Form SSA-3369-BK, Work History Report (Social Security Administration) Instructions

Provide the total time, in hours and/or minutes, spent climbing ladders, ropes, or scaffolds in a typical workday.

Enter the amount of time, in hours and minutes, spent climbing ladders, ropes, or scaffolds in a typical workday.

Provide the duration in hours and minutes that you spend climbing ladders, ropes, or scaffolds in a typical workday.

Enter the duration you spend climbing ladders, ropes, or scaffolds in a typical workday.

Enter the duration spent climbing stairs or ramps during a typical workday.

Enter the amount of time, in hours or minutes, spent climbing stairs or ramps during a typical workday.

Enter the duration in hours and minutes that you spent climbing stairs or ramps in a typical workday.

Provide the duration in hours and/or minutes spent climbing stairs or ramps during a typical workday.

Enter the duration, in hours and/or minutes, that you spend crawling during a typical workday.

Enter the time spent crawling (moving on hands and knees) during a typical workday.

Enter the amount of time spent crawling (moving on hands and knees) in a typical workday, in hours and minutes.

Enter the duration you spend crawling (moving on hands and knees) in a typical workday, in hours and minutes.

Enter the amount of time, in hours and minutes, spent crouching during a typical workday.

Enter the amount of time spent crouching (bending legs and back down and forward) in hours and minutes during a typical workday.

Please provide the duration, in hours and minutes, that you spend crouching (bending legs and back down and forward) during a typical workday.

Enter the duration of time spent crouching in a typical workday, in hours and/or minutes.

Provide a detailed description of the machines, tools, and equipment used regularly for this job, and explain their purpose.

Provide a detailed explanation of the exposures experienced and their frequency.

Please specify the frequently lifted weight if it is not among the provided options.

Check this box if the weight frequently lifted in the job (1/3 to 2/3 of the workday) was less than 1 pound.

Check this box if the weight frequently lifted in the job (1/3 to 2/3 of the workday) was less than 10 pounds.

Check this box if the weight frequently lifted in the job (1/3 to 2/3 of the workday) was 10 pounds.

Check this box if the weight frequently lifted in the job (1/3 to 2/3 of the workday) was 25 pounds.

Check this box if the weight frequently lifted in the job (1/3 to 2/3 of the workday) was 50 pounds or more.

Check this box if the weight frequently lifted in the job (1/3 to 2/3 of the workday) was an amount not listed in the other options.

Enter the specific weight, if different from the options provided, that is frequently lifted during a typical workday.

Check this box if the weight frequently lifted (1/3 to 2/3 of the workday) was less than 1 lb.

Check this box if the weight frequently lifted (1/3 to 2/3 of the workday) was less than 10 lbs.

Check this box if the weight frequently lifted (1/3 to 2/3 of the workday) was 10 lbs.

Check this box if the weight frequently lifted (1/3 to 2/3 of the workday) was 25 lbs.

Check this box if the weight frequently lifted (1/3 to 2/3 of the workday) was 50 lbs. or more.

Check this box if the weight frequently lifted (1/3 to 2/3 of the workday) was an amount not listed in the other options.

Enter the frequently lifted weight if it is not among the predefined options.

Check this box if you frequently lift less than 1 pound during 1/3 to 2/3 of your workday.

Check this box if you frequently lift less than 10 pounds during 1/3 to 2/3 of your workday.

Check this box if you frequently lift 10 pounds during 1/3 to 2/3 of your workday.

Check this box if you frequently lift 25 pounds during 1/3 to 2/3 of your workday.

Check this box if you frequently lift 50 pounds or more during 1/3 to 2/3 of your workday.

Check this box if the weight you frequently lift during 1/3 to 2/3 of your workday is not listed among the other options.

Enter the weight frequently lifted if it is not among the provided options.

Provide the first name, middle initial, last name, and suffix of the applicant.

Enter the Social Security Number of the applicant.

Enter the primary daytime phone number where the applicant can be reached, including the area code or IDD and country code if applicable.

If available, enter a secondary daytime phone number where the applicant can be reached, including the area code or IDD and country code if applicable.

Enter the job title for the first job.

Enter the type of business for the first job.

Enter the start date for the first job.

Enter the end date for the first job.

Enter the job title for the second job.

Enter the type of business for the second job.

Enter the start date for the second job.

Enter the end date for the second job.

Enter the job title for the third job.

Enter the type of business for the third job.

