Form SSA-3369-BK, Work History Report (Social Security Administration) Completed Form Examples and Samples

Explore comprehensive examples and samples of a completed Form SSA-3369-BK, the Work History Report. Our filled-out guides demonstrate how to accurately detail past jobs, duties, and physical demands for your Social Security disability claim.
Form SSA-3369-BK, Work History Report (Social Security Administration) has a complex Form Complexity Index of 70/100 — Instafill’s AI completes it in under a minute.
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Completed Form SSA-3369-BK Work History Report for a disability claim due to a physical condition

Form SSA-3369-BK Example – Disability Claim for Physical Impairment

How this form was filled:

This example shows how to complete the SSA-3369-BK for a person who stopped working due to a physical impairment. It details three jobs over the last 15 years, with a focus on the most recent role as a Construction Foreman. The form highlights the physically demanding nature of the job, including heavy lifting, long periods of standing, and specific machine use, to support a Social Security disability claim.

Information used to fill out the document:

  • Claimant Name: Maria Garcia
  • Social Security Number: 000-00-1234
  • Date of Completion: 05/15/2026
  • Work History Period: 2011 - 2026
  • Job 1 Title: Construction Foreman
  • Job 1 Employer: BuildRight Construction
  • Job 1 Dates: June 2018 to January 2026
  • Job 1 Final Pay: $35.00 per hour
  • Job 1 Duties: Supervised a crew of 5, read blueprints, operated forklifts, and performed quality control checks. Required lifting heavy materials and constant movement around the job site.
  • Job 1 Physical Demands: Lifted and carried up to 75 lbs frequently. Stood/walked for 7-8 hours per day. Frequently stooped, kneeled, and crouched.
  • Job 2 Title: Carpenter
  • Job 2 Employer: ABC Builders
  • Job 2 Dates: March 2014 to May 2018
  • Job 3 Title: General Laborer
  • Job 3 Employer: City Works Dept
  • Job 3 Dates: January 2011 to February 2014

What this filled form sample shows:

  • Complete listing of all jobs performed in the 15-year period prior to the disability claim.
  • Detailed description of the most recent job, including specific duties and responsibilities.
  • Clear quantification of physical requirements like lifting weights (lbs) and hours spent standing/walking.
  • Accurate information on pay rates, hours per day, and days per week for each position.
  • Demonstrates how to connect job duties to the claimant's disabling condition.

Form specifications and details:

Form Name: Form SSA-3369-BK, Work History Report
Issuing Agency: Social Security Administration (SSA)
Use Case: Disability claim based on a physical impairment (severe back condition) preventing strenuous labor.
Purpose: To provide the SSA with a detailed account of a claimant's past work to help determine their ability to perform other work.
Categories: SEC forms, SOC forms, SSA forms, social security forms, social work forms
Created: February 10, 2026 11:22 PM
Completed Form SSA-3369-BK Work History Report for a disability claim due to a physical condition