TN 14 (07-18)

A. Purpose of the work activity report

The field office (FO) and processing center (PC) use the form SSA-821-BK (Work Activity Report - Employee) to document work activity and work incentives prior to making a substantial gainful activity (SGA) determination for initial claims, appeals, and continuing disability review (CDR) cases. To document the SGA decision and rationale, use the form SSA-823 (Report of SGA Determination – For SSA Use Only).

Consider any applicable work incentives. If work incentives are involved, request needed work incentive documentation from the beneficiary/employer (DI 13010.001), and FO tickle for 15 days, payment center (PC) 35 days.

B. When to complete form SSA-821-BK

You must complete form SSA-821-BK for all work issue CDRs, EXRs, appeals, and initial applications involving employment:

• after the alleged onset date (AOD);

• after the potential onset date (POD) when the POD is earlier than the AOD;

• after the date the claimant alleges his or her impairment(s) first began to interfere with his or her ability to work;

• work activity within the CDR review period;

• after the controlling date in disabled widow(er)'s benefit (DWB) claims;

• any time in childhood disability benefit (CDB) claims;

• after the filing date in initial Supplemental Security Income (SSI) claims (for statutory blindness cases, see DI 11005.072B.2.); and

• for comparability determinations in blindness claims after age 55 (see DI 13010.135).

NOTE: You do not have to complete a form SSA-821-BK in “clearly not SGA” cases. For more information on how to evaluate and process clearly not SGA cases, see DI 10505.003.

C. How to access and save form SSA-821-BK

1. Initial claims for certified electronic folder (CEF) cases

Access form SSA-821-BK through Electronic Disability Collect System (EDCS). Use the following instructions to process CEF cases:

• complete form SSA-821-BK per DI 10505.035D in this section;

• store form SSA-821-BK in eView; and

• check eView for legibility.

2. Initial claims for CEF exclusions

Any claim excluded from electronic processing results in a paper folder. If you are creating a form SSA-821-BK for a CEF exclusion or limitation case:

• access form SSA-821-BK through UniForms;

• fax form SSA-821-BK into the Non-Disability Repository for Evidentiary Documents (NDRed); and

• insert it into the blue section of the Modular Disability Folder (MDF).

NOTE: It is extremely important that form SSA-821-BK and any related documents are available to the DDS. Before transferring any case to the DDS, the FO must always check the certified claims file record management system (CFRMS) for any form SSA-821-BK and related documents not stored in the paper folder. If there are CFRMS forms that are not in the MDF, print and place them in the MDF prior to forwarding to the DDS.

3. Work CDR cases

Prepare form SSA-821-BK as generated by eWork for all work CDR cases. Initiate work CDR by attempting telephone contact with the beneficiary. If successful, complete the SSA-821 and sign using attestation.

If unsuccessful in reaching the beneficiary by telephone, initiate a work CDR by mailing an SSA-821-BK, and tickle the case for 15 days for the FO, or 35 days for PC.

NOTE: Request only one SSA-821-BK unless the beneficiary requests a replacement SSA-821-BK.

a. Attestation for SSA-821-BK

For attestation, take these actions:

• use the attestation script outlined in Alternative Signature methods - GN 00201.015F;

• complete form SSA-821-BK per DI 10505.035D in this section;

• enter “ATTEST” along with the office code and name of the interviewer beneath the penalty clause in the block provided for “Signature of claimant, Beneficiary or Representative;”

• document the eWork development worksheet with an “ATTEST” issue and enter the receipt date;

• scan form SSA-821-BK into eView or NDRed; and

• give or mail the claimant a attestation cover notice generated from the document processing system (DPS) and a copy of form SSA-821-BK.

NOTE: Work CDR attestation applies only when development is done using the eWork development worksheet.

b. Wet signatures

For wet signatures, take these actions:

• scan the form into eView or NDRed; and

• receipt in the eWork issue.

NOTE: If the FO receives an SSA-821-BK for a work CDR under PC jurisdiction, fax form SSA-821-BK into paperless by using the barcode OTHER-Post Entitlement, and add the remark “WCDR pending in PC jurisdiction.” For more information on routing work CDR documentation, refer to DI 13010.026B.

