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.

Instructions and Help about SSA-3369-BK

This is the work history report provided to claimants who have applied for Social Security disability benefits this form does come directly from the Social Security office it is not sent to you from your attorney it is sent to you from the Social Security office in order for them to gather all the information they need in order to make a decision on whether you qualify for disability benefits and if you will be awarded obviously the more work you have the more work credits you have which will affect the award amount we often have clients that ask us if they have to fill this out or how much of it they have to fill out do they really have to go back 15 years and the answer to those questions or yes to all of them you do need to fill this out your attorney cannot do this for you because you know your history the best however at least here at the Kali law firm where he'll be happy to help you walk you through the form and if you just physically cannot write or tie then of course we would help you with it if you don't have someone at home that can do it for you the first page section one just asks for your name social security number and daytime telephone number where you can be reached any time you need to put all this information in because this will associate it to your disability application section two is information about your work so the first portion it does asks to list all the jobs that you've had in the last 15 years you need to list everything that you've had what your job was what type of business it and the days that you work as close to as accurate as possible obviously 15 years ago it's hard to remember exact dates and that's fine don't worry about it just keep it as you know accurate as possible once you've listed just all your jobs and the next several pages each pages for each job and is asking for very specific information it's asking for your rate of pay whether it's hourly or salary how much you worked how many days per week that you worked and then a description of the job itself what did you do all day they're going to get a sense of just your type what type of work that you're qualified to do you were healthy and then ultimately based on this and then Medical has history and other things they'll be able to determine if you're able to continue doing this sort of job this is why you've hired an attorney we do the argument for you defense for you, but we do need you to fill out this information after you've given a description of the job you will just answer the remaining questions give them an idea of how often or how what the frequency of how much you did something like walking or standing were you on your feel a day did you have to crawl or crouched let's say you're someone that has a shoulder injury, and you can no longer lift things, but that's what all your work history is that's good supporting your case you want to make sure you give them accurate information of how much you lifted during your jobs again this section...

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.