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Form SSA-3369-BK, Work History Report (Social Security Administration), page 1
Complex · 70/100Form Complexity Index

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What this form asks for

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Form SSA-3369-BK, Work History Report, is a Social Security Administration form used by the disability determination office to evaluate your past relevant work and understand how your medical conditions may affect your ability to perform work you are qualified to do. It collects detailed information about each job (duties, tools/equipment, interaction with others, physical activities like standing/walking/sitting, lifting/carrying, and environmental exposures) for the 5 years before you became unable to work. Providing complete and accurate work history is important because it can directly affect how SSA assesses your functional limitations and eligibility for disability benefits. Today, this form can be filled out quickly and accurately using AI-powered services like Instafill.ai, which can also convert non-fillable PDF versions into interactive fillable forms.
Fillable fields392
Pages14
Sections103
Questions that depend on earlier answers2
Form Complexity IndexComplex, 70/100

The AI checks your answers before you download

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

Applicant Name completeness and character validation

Ensures the applicant’s name (First, Middle Initial, Last, and optional Suffix) is present and uses valid characters (letters, spaces, hyphens, apostrophes) with reasonable length limits. This is important for identity matching and to prevent downstream system errors caused by unexpected symbols or excessively long strings. If validation fails, the submission should be blocked or routed for manual review with a clear prompt to correct the name fields.

Social Security Number (SSN) format and plausibility check

Validates that the SSN is exactly 9 digits (or formatted as XXX-XX-XXXX) and is not an obviously invalid value (e.g., all zeros, 123456789, 000-00-0000). This is critical for correctly associating the work history report with the claimant’s record and preventing misfiled evidence. If validation fails, the form should not be accepted until a valid SSN is provided or the case is flagged for identity verification.

Daytime phone number format validation (primary/secondary)

Checks that phone numbers include a valid structure: for US/Canada, 10 digits with optional punctuation; for international, allows leading '+' and country code with a minimum digit count. This matters because adjudicators may need to contact the claimant or preparer, and invalid numbers delay development. If validation fails, require correction or allow 'none' only if the form design permits and a reason is captured.

Section 2 job list required fields per listed job

For each job row that has any data entered, validates that Job Title, Type of Business, and both Dates Worked (From/To) are provided. This ensures each job entry is usable for vocational analysis and prevents partial rows that cannot be interpreted. If validation fails, prompt the user to complete missing fields or remove the incomplete job row.

Dates Worked (MM/YYYY) format and calendar validity

Validates that each job’s From and To dates follow MM/YYYY, with month between 01 and 12 and a reasonable year range (e.g., not far future). Correct date formatting is essential for determining the relevant 5-year period and sequencing jobs. If validation fails, reject the date entry and request correction in the required format.

Dates Worked logical order and overlap consistency

Ensures that for each job, the To date is the same as or after the From date, and flags improbable overlaps across multiple jobs (e.g., two full-time jobs with identical dates) for review. Logical consistency supports accurate work chronology and prevents misinterpretation of work activity. If validation fails, require correction for reversed ranges and generate a warning (not necessarily a hard stop) for overlaps that may be legitimate.

And 10 more checks
  • Job ordering rule: most recent job listed first
  • Job duration minimum rule (exclude jobs held under 30 days)
  • Rate of pay numeric validation and 'Per' selection exclusivity
  • Hours per day and days per week range validation
  • Standing/Walking/Sitting time sum equals Hours per Day
  • Activity duration format and non-negative constraints
  • One-hand vs both-hands / one-arm vs both-arms selection consistency
  • Lifting weights selection logic (heaviest vs frequently lifted)
  • Conditional narrative requirements for YES/checked items
  • Section 4 preparer identity and contact completeness (including date)

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

What the AI walks you through.

