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DI 22515.030: Use of Work History Report Form SSA-3369-BK

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  • Effective Dates: 08/22/2017 - Present
  • Effective Dates: 05/16/2018 - Present
  • TN 2 (08-17)
  • TN 4 (05-18)
  • DI 22515.030 Use of Form SSA-3369-BK (Work History Report)
  • DI 22515.030 Use of Work History Report Form SSA-3369-BK
  • A. Vocational Development
  • A. Vocational development
  • 1. Development by Telephone or Direct Contact
  • IMPORTANT: For title II claims with a date last insured or prescribed period in the past, ask the claimant to document each job held during the 15 years prior to the date last insured or the end of the prescribed period.
  • If you decide you need to obtain detailed vocational information (in addition to that shown on Form SSA-3368-BK (Disability Report – Adult) for the claimant's usual job), proceed as follows:
  • * If you obtain vocational information by phone or in person and documentation of the claimant's usual job supports a finding of ability to perform past relevant work, do not document other past work.
  • For an overview of vocational evidence development, see DI 22515.001.
  • 1. Telephone or direct contact development
  • When you need detailed vocational information (in addition to that shown on the SSA-3368-BK (Disability Report – Adult) for the claimant's described job), proceed as follows:
  • * If you obtain vocational information by phone or in person and documentation of the claimant's described job supports a finding of ability to perform past relevant work (PRW), do not document other past work. You can stop vocational development if the claimant has the ability to perform PRW. For detailed information about capacity for PRW, see
  • * DI 25005.020 Past Relevant Work (PRW) as the Claimant Performed It
  • * DI 25005.025 Past Relevant Work (PRW) as Generally Performed in the National Economy
  • * If documentation of other past work is necessary, fully develop each successive job until you identify a relevant job the claimant can perform.
  • 2. Development by Mail
  • 2. Mail development
  • If you mail the SSA-3369-BK to the claimant, ask the claimant to document each job held during the 15 years before becoming unable to work because of his or her illnesses, injuries or conditions. For title II claims with a date last insured or prescribed period in the past, ask the claimant to document each job held during the 15 years prior to the date last insured or the end of the prescribed period.
  • When you mail the SSA-3369-BK to the claimant, include a cover letter asking the claimant to document each job held during the 15 years before becoming unable to work because of his or her illnesses, injuries or conditions. You may print and send a partially completed SSA-3369-BK to assist the claimant. You may copy information from the SSA-3368 and paste it into an SSA-3369 to send a partially completed SSA-3369-BK to the claimant.
  • B. Description of Form
  • The “relevant period” is not always date of adjudication. You may advise the individual to address a specific period. For example, for title II claims with a date last insured or prescribed period in the past, ask the claimant to document each job held during the 15 years prior to the date last insured or the end of the prescribed period. For instructions on how to determine the relevant period for different types of claims, see DI 25001.001A.64.
  • 1. Section 1 (Information About the Disabled Person)
  • Claimants are generally not familiar with our forms or with the way we use the work description. If the claimant’s completion of the mailed SSA-3369-BK is insufficient, take necessary actions described in DI 22515.030D in this section.
  • The SSA-3369-BK includes space for identifying information. (Get this information from the SSA-3368-BK or other form in file.)
  • 3. Special medical-vocational profiles development
  • Gather vocational details early in the development process to determine if a claimant meets a special medical-vocational profile. For information on special medical-vocational profiles, see DI 25010.001.
  • NOTE: The DDS or FO is to complete the identifying information in every case in which completion of the SSA-3369-BKhttp://inform.ssahost.ba.ssa.gov/pdfs/ssa3368.pdf is required.
  • Be alert for information that shows:
  • * 35 years or more in unskilled arduous work with a marginal or less education (grade 6 or less) – arduous unskilled work profile;
  • * No relevant work, age 55 or older with a limited or less education (grade 11 or less) – no work experience profile; or
  • * 30 years or more in one job or field of work, age 60 or older with a limited or less education – lifetime commitment profile.
