This form contains 392 fields organized into 120 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
Activity Row 1 - Standing and walking (combined)
Row 1 - Standing and walking (combined) - Hours/Minutes	Text	Enter how much of your typical workday you spend standing and walking (combined), expressed as hours and minutes.
Activity 1 - Standing and walking (combined)	Time	Enter the amount of time you typically spend standing and walking (combined) during a normal workday.
Row 1 — Standing and walking (combined) Hours/Minutes	Text	Enter the amount of your typical workday spent standing and walking (combined) as hours and minutes.
Activity Row 10 - Reaching overhead (above the shoulder) (One Arm / Both Arms / Hours)
Row 10 - Reaching overhead (above the shoulder) - One Arm	Checkbox	Check this box if you reach overhead (above shoulder level) using one arm during a typical workday.
Row 10 - Reaching overhead (above the shoulder) - Both Arms	Checkbox	Check this box if you reach overhead (above shoulder level) using both arms during a typical workday.
Row 10 — Reaching overhead (above the shoulder) - Hours	Time	Enter how much time you spend reaching overhead (above the shoulder) during a typical workday.
Activity Row 10 - Reaching overhead (above the shoulder) (One Arm, Both Arms, Hours)
Row 10 - Reaching overhead (above the shoulder): One Arm	Checkbox	Check this box if, during a typical workday, you reach overhead (above shoulder level) using only one arm.
Row 10 - Reaching overhead (above the shoulder): Both Arms	Checkbox	Check this box if, during a typical workday, you reach overhead (above shoulder level) using both arms.
Row 10 - Reaching overhead (Hours)	Time	Enter the amount of time (hours and minutes) you spent reaching overhead (above the shoulder) in a typical workday.
Row 10 - Reaching overhead (above the shoulder): One Arm	Checkbox	Check this box if, in a typical workday, you perform reaching overhead (above shoulder level) using one arm.
Row 10 - Reaching overhead (above the shoulder): Both Arms	Checkbox	Check this box if, in a typical workday, you perform reaching overhead (above shoulder level) using both arms.
Activity Row 10 - Reaching overhead (Hours)	Time	Enter the amount of time you typically spend reaching overhead (above the shoulder) in a normal workday as hours and minutes.
Activity Row 11 - Climbing stairs or ramps (Hours)
Activity 11 - Climbing stairs or ramps (Hours)	Text	Enter the amount of time you spend climbing stairs or ramps in a typical workday, expressed in hours and minutes (for example, 1:30 for one hour thirty minutes).
Activity 11 - Climbing stairs or ramps (Hours)	Time	Enter the amount of time you typically spent climbing stairs or ramps during a normal workday.
Row 11 - Climbing stairs or ramps (Hours)	Text	Enter how much time you typically spend climbing stairs or ramps in a normal workday, expressed in hours and minutes (for example "2 hours 30 minutes" or "2:30").
Activity Row 12 - Climbing ladders, ropes, or scaffolds (Hours)
Activity Row 12 - Climbing ladders, ropes, or scaffolds (Hours)	Number	Enter the amount of time you typically spend climbing ladders, ropes, or scaffolds during a normal workday.
Row 12 — Climbing ladders, ropes, or scaffolds (Hours)	Text	Enter the amount of time you typically spend climbing ladders, ropes, or scaffolds during a workday, expressed as hours and minutes (for example, "1 hr 30 min" or "1:30").
Row 12: Climbing ladders, ropes, or scaffolds (Hours)	Time	Enter the amount of time you typically spend climbing ladders, ropes, or scaffolds during a usual workday.
Activity Row 2 - Sitting
Row 2 — Sitting	Time	Enter the amount of time you typically spend sitting during a normal workday.
Row 2 - Sitting (Hours/Minutes)	Time	Enter the amount of time you spent sitting during a typical workday, expressed in hours and minutes.
Activity Row 2 — Sitting (Hours/Minutes)	Text	Enter the amount of time you spend sitting during a typical workday for this activity row, expressed in hours and minutes (for example, "6 hours 30 minutes" or "6:30").
Activity Row 3 - Stooping (bending down & forward at waist)
Row 3 — Stooping (Hours/Minutes)	Text	Enter the amount of time you typically spend stooping (bending down and forward at the waist) during a normal workday, using hours and minutes (for example, 1:30 for one hour 30 minutes).
Row 3 – Stooping time	Time	Enter the amount of time in a typical workday you spend stooping (bending down and forward at the waist).
Row 3 - Stooping (Hours/Minutes)	Text	Enter the amount of time you spend stooping (bending down and forward at the waist) during a typical workday, reported in hours and minutes (for example, 1 hr 30 min).