  1. Go to Instafill.ai and upload the SSA-3369-BK PDF (or select SSA-3369-BK from the form library).
  2. Enter claimant identification details in Section 1 (name, Social Security number, and daytime phone numbers).
  3. List all jobs held in the 5 years before you became unable to work in Section 2 (most recent first), including job title, type of business, and dates worked.
  4. For each job (Job No. 1 through Job No. 5, and additional jobs if applicable), provide pay and schedule details and describe daily tasks, report-writing, supervision, tools/equipment used, and interaction with others.
  5. Complete the physical demands and work conditions for each job (standing/walking/sitting, postural activities, hand use, reaching, climbing, lifting/carrying, and environmental exposures) and explain how medical conditions affect ability to do the job.
  6. Use Section 3 (Remarks) to add clarifications, extra space answers, or additional jobs, referencing the job number and question being addressed.
  7. Finish Section 4 (Who is completing this report), review Instafill.ai’s validation checks for missing/inconsistent items, then download/print and send or bring 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 you became unable to work)
People often list their “last 5 years of work” from today, or they list their entire work history, instead of focusing on the 5-year window before the date they became unable to work due to medical conditions. This can cause SSA to evaluate the wrong jobs and delay the disability determination while they request clarification. To avoid this, identify your “unable to work” onset date first, then list only jobs within the 5 years immediately before that date. AI-powered tools like Instafill.ai can help by prompting for the onset date and automatically filtering/flagging jobs that fall outside the required window.
Including jobs held fewer than 30 calendar days
The form instructs you not to include jobs you held less than 30 calendar days, but many people include short stints because they feel every job “counts.” Including these can clutter the record and may trigger follow-up questions that slow processing. To avoid this, check each job’s start/end dates and exclude any job that lasted under 30 calendar days (unless SSA specifically asks later). Instafill.ai can automatically calculate job duration from dates and warn you when a job appears to be under 30 days.
Not listing all job titles separately (especially with the same employer)
Applicants frequently combine multiple roles at the same employer into one entry (e.g., “Warehouse worker” covering picker, forklift operator, and lead). SSA needs each distinct job title because duties and physical/mental demands can differ significantly, and combining them can lead to an inaccurate assessment of your past relevant work. To avoid this, list each job title separately even if the employer was the same, and use Section 3 (Remarks) to explain transitions or overlapping duties. Instafill.ai can help structure multiple roles under one employer into separate job entries with consistent dates and descriptions.
Using vague job titles or unclear “type of business”
People often write broad titles like “Manager,” “Clerk,” or “Laborer,” and put a generic business type like “Company” or “Office.” Vague entries make it harder for SSA to match your work to standardized occupational categories, which can lead to misclassification and additional development requests. To avoid this, use specific titles (e.g., “Retail Assistant Store Manager,” “Accounts Payable Clerk,” “Construction Laborer—Concrete”) and specify the industry (e.g., “Big-box retail,” “Medical billing office,” “Residential construction”). Instafill.ai can suggest standardized, clearer job titles and ensure the business type is specific enough.
Incorrect date formats or incomplete dates (MM/YYYY required)
A common error is entering full dates (MM/DD/YYYY), only years, or leaving months blank in the “Dates Worked From/To” fields that require MM/YYYY. Incorrect or inconsistent dates can create gaps/overlaps that prompt SSA to question the accuracy of the work history and request corrections. To avoid this, always use two-digit month and four-digit year (e.g., 03/2021) and estimate if necessary rather than leaving it blank. Instafill.ai can enforce the required date format and flag impossible ranges (like an end date before a start date).
Rate of pay entered without selecting the correct “Per” unit (hour/day/week/month/year)
Many people enter a dollar amount but forget to check whether it was per hour, per week, etc., or they check the wrong unit (e.g., entering an hourly wage but checking “Year”). This can distort how SSA interprets the job’s earnings level and may lead to follow-up questions or misinterpretation of the work’s nature. To avoid this, enter the amount and always check exactly one “Per” box that matches how you were paid; if pay varied, estimate and explain in Remarks. Instafill.ai can detect mismatches (e.g., $18 with “Year”) and prompt you to correct the unit.
Hours-per-day and activity totals don’t reconcile (standing/walking + sitting must equal hours/day)
The form explicitly states that standing/walking (combined) plus sitting should equal the “Hours per Day,” but many submissions don’t add up due to rounding, forgetting breaks, or leaving one field blank. Inconsistent totals reduce credibility and can cause SSA to question the accuracy of the physical demands you report. To avoid this, decide your typical workday length first, then allocate time so the totals match (use minutes if needed to make it exact). Instafill.ai can automatically validate the math and prevent submission when totals don’t reconcile.
Skipping “one hand vs both hands” / “one arm vs both arms” checkboxes
Applicants often fill in the time spent using fingers/hands/reaching but forget to indicate whether it was one hand/arm or both. Missing laterality details can weaken the functional picture SSA needs, especially when the claimant has an impairment affecting one side (e.g., dominant hand injury). To avoid this, always select the appropriate one/both option for each activity you report time for, and be consistent with your actual job demands. Instafill.ai can prompt for the required checkbox whenever a duration is entered and flag missing pairings.
Leaving “interaction with others” details blank after checking YES
A frequent mistake is checking YES for interacting with coworkers/public but not describing who, how (phone/in-person), purpose, and time spent. SSA uses this to understand social and cognitive demands; missing details can lead to an incomplete assessment and requests for more information. To avoid this, quantify interaction (e.g., “in-person customer service ~5 hours/day; phone calls ~1 hour/day”) and describe the nature of the interaction (conflict resolution, training, sales, etc.). Instafill.ai can guide you with structured prompts to capture all required interaction elements.
Not explaining lifting/carrying with specifics (what, how far, how often) or choosing inconsistent weights
People often select a heaviest/frequent weight category but don’t explain what was lifted, how far it was carried, and how often—yet the form explicitly asks for those details. Others pick weights that conflict with their job description (e.g., “heaviest <10 lbs” for a warehouse job), which can undermine credibility and trigger follow-up. To avoid this, provide concrete examples (e.g., “lifted 40-lb boxes from pallet to cart, carried ~20 feet, 10–15 times/day”) and ensure the checkbox selections match your narrative. Instafill.ai can cross-check your narrative against selected weight ranges and prompt you to resolve inconsistencies.
Checking exposure boxes but not describing frequency/intensity (or forgetting exposures entirely)
Applicants commonly check exposures like loud noise, vibrations, hazardous substances, or extreme temperatures but fail to describe how often they were exposed (daily/weekly) and in what context. Without frequency and context, SSA can’t accurately evaluate environmental limitations and may request clarification. To avoid this, add specifics such as “loud noise from machinery ~6 hours/day” or “cleaning chemicals 2–3 times/week for 30 minutes.” Instafill.ai can require a frequency description whenever any exposure box is checked.
Forgetting Section 4 (who completed the report) or missing the completion date
Many people focus on the job pages and overlook Section 4 at the bottom of the last page, especially the completion date and whether the claimant or someone else filled it out. Missing Section 4 can make the submission incomplete and may lead to rejection or a request to re-submit, delaying the claim. To avoid this, always complete the date (MM/DD/YYYY) and, if someone else helped, provide their name, relationship, address, and phone number. Instafill.ai can add a completion checklist and prevent finalization until Section 4 is fully completed.

