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 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. |
Created: February 10, 2026 11:22 PM
