READ ALL OF THIS INFORMATION BEFORE
YOU BEGIN COMPLETING THIS FORM
WORK HISTORY REPORT-Form SSA-3369-BK
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
WorkHistoryReport--FormSSA-3369-BKHOW TO COMPLETE 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.
• 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
REMEMBER TO GIVE US THE NAME AND ADDRESS OF THE PERSON
COMPLETING THIS FORM ON PAGE 8
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.
Privacy Act and Paperwork Reduction Act Statements
The Social Security Administration