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 70 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?
This form helps the disability decision office understand the work you did and the physical and mental demands of each job. SSA uses it to evaluate how your medical conditions may affect your ability to do work you’re qualified for.
Who needs to fill out the SSA-3369-BK?
The person applying for Social Security disability benefits usually completes it. 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 due to your medical conditions. Start with your most recent job first.
Do I include short-term jobs or jobs I only had briefly?
Do not include jobs you held for less than 30 calendar days. Include all other jobs in the 5-year period, even if they were for the same employer.
Do I need to include self-employment or gig work (like rideshare driving)?
Yes. The form specifically says to include self-employment, such as rideshare driving, hair styling, or other independent work.
Do I include work I did outside the United States?
Yes. The form instructs you to include work performed in a foreign country if it falls within the relevant 5-year period.
What information do I need for each job in Section 2?
You’ll list the job title, type of business, and dates worked (MM/YYYY to MM/YYYY). For Jobs 1–5, you also provide details like pay rate, schedule, tasks, tools/equipment, interaction with others, physical activities, lifting/carrying, exposures, and how your medical conditions affect the job.
What if I can’t remember exact dates, pay, or hours for a job?
Provide your best estimate and complete as much as you can. If you don’t know an answer, write “don’t know,” “none,” or “does not apply,” as appropriate.
How do I fill out the standing/walking/sitting time so it’s correct?
The combined time for standing/walking plus sitting should equal your “Hours per Day” for that job. Use hours and minutes, and estimate if needed.
How should I describe my job duties so SSA understands them?
Describe what you did in a typical workday with specific tasks (for example: stocking, scheduling, data entry, customer service, cleaning, operating machinery). Include details about reports you wrote, supervision duties, and the tools/equipment you used and what you used them for.
What does the form mean by “lifting and carrying” and “heaviest” vs. “frequently” lifted weight?
You should explain what you lifted, how far you carried it, and how often. “Heaviest” is the maximum weight you lifted, while “frequently lifted” means the weight you lifted about 1/3 to 2/3 of the workday.
What should I put for workplace exposures (heat, cold, noise, hazardous substances, etc.)?
Check all exposures that applied to the job (such as loud noise, moving mechanical parts, humidity, or hazardous substances). Then describe what the exposure was and how often you were exposed (for example: “loud machinery noise 6 hours/day”).
Where do I explain how my medical conditions affected my ability to do each job?
Each job detail section includes a prompt to explain how your medical conditions would affect your ability to do that job. Be specific about limitations (for example: standing tolerance, lifting limits, concentration issues, pain, fatigue, or need for breaks).
What is Section 3 (Remarks) for, and when should I use it?
Use Section 3 if you need more space or want to add clarifying details that didn’t fit elsewhere. Reference the job number and the question you’re adding information about, and attach extra sheets if you have more than five jobs with full details.
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 SSA address listed for comments). SSA estimates it takes about 40 minutes to read instructions, gather facts, and complete the form.
Can AI tools help me fill out this form, and how would I use Instafill.ai?
Yes—AI tools like Instafill.ai can help auto-fill form fields accurately and save time by pulling details you provide into the correct boxes. Typically, you upload the SSA-3369-BK PDF to Instafill.ai, answer guided questions about your jobs and duties, and the tool populates the form for you to review before you download and submit it.
What if my SSA-3369-BK PDF isn’t fillable (it’s a flat/scanned PDF)?
If the PDF is not fillable, services like Instafill.ai can convert a flat, non-fillable PDF into an interactive fillable form. After conversion, you can type directly into fields and complete it more cleanly and quickly.
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