SSA-3369-BK 2003 free printable template

Job Title Type of Business Dates Worked Month Year From To FORM SSA-3369-BK 12-2003 EF 12-2003 Destroy Prior Editions PAGE 1 Your Number Area Code Give us more information about Job No. 1 listed on Page 1. WORK HISTORY REPORT-Form SSA-3369-BK READ ALL OF THIS INFORMATION BEFORE YOU BEGIN COMPLETING 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...

How to fill out SSA-3369-BK

How to fill out SSA-3369-BK

1. Begin by obtaining the SSA-3369-BK form from the Social Security Administration website or your local office.
2. Fill in your personal information at the top including your name, Social Security number, and contact information.
3. Provide details about your work history, including the names and addresses of employers, job titles, and dates of employment.
4. Describe the duties and tasks you performed in each job listed.
5. Indicate any physical or mental limitations that prevent you from doing the work you previously did.
6. If applicable, list any other jobs that you believe you could perform, along with the reasons you believe they are achievable.
7. Complete the section about your medical conditions, including details about treatments and healthcare providers.
8. Review the completed form for accuracy and clarity.
9. Sign and date the form at the bottom.

Who needs SSA-3369-BK?

1. Individuals applying for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) who have work history and need to detail their limitations.

People Also Ask about

What is the pain questionnaire for Social Security disability?

The pain questionnaire is asking how pain limits the individual and how often they are experiencing the pain. This form will also ask about any medications they are taking and any side effects the medication is causing. Side effects from medications can also help you show how else your client is limited.

How to answer questions on a function report for disability?

How to Fill Out an Adult Function Report for Disability (7 Tips) Answer Every Question and Be Honest! Answer Only the Questions Being Asked. Give as Much Detail as You Can. Be Consistent (Some Questions Overlap) Be Specific on Question 5 of the Function Report. Don't Limit Your Answers to the Space on the Form.

Why did I receive a SSA 3373 BK?

DDS requires the completion of the SSA-3373 when they do not have enough information in the medical records to determine whether the person's impairments are keeping them from being able to function in a work environment.

How do you answer a disability questionnaire?

How to Answer Disability Questionnaires Write clearly and legibly. Avoid erasures as much as possible. Do not leave any section of the form blank (unless otherwise specified). Give consistent answers. Answer the questions truthfully. Follow the instructions on the form.

When is pain considered a disability?

If you have a chronic pain condition that renders you incapable of working, you may qualify for Social Security disability (SSD) benefits. However, qualifying can be a challenge because the Social Security Administration has a strict definition of what it means to be disabled.

What is form SSA 3369 BK?

The Work History Report (SSA-3369) helps Disability Determination Services (DDS) to obtain detailed vocational information about the jobs the applicant held in the 15 years prior to becoming unable to work due to his or her illnesses, injuries, or conditions.

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What is SSA-3369-BK?

SSA-3369-BK is a form used by the Social Security Administration (SSA) to assess an individual's work history and the impact of their medical conditions on their ability to work.

Who is required to file SSA-3369-BK?

Individuals who are applying for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) benefits are required to file SSA-3369-BK.

How to fill out SSA-3369-BK?

To fill out SSA-3369-BK, provide detailed information about your work history, including job titles, duties, and how your medical conditions affect your ability to perform these jobs.

What is the purpose of SSA-3369-BK?

The purpose of SSA-3369-BK is to collect necessary information about the applicant's work history and assess their functional limitations due to disabilities for the purpose of determining eligibility for benefits.

What information must be reported on SSA-3369-BK?

The form requires information about your past work, including job titles, dates of employment, earnings, and descriptions of your job duties, as well as details about your medical conditions.