Enter the start date for the third job.

Enter the end date for the third job.

Enter the job title for the fourth job.

Enter the type of business for the fourth job.

Enter the start date for the fourth job.

Enter the end date for the fourth job.

Enter the job title for the fifth job.

Enter the type of business for the fifth job.

Enter the start date for the fifth job.

Enter the end date for the fifth job.

Enter the job title for the sixth job.

Enter the type of business for the sixth job.

Enter the start date for the sixth job.

Enter the end date for the sixth job.

Enter the job title for the seventh job.

Enter the type of business for the seventh job.

Enter the start date for the seventh job.

Enter the end date for the seventh job.

Enter the job title for the eighth job.

Enter the type of business for the eighth job.

Enter the start date for the eighth job.

Enter the end date for the eighth job.

Enter the job title for the ninth job.

Enter the type of business for the ninth job.

Enter the start date for the ninth job.

Enter the end date for the ninth job.

Enter the job title for the tenth job.

Enter the type of business for the tenth job.

Enter the start date for the tenth job.

Enter the end date for the tenth job.

Enter the combined hours and minutes spent standing and walking in a typical workday.

Enter the hours and minutes spent sitting in a typical workday.

Enter the hours and minutes spent stooping (bending down & forward at waist) in a typical workday.

Enter the hours and minutes spent kneeling (bending legs to rest on knees) in a typical workday.

Enter the hours and minutes spent crouching (bending legs & back down & forward) in a typical workday.

Enter the hours and minutes spent crawling (moving on hands and knees) in a typical workday.

Check this box if your job requires you to use fingers to touch, pick, or pinch with one hand.

Check this box if your job requires you to use fingers to touch, pick, or pinch with both hands.

Enter the hours and minutes spent using fingers to touch, pick, or pinch (e.g., using a mouse, keyboard, turning pages, or buttoning a shirt) in a typical workday.

Check this box if your job requires you to use one hand to seize, hold, grasp, or turn objects.

Check this box if your job requires you to use both hands to seize, hold, grasp, or turn objects.

Enter the hours and minutes spent using hands to seize, hold, grasp, or turn (e.g., holding a large envelope, a small box, a hammer, or water bottle) in a typical workday.

Check this box if your job requires you to reach with one arm at or below shoulder level.

Check this box if your job requires you to reach with both arms at or below shoulder level.

Enter the hours and minutes spent reaching at or below the shoulder in a typical workday.

Check this box if your job requires you to reach with one arm above shoulder level.

Check this box if your job requires you to reach with both arms above shoulder level.

Enter the hours and minutes spent reaching overhead (above the shoulder) in a typical workday.

Enter the hours and minutes spent climbing stairs or ramps in a typical workday.

Enter the hours and minutes spent climbing ladders, ropes, or scaffolds in a typical workday.

Explain what you lifted, how far you carried it, and how often you did it in a typical workday.

Check this box if the heaviest weight you lifted in your job was less than 1 pound.

Check this box if the heaviest weight you lifted in your job was less than 10 pounds.

Check this box if the heaviest weight you lifted in your job was 10 pounds.

Check this box if the heaviest weight you lifted in your job was 20 pounds.

Check this box if the heaviest weight you lifted in your job was 50 pounds.

Check this box if the heaviest weight you lifted in your job was 100 pounds or more.

Check this box if the heaviest weight you lifted was a different amount not listed.

If you selected "Other" for the heaviest weight lifted, specify the weight.

Check this box if the weight you frequently lifted (1/3 to 2/3 of the workday) was less than 1 pound.

Check this box if the weight you frequently lifted (1/3 to 2/3 of the workday) was less than 10 pounds.

Check this box if the weight you frequently lifted (1/3 to 2/3 of the workday) was 10 pounds.

Check this box if the weight you frequently lifted (1/3 to 2/3 of the workday) was 25 pounds.

Check this box if the weight you frequently lifted (1/3 to 2/3 of the workday) was 50 pounds or more.

Check this box if the weight you frequently lifted was a different amount not listed.

If you selected "Other" for the weight frequently lifted, specify the weight.

Check this box if your job exposed you to outdoor conditions.

Check this box if your job exposed you to extreme heat not related to weather.

Check this box if your job exposed you to extreme cold not related to weather.

Check this box if your job exposed you to wet conditions.

Check this box if your job exposed you to high humidity.

Check this box if your job exposed you to hazardous substances.

