Form SSA-3369-BK, Work History Report Completed Form Examples and Samples
Explore a complete, filled-out example of Form SSA-3369-BK, the Work History Report. This sample provides a clear guide on how to detail your past jobs, duties, and physical requirements for a Social Security disability claim.
Form SSA-3369-BK Example – Work History Report for a Disability Claim
How this form was filled:
This is an example of a completed Form SSA-3369-BK for Maria Rodriguez, who is applying for disability benefits due to severe osteoarthritis. The form details her work history over the last 15 years, including her most recent job as an Office Clerk and a previous role as a Retail Cashier. It provides specific information on job duties, hours, pay, and the physical demands of each position, which is critical for the Social Security Administration's evaluation.
Information used to fill out the document:
- Claimant Name: Maria S. Rodriguez
- Social Security Number: XXX-XX-1234
- Date Stopped Working: 10/15/2025
- Reason for Stopping Work: Severe Osteoarthritis preventing me from sitting for long periods and using a keyboard.
- Job 1 Title: Office Clerk
- Job 1 Employer: City Legal Services
- Job 1 Dates: January 2018 to October 2025
- Job 1 Pay: Started at $18.00/hour, ended at $22.00/hour
- Job 1 Hours per Week: 40
- Job 1 Duties: Answered multi-line phones, scheduled client appointments, performed data entry of case files, maintained physical and digital records. Used a computer for 6-7 hours per day. Occasionally had to lift and move boxes of paper weighing up to 20 lbs.
- Job 2 Title: Retail Cashier
- Job 2 Employer: SuperMart Foods
- Job 2 Dates: March 2012 to December 2017
- Job 2 Pay: Started at $10.00/hour, ended at $14.00/hour
- Job 2 Hours per Week: 35
- Job 2 Duties: Operated a POS cash register to process customer payments. Scanned and bagged groceries. Provided customer service. Required standing for 7-8 hours per shift and frequently lifting grocery bags up to 25 lbs.
What this filled form sample shows:
- Complete work history provided for the 15-year period prior to stopping work.
- Detailed descriptions of job duties for each position.
- Specific information on physical demands, including hours of standing/sitting and weights lifted.
- Clear documentation of pay rates, hours, and dates of employment.
- A precise date and reason are given for why the applicant stopped working.
Form specifications and details:
| Form Name: | Form SSA-3369-BK, Work History Report |
| Agency: | Social Security Administration (SSA) |
| Use Case: | Documenting past relevant work as part of an application for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI). |
Created: February 05, 2026 08:21 PM