D. How to complete form SSA-821-BK (Work Activity Report – Employee)

1. Cover notice

The cover notice must remain attached to form SSA-821-BK. The notice provides the public with information about:

• why we are requesting work information;

• when we expect the claimant to return the form; and

• the employer information we have in our records.

In addition, the cover notice provides referral information and advises the claimant or beneficiary to read the mandatory enclosed pamphlet, “Working While Disabled-How We Can Help.” Be sure to include this publication when you mail or give form SSA-821-BK to the claimant or beneficiary.

2. Section: Identification - To Be Completed by SSA

Complete as follows:

• enter name(s) and SSN(s) in the appropriate boxes;

• check appropriate “Blind” or “Not Blind” box;

• display claim number and beneficiary identification code (BIC); and

• insert appropriate work development date (i.e., alleged onset date, date of onset, date of entitlement, or last determination date).

3. Section: Information - To Be Answered By Person Applying For or Receiving Benefits

a. Question 1

Check whether there was employment income or wages. If there was no work activity since the date in the identification section, but you have reported earnings, check “no.” If you check “no”, you must answer question 2, otherwise, skip to question 3.

b. Question 2

Capture information about income that does not represent work activity. Check the type of payment received, the name and address of the payer, and the amount paid.

c. Questions 3A - 3C

eWork propagates employer information for you. If the claimant or beneficiary is manually completing this form, make sure he or she provides sufficient information for you to evaluate the work activity.

d. Question 4

Determine if the claimant or beneficiary received any other payment(s) or benefit(s), in addition to his or her regular pay from the employer. If you check “no,” go to Question 5. If “yes,” check all that apply.

e. Question 5

Capture information about possible subsidy. Check for any additional help or special conditions that may apply. For more information on subsidy, see DI 10505.010.

f. Questions 6A - 6B

Check for any possibility of an unsuccessful work attempt (UWA). For more information on UWA, see DI 11010.145.

g. Question 7

Capture information on possible impairment-related work expenses (IRWE). Describe any items or services that the claimant or beneficiary spent his or her money on that relates to his or her physical or mental conditions. For more information on IRWE, see DI 10520.001.

4. Section: Remarks

Document any additional information that the claimant or beneficiary did not have space for in other parts of form SSA-821-BK. Do not use this section to document your SGA rationale.

5. Section: Signature

Take the following actions:

• Inform the claimant or beneficiary that by attesting this form they are authorizing any employer, agency, or other organization to disclose information about their physical and mental conditions, or their work to SSA, or the State Agency that may determine their entitlement to disability benefits;

• You may take a signature proxy on form SSA-821-BK during an initial claim or when completing a work CDR using the eWork development worksheet. For more information on alternative signature requirements, see GN 00201.015 or DI 81010.120; and

• If a third party refuses to sign, document the form with “Refused to sign.” Also note the source of the information, and if possible, the reason for the refusal.

E. Diary for the return of form SSA-821-BK

1. FO instructions

a. Initial Claims:

Establish a 15-day diary on the development worksheet (DW01) in the Modernized Claims System (MCS) or Modernized Supplemental Security Income Claims System (MSSICS). If the claimant does not return the SSA-821-BK and there is enough information in the file to make an SGA decision (including the date SGA stopped), document the SGA decision, the date SGA stopped, and the claimant’s failure to submit the SSA-821-BK on the SSA-823 and in the EDCS 3367.

If there is not enough information in the file to make an SGA decision, follow the procedures found in DI 10505.005.D. If you can make an SGA decision after following the procedures in POMS DI 10505.005.D:

• Deny the claim if the claimant is still engaging in SGA.

• If SGA has stopped, transfer the claim to DDS with a note in the SSA-823 documenting your efforts to obtain cooperation. Document the date the claimant last performed SGA on the SSA-823 and the potential onset data on the SSA-3367.

Once you have followed the steps in DI 10505.005.D. if you still do not have enough information to make an SGA determination, follow the Failure to Submit Essential Evidence procedure found in GN 01010.410 for Title II claims and the instructions found in SI 00601.110 for Title XVI claims.

• If the claimant does not respond, and no other evidence is available, send out a closeout letter and deny the claim for insufficient evidence after the closeout period expires.

b. Post Entitlement (PE):

eWork automatically establishes a 15-day diary on the development worksheet when you print the SSA-821-BK. If you cannot use eWork, establish the issue on the CDR development worksheet (CDRW) of the Disability Control File (DCF).