Check this box if your job exposed you to moving mechanical parts.

Check this box if your job exposed you to high, exposed places.

Check this box if your job exposed you to heavy vibrations.

Check this box if your job exposed you to loud noises.

Check this box if your job exposed you to other conditions not specifically listed.

If the job exposed you to other conditions not listed, describe them here.

Describe the exposure(s) and how often you were exposed if any boxes were checked in the previous section.

Explain how your medical conditions would affect your ability to do this job.

Provide any additional information that could not be given in earlier parts of this report, including job title numbers and questions to which you are referring.

Enter the date this report was completed.

Check this box if the person listed in 1.A. is completing this report.

Check this box if someone other than the person listed in 1.A. is completing this report, and then provide the requested information below.

Enter the first name, middle initial, and last name of the person completing this report.

Enter the relationship of the person completing this report to the person listed in 1.A.

Enter the street address or Post Office Box number for the mailing address, including any apartment number if applicable.

Enter the city for the mailing address.

Enter the state or province for the mailing address.

Enter the ZIP or postal code for the mailing address.

Enter the country for the mailing address if it is not the USA.

Enter a daytime phone number where you can be reached or left a message, including the area code or International Direct Dialing (IDD) and country code if outside the USA or Canada.

Check this box if the heaviest weight lifted in a typical workday was less than 1 lb.

Check this box if the heaviest weight lifted in a typical workday was less than 10 lbs.

Check this box if the heaviest weight lifted in a typical workday was 10 lbs.

Check this box if the heaviest weight lifted in a typical workday was 20 lbs.

Check this box if the heaviest weight lifted in a typical workday was 50 lbs.

Check this box if the heaviest weight lifted in a typical workday was 100 lbs. or more.

Check this box if the heaviest weight lifted does not fall into any of the predefined categories, and specify the weight in the provided space.

Enter the heaviest weight lifted if it is not one of the predefined options.

Check this box if the heaviest weight lifted was less than 1 lb.

Check this box if the heaviest weight lifted was less than 10 lbs.

Check this box if the heaviest weight lifted was 10 lbs.

Check this box if the heaviest weight lifted was 20 lbs.

Check this box if the heaviest weight lifted was 50 lbs.

Check this box if the heaviest weight lifted was 100 lbs. or more.

Check this box if the heaviest weight lifted does not fall into any of the other categories.

Enter the heaviest weight lifted if it is not one of the predefined options.

Check this box if the heaviest weight lifted in a typical workday was less than 1 lb.

Check this box if the heaviest weight lifted in a typical workday was less than 10 lbs.

Check this box if the heaviest weight lifted in a typical workday was 10 lbs.

Check this box if the heaviest weight lifted in a typical workday was 20 lbs.

Check this box if the heaviest weight lifted in a typical workday was 50 lbs.

Check this box if the heaviest weight lifted in a typical workday was 100 lbs. or more.

Check this box if the heaviest weight lifted in a typical workday is not covered by the other options provided.

Enter the heaviest weight lifted if it is not among the listed options.

Check this box if the heaviest weight lifted in a typical workday was less than 1 pound.

Check this box if the heaviest weight lifted in a typical workday was less than 10 pounds.

Check this box if the heaviest weight lifted in a typical workday was 10 pounds.

Check this box if the heaviest weight lifted in a typical workday was 20 pounds.

Check this box if the heaviest weight lifted in a typical workday was 50 pounds.

Check this box if the heaviest weight lifted in a typical workday was 100 pounds or more.

Check this box if the heaviest weight lifted in a typical workday falls into a category not listed.

Enter the heaviest weight lifted if it is not among the provided options.

Check this box if Job No. 5 required interaction with coworkers, the general public, or anyone else.

Check this box if Job No. 5 did not require interaction with coworkers, the general public, or anyone else.

Describe with whom you interacted, the purpose of the interaction, how you interacted, and the time spent interacting per workday or workweek for this job.

Check this box if Job No. 4 required you to interact with coworkers, the general public, or anyone else.

Check this box if Job No. 4 did not require you to interact with coworkers, the general public, or anyone else.

Describe who you interacted with, the purpose of the interaction, how you interacted, and how much time you spent doing it per workday or workweek for Job No. 4.

Check this box if Job 2 required you to interact with coworkers, the general public, or anyone else.

Check this box if Job 2 did not require you to interact with coworkers, the general public, or anyone else.