Activity Row 4 - Kneeling (bending legs to rest on knees)
Row 4 — Kneeling (Hours/Minutes)	Text	Enter the amount of time you typically spend kneeling (bending legs to rest on knees) during a workday, in hours and minutes (for example, 1:30 for one hour thirty minutes or 1 hr 30 min).
Row 4 — Kneeling (Hours/Minutes)	Text	Enter the amount of time you typically spend kneeling (bending legs to rest on knees) during a workday as hours and minutes (for example, 1 hour 30 minutes).
Row 4 - Kneeling (hours/minutes)	Time	Enter how much of a typical workday you spend kneeling (bending legs to rest on knees).
Activity Row 5 - Crouching (bending legs & back down & forward)
Row 5 - Crouching (bending legs & back down & forward) — Time per workday	Time	Enter how much of a typical workday you spend crouching (bending legs and back down and forward).
Row 5 - Crouching (hours per day)	Time	Enter the total time you spend crouching (bending legs and back down and forward) during a typical workday.
Activity Row 5 — Crouching (Hours/Minutes)	Time	Enter the amount of time in a typical workday you spend crouching (bending legs and back down and forward).
Activity Row 6 - Crawling (moving on hands and knees)
Row 6 — Crawling (moving on hands and knees) — Time per Workday	Time	Enter the amount of time you spend crawling (moving on hands and knees) during a typical workday.
Row 6 - Crawling (moving on hands and knees)	Time	Enter the amount of time during a typical workday you spend crawling (moving on hands and knees).
Activity 6 — Crawling (hours/minutes)	Time	Enter the amount of your typical workday spent crawling (moving on hands and knees).
Activity Row 7 - Using fingers to touch (One Hand, Both Hands, Hours)
Activity Row 7 - Using fingers to touch: One Hand	Checkbox	Check this box if, in a typical workday, you use the fingers of one hand to touch, pick, or pinch (for example, using a mouse, keyboard, turning pages, or buttoning a shirt).
Activity Row 7 - Using fingers to touch: Both Hands	Checkbox	Check this box if, in a typical workday, you use the fingers of both hands to touch, pick, or pinch (for example, using a keyboard with both hands, handling objects, or performing tasks that require two-handed finger use).
Row 7 - Using fingers to touch (Hours)	Time	Enter how much of your typical workday you spend using your fingers to touch, pick, or pinch (e.g., using a mouse, keyboard, turning pages, buttoning) for the activity shown in Row 7.
Activity Row 7 - Using fingers to touch, pick, or pinch (One Hand / Both Hands / Hours)
Row 7 — One Hand (Using fingers to touch, pick, or pinch)	Checkbox	Check this box if, during a typical workday, you perform the activity 'using fingers to touch, pick, or pinch' primarily with one hand.
Row 7 — Both Hands (Using fingers to touch, pick, or pinch)	Checkbox	Check this box if, during a typical workday, you perform the activity 'using fingers to touch, pick, or pinch' requiring the use of both hands.
Row 7 — Using fingers (hours per workday)	Time	Enter how much of your typical workday you spend using your fingers to touch, pick, or pinch (for example, using a mouse, keyboard, turning pages, or buttoning a shirt).
Activity Row 7 - Using fingers to touch/pick/pinch (One Hand, Both Hands, Hours)
Row 7 - One Hand (Using fingers to touch, pick, or pinch)	Checkbox	Check this box if, during a typical workday, you used one hand to perform activities that require using fingers to touch, pick, or pinch (e.g., using a mouse, keyboard, turning pages, or buttoning a shirt).
Row 7 - Both Hands (Using fingers to touch, pick, or pinch)	Checkbox	Check this box if, during a typical workday, you used both hands to perform activities that require using fingers to touch, pick, or pinch (e.g., using a mouse, keyboard, turning pages, or buttoning a shirt).
Row 7 - Using fingers (Hours/Minutes)	Time	Enter the amount of time you typically spend during a workday using your fingers to touch, pick, or pinch (for example, using a mouse or keyboard, turning pages, or buttoning a shirt).
Activity Row 8 - Using hands to seize, hold, grasp, or turn (One Hand / Both Hands / Hours)
Using hands to seize, hold, grasp, or turn — One Hand	Checkbox	Check this box if, in a typical workday, you use one hand to seize, hold, grasp, or turn objects (for example, holding a large envelope, a small box, a hammer, or a water bottle).
Using hands to seize, hold, grasp, or turn — Both Hands	Checkbox	Check this box if, in a typical workday, you use both hands to seize, hold, grasp, or turn objects (for example, holding a large envelope, a small box, a hammer, or a water bottle).
Row 8 — Using hands to seize/hold/grasp/turn: Hours per workday	Time	Enter how much time in a typical workday you spend using your hands to seize, hold, grasp, or turn objects (for example, holding a large envelope, small box, hammer, or bottle).
