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Form approved omb 0960 0578 2009

Form approved omb 0960 0578 2009-2026

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The document is a Work History Report from the Social Security Administration, specifically Form SSA-3369-BK. It collects detailed information about an individual's work history over the past 15 years, including job titles, types of businesses, dates worked, pay rates, job descriptions, and physical demands of each job. The report is intended to assist in evaluating the individual's eligibility for disability benefits.

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Click ‘Get Form’ to open it in the editor.
Begin with Section 1, where you will enter your personal information. Fill in your name, Social Security number, and daytime telephone number. Ensure accuracy as this information is crucial for processing.
Move to Section 2, which requires details about your work history. List all jobs held in the last 15 years. For each job, provide the title, type of business, and dates worked. Use the provided fields to estimate hours and pay.
For each job listed, describe your daily responsibilities and any equipment used. This section helps clarify your work experience related to your disability claim.
Complete Section 3 by adding any additional remarks or information that could not fit in previous sections. Don’t forget to include your name and date at the bottom of this page.

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Versions	Form popularity	Fillable & printable
2014	4.9 Satisfied (393 Votes)
2011	4.2 Satisfied (67 Votes)
2009	4.2 Satisfied (36 Votes)
2008	4 Satisfied (34 Votes)
2005	4 Satisfied (28 Votes)
2003	4 Satisfied (27 Votes)

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