Provide details about who you interacted with for Job No. 2, the purpose of the interaction, how you interacted, and the time spent per workday or workweek.

List the machines, tools, and equipment used regularly when doing Job No. 2, and explain their purpose.

Enter the rate of pay for Job No. 2.

Check this box if the rate of pay for Job No. 2 is specified per hour.

Check this box if the rate of pay for Job No. 2 is specified per day.

Check this box if the rate of pay for Job No. 2 is specified per week.

Check this box if the rate of pay for Job No. 2 is specified per month.

Check this box if the rate of pay for Job No. 2 is specified per year.

Enter the estimated number of hours worked per day for Job No. 2.

Enter the estimated number of days worked per week for Job No. 2.

Describe the type of report you wrote or completed for Job No. 2 and how much time you spent on it per workday or workweek.

Describe who or what you supervised and what supervisory duties you had for Job No. 2.

Provide a detailed description of the tasks performed in a typical workday for Job No. 2.

Provide a detailed description of the machines, tools, and equipment regularly used for Job 3, and explain what they were used for.

Check this box if Job 3 required you to interact with coworkers, the general public, or anyone else.

Check this box if Job 3 did not require you to interact with coworkers, the general public, or anyone else.

Describe who you interacted with, the purpose of the interaction, how you interacted, and how much time you spent doing it per workday or workweek for Job 3.

Enter the rate of pay for Job 3.

Enter the number of hours worked per day for Job 3.

Enter the number of days worked per week for Job 3.

Describe the type of report you wrote or completed for Job No. 3 and how much time you spent on it per workday or workweek.

Enter details about who or what was supervised and the supervisory duties performed for Job 3.

Provide a detailed description of the tasks performed in a typical workday for Job No. 3.

Provide details about the job exposure(s) checked, including how often you were exposed.

Provide details about the selected job exposure(s) and how often you were exposed to them.

Provide a detailed explanation of the job exposure(s) and how often you were exposed if one or more boxes were checked above.

Check this box if the job exposed you to outdoor conditions.

Check this box if the job exposed you to extreme heat that was not related to weather.

Check this box if the job exposed you to extreme cold that was not related to weather.

Check this box if the job exposed you to wet conditions.

Check this box if the job exposed you to high humidity.

Check this box if the job exposed you to hazardous substances.

Check this box if the job exposed you to moving mechanical parts.

Check this box if the job exposed you to high, exposed places.

Check this box if the job exposed you to heavy vibrations.

Check this box if the job exposed you to loud noises.

Check this box if the job exposed you to any other conditions not listed.

Please describe the other job exposure and how often you were exposed to it.

Provide details about an additional job exposure not listed above.

Check this box if the job exposed you to extreme heat not caused by weather.

Check this box if the job exposed you to extreme cold not caused by weather.

Check this box if the job exposed you to wet conditions.

Check this box if the job exposed you to high humidity.

Check this box if the job exposed you to hazardous substances.

Check this box if the job exposed you to moving mechanical parts.

Check this box if the job exposed you to high, exposed places.

Check this box if the job exposed you to heavy vibrations.

Check this box if the job exposed you to loud noises.

Check this box if the job exposed you to other conditions not listed.

Please describe any other job exposures not listed in the provided options.

Check this box if your job exposed you to outdoor conditions.

Check this box if your job exposed you to extreme heat that was not related to weather.

Check this box if your job exposed you to extreme cold that was not related to weather.

Check this box if your job exposed you to wetness.

Check this box if your job exposed you to humidity.

Check this box if your job exposed you to hazardous substances.

Check this box if your job exposed you to moving mechanical parts.

Check this box if your job exposed you to high, exposed places.

Check this box if your job exposed you to heavy vibrations.

Check this box if your job exposed you to loud noises.

Check this box if your job exposed you to other conditions not explicitly listed.

Provide details for any other job exposure not listed.

Provide a detailed list of the machines, tools, and equipment used regularly for Job No. 1, and explain what they were used for.

Check this box if Job No. 1 required interaction with coworkers, the general public, or anyone else.

Check this box if Job No. 1 did not require interaction with coworkers, the general public, or anyone else.

Describe with whom you interacted, the purpose of the interaction, how you interacted, and the time spent interacting per workday or workweek for Job No. 1.

Enter the rate of pay for Job No. 1.

Check this box if the stated rate of pay for Job No. 1 is per hour.

Check this box if the stated rate of pay for Job No. 1 is per day.

