SSA-3369-BK - Work History Report Form SSA-3369-BK (06-2024) UF Discontinue Prior Editions Social Security Administration Page 1 of 14 OMB No 0960-0578 WORK HISTORY REPORT PLEASE READ ALL OF THIS INFORMATION BEFORE COMPLETING THIS REPORT The office that makes the disability decision on your case will use the information you provide in this
DI 22515. 030 Use of Work History Report Form SSA-3369-BK When you mail the SSA-3369-BK to the claimant, include a cover letter asking the claimant to document each job held during the five years before becoming unable to work because of their illnesses, injuries or conditions
SSA - POMS: DI 81010. 025 - Completing Electronic Disability Collect . . . The EDCS 3369 collects detailed information and remarks about the types of work that the claimant alleges having performed in the 15 years prior to becoming unable to work When creating an EDCS case for an initial claim, determine whether it is necessary to complete an SSA-3369, per Completing the SSA-3369 - DI 11005 025
Social Security Forms | SSA The form you are looking for is not available online Many forms must be completed only by a Social Security Representative Please call us at 1-800-772-1213 (TTY 1-800-325-0778) Monday through Friday between 8 a m and 5:30 p m or contact your local Social Security office
DI 81010. 005 Electronic Disability Collect System (EDCS) Overview SSA-3369 Work History Report (if required per Completing the SSA-3369 - DI 11005 025) For details on completing EDCS forms for initial claims, see Completing EDCS Forms for Initial Claims - DI 81010 025
DI 22515. 003 Developing Sufficient Vocational Evidence If a claimant is experiencing homelessness, and had more than one job in the five-year period before they stopped working due to their medical condition(s), the field office will obtain a completed SSA-3369-BK