  • 2. Section 2 (Information About Your Work)
  • If the claimant potentially meets the arduous work or lifetime commitment profile, you will have to document the claimant’s work beyond the 15-year relevant period.
  • Page 1 of Section 2 provides space to list all the jobs the claimant had in the 15 years before becoming unable to work because of his or her illnesses, injuries, or conditions. It also provides space for the dates worked (month and year).
  • 4. Part-time work development
  • NOTE: If the claimant had a marginal education or less, and performed only arduous labor for 35 years or more, or the claimant could meet the lifetime commitment profile, document sufficient vocational evidence to develop for these profiles.
  • If the claimant has PRW that was part-time, and his or her RFC reflects an inability to sustain a 40-hour workweek, pursue targeted development about the work. This permits a function-by-function comparison of the claimant’s RFC and the requirements of his or her relevant part time work. For more information of part-time work that is substantial gainful activity (SGA), see DI 24510.057B.5.
  • 3. Section 2, Pages 2-7
  • B. Description of form
  • Pages 2-7 contain identical subsections. Each subsection asks specific information about the jobs listed on page 1 of Section 2 of the SSA-3369-BK, or Section 6 of the SSA-3368-BK. The SSA-3369-BKhttp://inform.ssahost.ba.ssa.gov/pdfs/ssa3368.pdf has subsections for describing up to 6 past jobs.
  • 1. Information about the disabled person (Section 1)
  • Each subsection asks for information about:
  • * the rate of pay and hours of work per day and per week.
  • * the use of machines, tools or other equipment.
  • * amount of bending, sitting, walking, or related activity.
  • * whether the claimant had to do any writing.
  • * basic job duties.
  • * other descriptive data providing a complete picture of the nature and duties of the job performed.
  • The SSA-3369-BK includes space for identifying information. (Get this information from the SSA-3368-BK or other form in file.)
  • NOTE: The Disability Determination Services (DDS) or the field office (FO) will complete the identifying information in every case in which completion of the SSA-3369-BK is required. For more information about completing the SSA-3369-BK see,
  • * DI 11005.025 Completing the SSA-3369
  • * DI 22515.003 Developing Sufficient Vocational Evidence
  • NOTE: If the job duties described do not match up with the claimant’s stated exertional demands, you will need to resolve the issue with the claimant if information about a particular job is material to the determination.
  • 2. Information about claimant work (Section 2)
  • EXAMPLE: The claimant stated he spent all day collecting trash from individual offices and then dumping that trash into a large dumpster at the end of the day. However, he also stated he performed no lifting as part of his job duties. You would need to clarify this information if the claimant’s ability to do that job was material to the determination. Unless someone accompanied the claimant and lifted the trash for the claimant from the individual containers and into the dumpster at the end of the day, lifting was part of his job duties.
  • List all the jobs the claimant had in the 15 years before becoming unable to work because of his or her illnesses, injuries, or conditions. Section 2 provides space for the dates worked (From MM/YY, To MM/YY).
  • IMPORTANT: In the SSA-3368-BK item 6D, we do not require that combined hours spent climbing, stooping, kneeling, crouching, crawling match up to the numbers of hours the claimant worked per day. We also do not require that combined hours handling, writing, typing, handling small objects or reaching match up to the numbers of hours the claimant worked per day. There may be time during the day that the claimant does none of those activities.
  • 3. Subsections for each job (Section 2)
  • 4. Section 3 (Remarks)
  • In each subsection, provide specific information about the jobs listed on the SSA-3369-BK, or Section 6 of the SSA-3368-BK. Section 2 provides space for describing up to six past jobs. Each subsection asks specific information about:
  • * rate of pay and hours of work per day and per week;
  • * basic job duties;
  • * use of machines, tools or other equipment;
  • * use of technical knowledge or skills;
  • * whether the claimant had to do any writing, or complete reports;
  • * amount of bending, sitting, walking, or related activity;
  • * amount, frequency, and duration of lifting, carrying, pushing or pulling;
  • * other descriptive data providing a complete picture of the nature and duties of the job performed; and
  • * any supervisory or lead worker duties.
  • Section 3 provides space for the claimant to continue his/her history or to give any other information about his/her past relevant work.
  • 4. Remarks (Section 3)
  • NOTE: We have removed the signature and witness sections from the SSA-3369-BK, as a step toward the paperless process. In place of the signature section, the SSA-3369-BK provides space for the claimant or the person who completes the form for the claimant to print his or her name, address, date, and Email address (optional).
  • Section 3 provides space for the claimant to continue his or her history or to give any other information about his or her PRW. It asks for the name of the person completing the form, if it is not the claimant.
  • 5. DDS Processing of Form 3369-BK
  • C. DDS Processing of the 3369-BK
  • Section 1
  • For instructions on how to complete the SSA-3369-BK, see DI 11005.025.
  • 1. Section 1
  • Complete parts A, B, and C. This information should be available from the SSA-3368-BK or other file documents.
  • 6. Section 2, Page 1
  • 2. Section 2
  • Page 1
  • Do not ask the claimant to complete the work history chart on page 1 of section 2 if Section 6.A of the SSA-3368-BK is adequately completed.
  • You do not need to ask the claimant to complete the work history chart on page 1 of section 2 if Section 6.A of the SSA-3368-BK is adequately completed. You may copy the information from the SSA-3368-BK into an SSA-3369-BK that you mail to the claimant.
  • 7. Section 2, Pages 2-7
  • Pages 2-7
  • Obtain this information for every job other than the claimant's usual job (provided the claimant's usual job is adequately described on the SSA-3368-BK).
  • Obtain detailed information for every job that is not adequately described elsewhere (such as on the SSA-3368-BK). If you request an SSA-3369 by mail and you already have adequate description of the usual job, you may advise the claimant that he or she need not repeat that description.
  • If there is insufficient space on the form to do this, use one or more additional
  • If there is insufficient space on the form to describe the claimant’s work, use one or more additional SSA-3369-BKs or other continuation sheet.
  • SSA-3369-BKs.
  • NOTE: If more than, one SSA-3369-BK is used, complete identifying information in Section 1, and as much of Section 2 as is necessary. Mark the second form “Supplementary” at the top. If a different continuation sheet is used, identify it clearly.
  • NOTE: If more than one SSA-3369-BK is used, complete Section 1, and as much of Section 2 as is necessary. Mark the second form “Supplementary” at the top.
  • 3. Section 3 – Remarks
  • 8. DDS Review of Form SSA-3369-BK
  • Provides space for the claimant to give any other information about his or her PRW.
  • Review the SSA-3369-BK by checking that all items and questions requiring a response are completed. (Even if the claimant is unable to give more than a nonspecific answer, such as, “I don't know” or “unknown” to a particular question or item involved, this assures that the claimant has not overlooked or omitted an item or question.)
  • 4. Person completing the form
  • After reviewing the SSA-3369-BK, telephone the claimant for further information, if needed.
  • Request that the claimant or the person completing the form for the claimant print his or her name, address, date, and email address (optional) in the spaces provided in Section 3 of the form.
  • If the SSA-3369-BK in file is unsigned, obtain the necessary additional information, and include it in the file without further review by the claimant.
  • 5. Follow up procedure
  • If a signed SSA-3369-BK is in file, document any additional information in the Claim Communications section of the electronic Claims Analysis Tool (eCAT).
  • If the claimant:
  • * Refuses to cooperate, see Refusal to Cooperate With Requests to the Claimant for Evidence or Action DI 23007.004.
  • * Fails to cooperate, see Failure to Cooperate With Requests to the Claimant for Evidence or Action DI 23007.005.
  • Include a cross reference to the information by date for identification on the SSA-3369-BK. Indicate which item or question number(s) you are modifying or supplementing.
  • D. DDS review of the SSA-3369-BK
  • EXCEPTION: For eCAT exclusions, document your findings on SSA-5002 (Report of Contact), or the Case Development Summary Worksheet as described in DI 20503.001.