Check this box if the stated rate of pay for Job No. 1 is per week.

Check this box if the stated rate of pay for Job No. 1 is per month.

Check this box if the stated rate of pay for Job No. 1 is per year.

Enter the estimated number of hours worked per day for Job No. 1.

Enter the estimated number of days worked per week for Job No. 1.

Describe the type of report you wrote or completed and how much time you spent on it per workday or workweek for Job No. 1.

Describe who or what was supervised and the supervisory duties performed for Job No. 1.

Provide a detailed description of the tasks performed for Job No. 1 in a typical workday.

Enter the rate of pay for Job No. 5.

Check this box if the rate of pay for Job Title No. 5 is calculated per hour.

Check this box if the rate of pay for Job Title No. 5 is calculated per day.

Check this box if the rate of pay for Job Title No. 5 is calculated per week.

Check this box if the rate of pay for Job Title No. 5 is calculated per month.

Check this box if the rate of pay for Job Title No. 5 is calculated per year.

Enter the number of hours worked per day for Job No. 5.

Enter the number of days worked per week for Job No. 5.

Provide a detailed description of the tasks performed in a typical workday for Job Title No. 5.

Enter the job title for Job No. 1.

Provide the job title for Job No. 2.

Enter the job title for Job No. 3.

Provide the job title for Job No. 4.

Enter the job title for Job No. 5.

Provide the duration of time spent kneeling during a typical workday, in hours or minutes.

Please provide the amount of time spent kneeling in a typical workday, in hours or minutes.

Enter the duration you spend kneeling during a typical workday, in hours or minutes.

Enter the duration, in hours and/or minutes, for kneeling during a typical workday.

Explain what you lifted, how far you carried it, and how often you did it in a typical workday.

Explain what you lifted, how far you carried it, and how often you did it in a typical workday.

Provide a detailed explanation of what was lifted, how far it was carried, and how often this occurred in a typical workday.

Explain what you lifted, how far you carried it, and how often you did it in a typical workday.

Describe the machines, tools, and equipment used regularly for Job No. 4 and explain what they were used for.

Provide a detailed explanation of how your medical conditions affect your ability to perform this job.

Provide a detailed explanation of how your medical conditions would affect your ability to perform this job.

Provide a detailed explanation of how your medical conditions impact your ability to perform this job.

Explain how your medical conditions would affect your ability to do this job.

Enter the Office of Management and Budget control number.

Enter the rate of pay for Job No. 4.

Check this box if the rate of pay for Job No. 4 is calculated per hour.

Check this box if the rate of pay for Job No. 4 is calculated per day.

Check this box if the rate of pay for Job No. 4 is calculated per week.

Check this box if the rate of pay for Job No. 4 is calculated per month.

Check this box if the rate of pay for Job No. 4 is calculated per year.

Check this box if you perform reaching at or below shoulder level using one arm during a typical workday.

Check this box if you perform reaching at or below shoulder level using both arms during a typical workday.

Enter the total time spent reaching at or below the shoulder in hours and minutes during a typical workday.

Check this box if reaching at or below shoulder level is performed using only one arm.

Check this box if reaching at or below shoulder level is performed using both arms.

Enter the amount of time in hours and minutes spent reaching at or below the shoulder during a typical workday.

Check this box if the activity of reaching at or below the shoulder is performed using both arms.

Enter the duration in hours or minutes that you spent reaching at or below the shoulder in a typical workday.

Check this box if you typically use one arm when performing the activity of reaching at or below the shoulder during your workday.

Check this box if you typically use both arms when performing the activity of reaching at or below the shoulder during your workday.

Enter the time spent reaching at or below the shoulder during a typical workday in hours and minutes.

Check this box if you used one arm for reaching overhead (above the shoulder) during your typical workday.

Check this box if you used both arms for reaching overhead (above the shoulder) during your typical workday.

Enter the amount of time, in hours and/or minutes, spent reaching overhead (above the shoulder) during a typical workday.

Check this box if your job required you to reach overhead (above the shoulder) using one arm.

Check this box if your job required you to reach overhead (above the shoulder) using both arms.

Enter the duration in hours or minutes that was spent reaching overhead (above the shoulder) in a typical workday.

Check this box if the job requires reaching overhead using one arm.

Check this box if the job requires reaching overhead using both arms.

Enter the amount of time, in hours or minutes, spent reaching overhead (above the shoulder) during a typical workday.

