perform.
2. Development by Mail
If you mail the SSA-3369-BK to the claimant, ask the claimant to 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 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 DDS or FO is to complete the identifying information in every case in which completion of the SSA-3369-BKhttp://inform.ssahost.ba.ssa.gov/pdfs/ssa3368.pdf 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 lifetime commitment profile, document sufficient vocational evidence to develop for these profiles.
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-BKhttp://inform.ssahost.ba.ssa.gov/pdfs/ssa3368.pdf has subsections for describing up to 6 past jobs.
Each subsection asks for information about:
the rate of pay and hours of work per day and per week.
the use of machines, tools or other equipment.
amount of bending, sitting, walking, or related activity.
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.
NOTE: If the job duties described do not match up with the claimant’s stated exertional demands, you will need to resolve the issue with the claimant if information about a particular job is material to the determination.
EXAMPLE: The claimant stated he spent all day collecting trash from individual offices and then dumping that trash into a large dumpster at the end of the day. However, he also stated he performed no lifting as part of his job duties. You would need to clarify this information if the claimant’s ability to do that job was material to the determination. Unless someone accompanied the claimant and lifted the trash for the claimant from the individual containers and into the dumpster at the end of the day, lifting was part of his job duties.
IMPORTANT: In the SSA-3368-BK item 6D, we do not require that combined hours spent climbing, stooping, kneeling, crouching, crawling match up to the numbers of hours the claimant worked per day. We also do not require that combined hours handling, writing, typing, handling small objects or reaching match up to the numbers of hours the claimant worked per day. There may be time during the day that the claimant does none of those activities.
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: We have removed the signature and witness sections from the SSA-3369-BK, as a step toward the paperless process. In place of the signature section, the SSA-3369-BK 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).
5. DDS Processing of Form 3369-BK
Complete parts A, B, and C. This information should be available from the SSA-3368-BK or other file documents.
6. 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 is adequately completed.
7. Section 2, Pages 2-7
Obtain this information for every job other than the claimant's usual job (provided 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
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.
8. DDS Review of Form SSA-3369-BK
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 the claimant has not overlooked or omitted an item or question.)
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, document any additional information in the Claim Communications section of the electronic Claims Analysis Tool (eCAT).
Include a cross reference to the information by date for identification on the SSA-3369-BK. Indicate which item or question number(s) you are modifying or supplementing.
EXCEPTION: For eCAT exclusions, document your findings on SSA-5002 (Report of Contact), or the Case Development Summary Worksheet as described in DI 20503.001.
9. 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.
10. Followup Procedure
If the claimant: