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Form SSA-3369-BK, Work History Report, page 1
Complex · 79/100Form Complexity Index

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What this form asks for

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Form SSA-3369-BK is a Social Security Administration Work History Report completed as part of a disability claim (such as SSDI or SSI). It asks for a list of jobs performed in the 5 years before the applicant became unable to work and requires detailed descriptions of job duties, physical demands (standing, walking, lifting, reaching, etc.), tools/equipment used, and workplace exposures. Disability examiners use this information to compare the applicant’s past work requirements to their current functional limitations and determine whether they can perform past work or other work. Providing complete, accurate job details helps avoid delays and supports an accurate disability determination.
Fillable fields392
Pages14
Sections136
Tables and lists1
Questions that depend on earlier answers116
Form Complexity IndexComplex, 79/100

The AI checks your answers before you download

18 checks built for this form, so a wrong date or a missing answer is caught before anyone else sees it.

Validates claimant name fields are present and properly structured (Section 1.A)

Checks that the claimant’s First Name and Last Name are provided, and that Middle Initial and Suffix (if provided) contain only expected characters (letters for middle initial; known suffix patterns like Jr., Sr., II, III). This is important for identity matching and to prevent downstream record-linking errors. If validation fails, the submission should be flagged as incomplete and routed for correction before adjudication.

Validates Social Security Number format and disallows invalid SSNs (Section 1.B)

Ensures the SSN is exactly 9 digits (allowing optional hyphens) and rejects clearly invalid values (e.g., all zeros, 123456789, 000-00-0000). Accurate SSN capture is critical for associating the work history with the correct claimant record. If validation fails, the form should be rejected or placed in a hold state requiring corrected SSN entry.

Validates claimant daytime phone number format and minimum contactability (Section 1.C)

Checks that at least one phone number (primary or secondary) is provided and that each provided number matches acceptable formats (e.g., NANP 10 digits for US/Canada, or includes IDD/country code for international). This matters because the agency may need to contact the claimant for clarification, and unreachable claimants delay decisions. If validation fails, prompt for a corrected number or require an alternate contact method per business rules.

Ensures at least one job is listed or an explicit 'none/don’t know' statement is provided (Section 2 job list)

Validates that the work history section contains at least one job entry within the 10-row list, or that the claimant explicitly indicates no qualifying jobs in the relevant period (e.g., via remarks). This is essential because the disability determination relies on past relevant work analysis. If validation fails, the submission should be flagged for missing core work history information.

Validates each listed job has required core fields: Job Title, Type of Business, and Dates Worked

For every job row that has any data, checks that Job Title, Type of Business, and both From and To dates are present (or a permitted placeholder like 'don’t know' if allowed by intake rules). These fields are required to classify the job and determine whether it falls within the relevant timeframe. If validation fails, the system should identify the specific job row and missing fields for correction.

Validates job dates are in MM/YYYY format and represent real calendar months

Ensures From and To values match MM/YYYY, with month between 01 and 12 and year within a reasonable range (e.g., not in the far future). Correct date formatting prevents misinterpretation and calculation errors in duration and recency. If validation fails, the job entry should be blocked from submission until corrected.

And 12 more checks
  • Checks logical consistency of job date ranges (From date must be on/before To date)
  • Flags jobs that appear to be shorter than 30 calendar days (exclusion rule)
  • Validates Job Detail sections are completed for each of Jobs 1–5 that are listed
  • Validates rate of pay is numeric, non-negative, and paired with exactly one pay period (Jobs 1–5)
  • Validates hours per day and days per week are within plausible bounds (Jobs 1–5)
  • Ensures standing/walking + sitting equals Hours per Day (time-allocation consistency)
  • Validates physical activity durations are in valid Hours/Minutes format and do not exceed the workday
  • Validates bilateral/unilateral selections are made when time is entered for hand/finger/reaching activities
  • Validates lifting/carrying selections are complete and logically consistent (heaviest vs frequently lifted)
  • Requires exposure frequency/details when any environmental exposure checkbox is selected
  • Validates interaction question branching: YES requires interaction details; NO must not include contradictory details
  • Validates Section 4 completion, including conditional requirements when 'Someone else' completes the report

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How to Fill Out SSA-3369-BK Online for Free in 2026

What the AI walks you through.

  1. Gather your work records for the 5 years before you became unable to work (job titles, employers/type of business, dates worked, pay rate, hours per day/week, and key duties).
  2. Complete Section 1 with the applicant’s identifying information (name, Social Security number, and reliable daytime phone numbers).
  3. In Section 2 (job list), enter each job held for 30 days or more during the relevant 5-year period, listing the most recent job first and including self-employment and foreign work.
  4. For each job detail page (Job No. 1–5 and additional jobs if needed), describe a typical workday: main tasks, any reports written, any supervision performed, tools/machines used, and the amount/type of interaction with coworkers or the public.
  5. For each job, complete the physical requirements and conditions: time spent standing/walking/sitting, postural activities (stooping, kneeling, crouching, crawling), hand use and reaching, lifting/carrying amounts and frequency, and any environmental exposures (noise, vibrations, hazardous substances, extreme temperatures, etc.).
  6. Explain for each job how your medical conditions would affect your ability to perform that work today, using specific limitations (e.g., cannot lift over X lbs, cannot stand more than Y minutes, difficulty concentrating, etc.).
  7. Use Section 3 (Remarks) for overflow details, clarifications, or additional jobs, then complete Section 4 to identify who filled out the report, provide contact information, sign/date as required by the requesting agency, and submit the completed form to the state agency that requested it.