NOTE: Request only one SSA-821-BK unless the beneficiary requests a replacement SSA-821-BK. You cannot use The Work Number (an employment verification system) unless you have a recently (within 12 months) signed/attested SSA-821-BK or a signed form SSA-8510. The SSA-8240 and the response captured in Wage and Employment Information Authorization (WEIA) are not approved authorizations for The Work Number.

If the beneficiary does not return the SSA-821-BK, make a decision based on the information you have in the file.

2. PC instructions

Route the paperless action control record (ACR) to the paperless diary-holding file (DHF) with a 35-day follow-up date.

NOTE: If the beneficiary is homeless, alleges a mental impairment, or the evidence suggests a mental impairment, try to identify a third party who can possibly assist.

If the beneficiary does not return the SSA-821-BK, make a decision based on the information you have in the file.

F. When the claimant or beneficiary returns form SSA-821-BK

1. Updating diary controls

FOs and PCs take these actions:

• FOs: Receipt in and update any outstanding diary controls in MCS/MSSICS, the DCF, or eWork, as appropriate; and

• PCs: Cancel any outstanding follow-up controls in paperless, the DCF, and eWork.

2. SSA-821-BK review

Review form SSA-821-BK to make sure the claimant or beneficiary answered all pertinent questions.

• Determine if verification of monthly earnings is needed. If so, or if the claimant or beneficiary does not return form SSA-821-BK, follow the development steps outlined in DI 10505.005C for post entitlement and DI 10505.005D for initial claims, whichever one applies.

• Determine if verification of work incentive information is needed. If so, follow DI 10505.010 and DI 10520.025 to verify and document subsidies and IRWE. Follow procedure in DI 10505.005.

G. When to complete form SSA-823 (Report of SGA Determination - For SSA Use Only)

You must complete form SSA-823 in all initial claim determinations that require an SSA-820-BK or SSA-821-BK. Complete the forms prior to sending the claim to DDS. In PE situations, you may complete the form if a rationale is necessary to document your decision considering subsidy, IRWE, or UWA issues. If eWork sufficiently documents all issues, you are not required to complete form SSA-823. If you are not using eWork, completion of the SSA-823 is mandatory. You are not required to complete form SSA-823 for work activity that is “clearly not SGA”. For information on documenting clearly not SGA cases, see DI 10505.003.

NOTE: For initial claims with an allegation of statutory blindness, see DI 11010.170.

H. How to complete form SSA-823 (Report of SGA Determination - For SSA Use Only)

1. Section: Identification

Take the following actions:

• complete the name of the claimant or beneficiary, and his or her own SSN;

• determine if blindness applies, and check the appropriate box; and

• complete the claim number and the beneficiary identification code (BIC).

2. Section: Instructions

Read the instructions carefully, and make the appropriate determination based on case circumstances.

3. Section: Initial Claim

a. Question 1

Check any initial claims considerations that apply to either a Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) claim. If any considerations apply, explain your rationale in 2.C. on form SSA-823.

b. Question 2

Make the SGA determination by marking either “A” or “B”. If you developed for subsidies, special conditions, UWAs, or IRWEs, mark “C,” and explain your rationale. Otherwise, you do not have to complete “C.”

4. Section: Continuing Disability Review/Post-Entitlement (CDR/PE)

a. Question 1

Check any continuing disability considerations that apply to the SSDI claim. If any considerations apply, explain your rationale in 2C.

b. Question 2

Make the SGA determination, completing A or B, if subsidies, special conditions, UWA, or IRWE exist, and explain your rationale in C.

5. Section: Signature and Date

Mark the basis of the SGA determination in the appropriate check box. Sign, date, and write your component code and telephone number.

I. References

• DI 10505.000 Evaluation and Development of Employment - Table of Contents

• DI 13010.025 Field Office (FO) Responsibilities in Work Continuing Disability Reviews (CDRs)

• DI 81010.090 Faxing Documents into the Certified Electronic Folder (CEF) Using Barcodes

• DI 81010.120 Using Form Attestation for Work Activity Reports

• DI 81010.140 Processing Field Office (FO) Determinations

• GN 00201.015 Alternative Signature Methods

• SM 00344.001 Detail Earnings Query (DEQY) Overview

• OS 15025.010 SSA-821-BK, Work Activity Report – Employee