Check this box if you performed overhead reaching activities using one arm.

Check this box if you performed overhead reaching activities using both arms.

Enter the duration, in hours and/or minutes, that you spend reaching overhead (above the shoulder) during a typical workday.

Describe the type of report you wrote or completed for Job Title No. 5 and the amount of time you spent on it per workday or workweek.

Enter the type of report you wrote or completed and how much time you spent on report writing per workday or workweek for Job No. 4.

Enter the total time spent sitting during a typical workday in hours and minutes. Fill so that the sum of time for standing, walking, and sitting equals the value of 'Hours per Day'

Enter the amount of time you spent sitting in a typical workday.

Please specify the duration of time spent sitting during a typical workday.

Enter the total hours and minutes spent sitting during a typical workday.

Provide the total amount of time spent standing and walking combined in a typical workday. Fill so that the sum of time for standing, walking, and sitting equals the value of 'Hours per Day'

Enter the total time in hours and minutes you spent standing and walking combined during a typical workday.

Enter the combined duration you spent standing and walking during a typical workday.

Provide the combined duration, in hours and minutes, that you spent standing and walking during a typical workday.

Enter the duration you spent stooping (bending down and forward at the waist) in a typical workday.

Please provide the amount of time, in hours and minutes, that you spend stooping (bending down & forward at the waist) during a typical workday.

Enter the total time, in hours and minutes, that you spend stooping (bending down and forward at the waist) during a typical workday.

Enter the duration you spend stooping in a typical workday.

Describe who or what you supervised and what supervisory duties you had, including examples like evaluating employee job performance, making schedules, or maintaining time records.

Describe who or what was supervised and the supervisory duties performed for Job No. 4, including examples such as evaluating employee performance, making schedules, or maintaining time records.

Describe in detail the tasks performed in a typical workday for Job Title No. 4.

Check this box if you use one hand for activities such as touching, picking, or pinching with your fingers.

Check this box if you use both hands for activities such as touching, picking, or pinching with your fingers.

Enter the time spent on activities requiring the use of fingers, such as touching, picking, or pinching, during a typical workday.

Check this box if you used only one hand for activities involving fingers to touch, pick, or pinch.

Check this box if you used both hands for activities involving fingers to touch, pick, or pinch.

Enter the time spent using fingers to touch, pick, or pinch in hours and minutes during a typical workday.

Check this box if you use one hand for activities such as touching, picking, or pinching with your fingers.

Check this box if you use both hands for activities such as touching, picking, or pinching with your fingers.

Enter the amount of time in hours and minutes spent using fingers to touch, pick, or pinch during a typical workday.

Check this box if you use one hand for activities like touching, picking, or pinching with your fingers, such as using a mouse, keyboard, turning pages, or buttoning a shirt.

Check this box if you use both hands for activities like touching, picking, or pinching with your fingers, such as using a mouse, keyboard, turning pages, or buttoning a shirt.

Enter the number of hours and minutes spent using fingers to touch, pick, or pinch during a typical workday.

Check this box if you use one hand for activities such as seizing, holding, grasping, or turning objects (e.g., a large envelope, a small box, a hammer, or a water bottle).

Check this box if you use both hands for activities such as seizing, holding, grasping, or turning objects (e.g., a large envelope, a small box, a hammer, or a water bottle).

Enter the amount of time in hours and/or minutes spent using hands to seize, hold, grasp, or turn objects during a typical workday.

Check this box if you use one hand to seize, hold, grasp, or turn objects (e.g., holding an envelope, a box, a hammer, or a water bottle) in a typical workday.

Check this box if you use both hands to seize, hold, grasp, or turn objects (e.g., holding an envelope, a box, a hammer, or a water bottle) in a typical workday.

Enter the number of hours and/or minutes spent using hands to seize, hold, grasp, or turn during a typical workday.

Check this box if you use one hand to seize, hold, grasp, or turn during your typical workday.

Check this box if you use both hands to seize, hold, grasp, or turn during your typical workday.

Enter the amount of time spent using hands to seize, hold, grasp, or turn.

Check this box if you use one hand to seize, hold, grasp, or turn during your typical workday.

Check this box if you use both hands to seize, hold, grasp, or turn during your typical workday.

Provide the total time in hours and minutes spent using hands to seize, hold, grasp, or turn during a typical workday.

Enter the number of hours worked per day for Job No. 4.

Enter the number of days worked per week for Job No. 4.