Common Mistakes in Completing SSA-3369-BK

The ones the AI is built to catch.

Listing the wrong time period (not the 5 years before disability began)
Many people list their “last 5 years of work” from today, or they include older jobs that feel important, instead of focusing on the 5 years before they became unable to work due to medical conditions. This can cause the disability examiner to evaluate the wrong work history and may lead to delays or incorrect conclusions about what work you can still do. To avoid this, identify your alleged onset date (when you became unable to work) and list only jobs performed in the 5-year window immediately before that date.
Including jobs held fewer than 30 calendar days
Applicants often include very short-term jobs, training stints, or “trial” employment because they want to be thorough. The form specifically says not to include jobs you held less than 30 calendar days, and including them can clutter the record and create follow-up questions. To avoid this, screen your list and omit any job that lasted under 30 calendar days; if it feels relevant, briefly explain it in Section 3 (Remarks) rather than listing it as a job entry.
Not listing each distinct job title (especially with the same employer)
People commonly list one employer and one title even when they had multiple roles (e.g., “Warehouse worker” but they were also a “Forklift operator” or “Lead”). This matters because SSA evaluates the physical/mental demands of each job, and different titles can have very different requirements. To avoid this, list every job title separately—even if it was for the same employer—and use the job numbers consistently when providing details later.
Using vague job titles or business types
Entries like “Worker,” “Manager,” or “Office” don’t tell SSA what the job actually was, and “Company” without the type of business doesn’t clarify the work setting. Vague titles can lead to misclassification of your past work and additional development requests. Use a specific title (e.g., “Retail cashier,” “Home health aide,” “Accounts payable clerk”) and a clear business type (e.g., “Big-box retail store,” “Residential construction,” “Medical clinic”).
Incorrect date format or incomplete dates (MM/YYYY required)
A frequent error is writing full dates (MM/DD/YYYY), only a year, or using words like “Spring 2021,” which doesn’t match the form’s MM/YYYY requirement for Dates Worked. Inconsistent or unclear dates can create gaps/overlaps that trigger follow-up and slow the decision. To avoid this, enter month and year for both “From” and “To” for every job, and if you truly can’t recall, write “don’t know” and estimate as closely as possible.
Pay rate and schedule mismatches (rate, per-unit, hours/day, days/week)
People often enter a dollar amount but forget to check whether it’s per hour/week/month, or they provide hours/day and days/week that don’t align with the pay type (e.g., annual salary but only listing 2 days/week). These inconsistencies can raise questions about whether the work was full-time, part-time, or substantial, and may require clarification. To avoid this, pick the correct pay unit, then ensure hours/day and days/week reflect your typical schedule for that job (estimate if needed).
Task descriptions that are too general or focus only on the job title
Many applicants write a one-line summary like “customer service” or “did paperwork,” which doesn’t describe the actual duties and demands of a typical day. SSA needs detail to understand skill level, complexity, pace, and physical/mental requirements; vague answers can lead to an inaccurate job classification. To avoid this, describe a typical workday with concrete tasks, frequency, and context (e.g., “answered 40–60 calls/day, entered orders in software, handled cash drawer, stocked shelves for 1–2 hours”).
Skipping the writing/reports and supervision follow-up questions
Applicants often overlook the conditional prompts about writing/completing reports and supervising others, especially if they think it was “minor.” Missing these details can understate the cognitive demands, responsibility level, and transferable skills of the job, which can affect the disability analysis. To avoid this, if you wrote anything (logs, incident reports, chart notes, inventory counts) or supervised anyone (training, scheduling, evaluations), describe what it was and how much time you spent on it.
Physical activity totals don’t add up (standing/walking/sitting must equal hours/day)
A very common mistake is listing standing, walking, and sitting times that exceed or fall short of the “Hours per Day,” or leaving one blank. This creates internal inconsistencies and can lead to follow-up requests or assumptions that don’t reflect your actual job demands. To avoid this, start with your total hours/day, then allocate standing/walking (combined) and sitting so they sum exactly to that total; use hours and minutes rather than rough phrases like “most of the day.”
Not specifying one vs. both hands/arms for fine manipulation, grasping, and reaching
People often check an activity but forget to indicate whether it was done with one hand/arm or both, or they mark both without thinking through the job. SSA uses these details to evaluate upper-extremity demands and how certain medical conditions may limit work. To avoid this, choose the accurate option (one vs. both) and estimate time spent; if tasks varied, describe the typical pattern in the space provided or in Remarks.
Lifting/carrying answers are incomplete (no items, distance, or frequency)
Applicants frequently check a weight box but don’t explain what was lifted, how far it was carried, or how often—yet the form explicitly asks for those details. Without specifics, SSA may misjudge exertional level (sedentary/light/medium/heavy) and request clarification. To avoid this, pair the weight selection with examples (e.g., “lifted 30-lb boxes of paper, carried 20–30 feet, 10–15 times/day”) and distinguish “heaviest” from “frequently lifted.”