  • Review the SSA-3369-BK by checking that all items and questions requiring a response are completed. Even if the claimant is unable to give more than a nonspecific answer, such as, “I don't know” or “unknown” to a particular question or item involved, this assures that the claimant has not overlooked or omitted an item or question.)
  • 9. Person Completing the Form
  • After reviewing the SSA-3369-BK, telephone the claimant for further information, if needed. When you obtain additional information about a job, identify which job and which information you are modifying or supplementing.
  • Request that the claimant or the person completing the form for the claimant print his or her name, address, date and email address (optional) in the spaces provided in Section 3 of the form.
  • Document any additional information in the Claim Communications section of the electronic Claims Analysis Tool (eCAT). For eCAT exclusions, document your findings on an SSA-5002 (Report of Contact), or the Case Development Summary Worksheet as described in DI 20503.001.
  • 10. Followup Procedure
  • NOTE: If more than one SSA-3369-BK is used, complete identifying information in Section 1, and as much of Section 2 and 3 as is necessary. Mark the second form “Supplementary” at the top. If a different continuation sheet is used, identify it clearly.
  • If the claimant:
  • * refuses to cooperate, see DI 23007.004 for instructions.
  • * fails to cooperate, see DI 23007.005 for instructions.
  • 1. Resolving inconsistent information
  • Determine whether the information on the SSA-3369-BK is clear, consistent, and material to the determination. Clarify any inconsistent information material to the determination, including inconsistencies between work demands and the claimant’s narrative descriptions. Do not pursue additional development to make clarifications on inconsistencies that are not material to the disability determination.
  • For example, when the expedite procedure applies PRW information is not material. For information on the expedited vocational procedures, see DI 25005.005.
  • If the job duties described seem inconsistent with the claimant’s stated exertional demands, clarify and resolve the issue with the claimant if information about a particular job is material to the determination.
  • For example, the claimant stated he spent all day collecting trash from individual offices and then dumping that trash into a large dumpster at the end of the day. However, he also stated he performed no lifting as part of his job duties. Clarify this inconsistent information if claimant’s ability to do that job, as he described, is material to the determination. i.e., if he was required to collect trash by lifting it into the dumpster at the end of the day, lifting was part of his job duties.
  • 2. Inconsistencies in time spent doing work requirements and hours worked
  • Only clarify time spent doing work requirements and hours worked if it is not possible to make reasonable assumptions about the claimant’s intended meaning. For example, the combined hours spent in various tasks do not need to match the total hours worked. Some tasks performed may overlap.
  • For example, a claimant may stand while stooping. In some instances, it may be difficult for the claimant to parse out the difference between hours standing and hours walking.
  • For example, if the claimant stated he stood six hours and walked six hours in an eight-hour day that is likely an indication that he spent six hours a day standing or walking intermittently.
  • Even for instances in which the claimant provides extremely inconsistent times spent doing various work requirements, it may be possible to rule out the claimant’s ability to do that job as performed without further clarifications.
  • For example, the lifting and carrying requirements of the job may be beyond the claimant’s RFC level, making further clarification of hours spent standing and walking immaterial to the determination.
  • E. References
  • DI 11005.025 Completing the SSA-3369
  • DI 20503.001 Documenting the Disability Folder – Disability Determination Services (DDS)
  • DI 22515.001 Overview of Vocational Evidence Development
  • DI 22515.003 Developing Sufficient Vocational Evidence
  • DI 23007.004 Refusal to Cooperate With Requests to the Claimant for Evidence or Action
  • DI 23007.005 Failure to Cooperate With Requests to the Claimant for Evidence or Action
  • DI 25005.005 Expedited Vocational Assessment at Steps 4 and 5 of Sequential Evaluation
  • DI 25005.020 Past Relevant Work (PRW) as the Claimant Performed It
  • DI 25005.025 Past Relevant Work (PRW) as Generally Performed in the National Economy
  • DI 25010.001 Special Medical-Vocational Profiles
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