SSA-3369-BK 2009 free printable template

FORM APPROVED OMB NO. 0960-0578 SOCIAL SECURITY ADMINISTRATION WORK HISTORY REPORT SECTION 1 - INFORMATION ABOUT THE DISABLED PERSON A. Name First Middle Initial Last JENNIFER DELMAR LEWIS XXX-XX-7002 C. DAYTIME TELEPHONE NUMBER If you have no number where you can be reached give us a daytime number where we can leave a message for you. u Your Number u Message Number u None Area Code Number List all of the jobs that you had in the 15 years before you became unable to work because of your...

How to fill out SSA-3369-BK

How to fill out SSA-3369-BK

1. Obtain Form SSA-3369-BK from the Social Security Administration's website or local office.
2. Read the instructions carefully to understand the purpose of the form.
3. Fill out the individual's personal information at the beginning of the form, including name, address, and social security number.
4. Provide details about the individual's medical condition in the relevant sections.
5. Include names and contact information for all healthcare providers who have treated the individual.
6. Describe the individual's daily activities and how their condition affects their ability to work.
7. Review the completed form for accuracy and completeness.
8. Sign and date the form before submitting it to the appropriate Social Security office.

Who needs SSA-3369-BK?

1. Individuals applying for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) who are required to provide information about their mental or physical impairments.

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 collect information about an individual's work history and medical conditions related to their disability claim.

Who is required to file SSA-3369-BK?

Individuals who are applying for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) and need to provide information on their work history and medical conditions are required to file SSA-3369-BK.

How to fill out SSA-3369-BK?

To fill out SSA-3369-BK, individuals should provide accurate details about their past jobs, medical conditions, treatment history, and any relevant work limitations. It's important to follow the instructions carefully and complete all sections.

What is the purpose of SSA-3369-BK?

The purpose of SSA-3369-BK is to gather comprehensive information about an applicant's work experience and health issues in order to assess their eligibility for disability benefits.

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

SSA-3369-BK requires reporting information such as job titles, job duties, dates of employment, medical diagnoses, treatment history, and how medical conditions affect the ability to work.