Frequently Asked Questions About SSA-3369-BK

 

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How does the AI fill out SSA-3369-BK?
You answer a few questions in plain words, or upload a document you already have. The AI reads what you give it and puts each answer into the right field of SSA-3369-BK, on every page, in seconds. It checks the answers against the form's own rules, and you review and change anything before you download, print or sign.
What happens to my information?
It is encrypted in transit and at rest, and it is never used to train AI.
How complex is SSA-3369-BK to fill out?
SSA-3369-BK has a Form Complexity Index of 79 out of 100, in the complex tier: 392 fillable fields across 14 pages. Instafill.ai's AI fills it in under a minute, with every field there for you to review before you download.
What is Form SSA-3369-BK (Work History Report) used for?
The disability decision office uses this form to understand the work you did and the physical and mental demands of each job. This helps them evaluate how your medical conditions affect your ability to do work you are qualified for.
Who should fill out this Work History Report?
The person applying for disability benefits should complete it whenever possible. If someone else fills it out for the applicant, they must complete Section 4 with their name, relationship, and contact information.
What time period of jobs do I need to list?
List all jobs you had in the 5 years before you became unable to work because of your medical conditions. List your most recent job first.
Do I include self-employment, gig work, or work done outside the United States?
Yes—include self-employment (such as rideshare driving or hair styling) and work performed in a foreign country. The goal is to capture all work during the relevant 5-year period.
Should I list short-term jobs or jobs I held for only a few weeks?
Do not include jobs you held for less than 30 calendar days. If you are unsure whether a job meets that threshold, explain the dates and details in Section 3 (Remarks).
What if I had multiple job titles with the same employer?
List all job titles even if they were for the same employer. Different titles can involve different duties and physical requirements, which can affect the disability evaluation.
What information do I need to gather before I start?
You should gather job titles, type of business, dates worked (month/year), pay rate, hours per day, and days per week for each job. You’ll also need details about your duties, tools/equipment used, physical activities, lifting/carrying, and any workplace exposures.
What if I can’t remember exact dates, pay, or hours for a job?
Provide your best estimate and include as much detail as you can. If you truly don’t know an answer, write “don’t know,” and you can add clarifying details in Section 3 (Remarks).
How detailed should my job duty description be for each job?
Be specific about what you did in a typical workday (for example, stocking shelves, scheduling appointments, maintaining records). Include details about any report-writing, supervising others, and the machines/tools/equipment you used and what you used them for.
How do I answer the question about interacting with coworkers or the public?
If you answer “Yes,” describe who you interacted with (coworkers, customers, clients), why (helping customers, coordinating work), how (in person, phone, computer), and how much time you spent doing it per day or week.
How do I complete the physical activity section (standing, walking, sitting, etc.)?
Enter the time spent on each activity in a typical workday using hours/minutes. The combined total for standing/walking and sitting should equal the “Hours per Day” you reported for that job.
What should I put for lifting and carrying if the weight varied?
Choose the best match for the heaviest weight you lifted and the weight you lifted frequently (about 1/3 to 2/3 of the workday). In the explanation box, describe what you lifted, how far you carried it, and how often.
What counts as workplace exposures (like loud noise or hazardous substances), and how should I describe them?
Exposures include things like outdoors, extreme heat/cold (non-weather related), wetness, humidity, hazardous substances, moving mechanical parts, high places, heavy vibration, and loud noises. Check all that apply and explain what you were exposed to and how often.
Where do I explain how my medical conditions affected my ability to do each job?
Each job section includes a prompt asking you to explain how your medical conditions would affect your ability to do that job. Describe specific limitations (for example, pain with lifting, difficulty standing, trouble concentrating) as they relate to the job’s tasks.
What if I need more space or I had more than five jobs to describe in detail?
Use Section 3 (Remarks) for extra space and reference the job title number and the question you are continuing. If you add more jobs beyond the five detailed job sections, attach separate sheets and provide the same type of information requested for Jobs 1–5.
Where do I send the completed SSA-3369-BK form, and how long does it take to complete?
Send or bring the completed form to the State agency that requested it (not to the Baltimore address, which is only for comments about the time estimate). SSA estimates it takes about 40 minutes to read the instructions, gather facts, and answer the questions.
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