Activity Row 8 - Using hands to seize/hold/grasp/turn (One Hand, Both Hands, Hours)
Activity Row 8 - Using hands to seize/hold/grasp/turn: One Hand	Checkbox	Check this box if, during a typical workday, you use one hand to seize, hold, grasp, or turn objects (e.g., holding a large envelope, a small box, a hammer, or a water bottle).
Activity Row 8 - Using hands to seize/hold/grasp/turn: Both Hands	Checkbox	Check this box if, during a typical workday, you use both hands together to seize, hold, grasp, or turn objects (e.g., holding a large envelope, a small box, a hammer, or a water bottle).
Activity Row 8 - Using hands to seize/hold/grasp/turn (Hours/Minutes)	Time	Enter how much of a typical workday you spend using your hands to seize, hold, grasp, or turn objects (for example, holding a large envelope, small box, hammer, or water bottle).
Activity Row 8 - One Hand	Checkbox	Check this box if, in a typical workday, you use one hand to seize, hold, grasp, or turn objects (e.g., holding a large envelope, a small box, a hammer, or a water bottle).
Activity Row 8 - Both Hands	Checkbox	Check this box if, in a typical workday, you use both hands to seize, hold, grasp, or turn objects (e.g., holding a large envelope, a small box, a hammer, or a water bottle).
Row 8 — Hours per Day: Using hands to seize/hold/grasp/turn	Time	Enter how much time you typically spend in a workday performing the activity of using hands to seize, hold, grasp, or turn objects (total hours and minutes).
Activity Row 9 - Reaching at or below the shoulder (One Arm / Both Arms / Hours)
Row 9 - Reaching at or below the shoulder: One Arm	Checkbox	Check this box if, in a typical workday, you reach at or below shoulder level using only one arm.
Row 9 - Reaching at or below the shoulder: Both Arms	Checkbox	Check this box if, in a typical workday, you reach at or below shoulder level using both arms.
Activity Row 9 — Reaching at or below the shoulder (Hours)	Time	Enter how much time you spend reaching at or below shoulder level during a typical workday.
Activity Row 9 - Reaching at or below the shoulder (One Arm, Both Arms, Hours)
Row 9 - Reaching at or below the shoulder: One Arm	Checkbox	Check this box if, during a typical workday, you reach at or below shoulder level using only one arm.
Row 9 - Reaching at or below the shoulder: Both Arms	Checkbox	Check this box if, during a typical workday, you reach at or below shoulder level using both arms.
Row 9 — Reaching at or below the shoulder (Hours/Minutes)	Text	Enter the amount of time you spend reaching at or below shoulder level in a typical workday using hours and minutes (for example, 2:30 for 2 hours 30 minutes).
Row 9 - Reaching at or below the shoulder: One Arm	Checkbox	Check this box if, in a typical workday, you reach at or below shoulder level using one arm (then record the hours/minutes in the Hours/Minutes column).
Row 9 - Reaching at or below the shoulder: Both Arms	Checkbox	Check this box if, in a typical workday, you reach at or below shoulder level using both arms (then record the hours/minutes in the Hours/Minutes column).
Row 9 - Reaching at or below the shoulder (Hours)	Time	Enter the amount of time during a typical workday you spent reaching at or below shoulder level.
Climbing ladders, ropes, or scaffolds - Hours/Minutes
Climbing ladders, ropes, or scaffolds — Hours/Minutes	Time	Enter the amount of time you typically spend climbing ladders, ropes, or scaffolds during a regular workday.
Climbing stairs or ramps - Hours/Minutes
Climbing stairs or ramps — Hours/Minutes	Time	Enter the amount of time you typically spent climbing stairs or ramps in a usual workday.
Crawling (moving on hands and knees) - Hours/Minutes
Crawling — Hours/Minutes	Time	Enter how much of a typical workday you spend crawling (moving on hands and knees), expressed as hours and minutes.
Crouching (bending legs & back down & forward) - Hours/Minutes
Crouching — Hours/Minutes	Time	Enter how much time, during a typical workday, you spend crouching (bending legs and back down and forward).
Daytime Phone Number and Extension
Daytime Phone Number	Text	Enter the phone number where we may reach you or leave a message during the day, including area code and country/IDD code if calling from outside the USA or Canada. Fill only if 'Someone else (Complete the information below)' is 'Yes'. Depends on: Someone else (Complete the information below)
Daytime Phone Extension	Text	If applicable, enter the phone extension or additional dialing digits for the daytime phone number; leave blank if none. Fill only if 'Someone else (Complete the information below)' is 'Yes'. Depends on: Someone else (Complete the information below)
Describe lifting and carrying (text)
Lifting and carrying description	Text	Describe what you lifted and carried in this job, including the items or objects, approximate weights, how far you carried them, and how often you did these tasks during a typical workday.
Eighth Activity Row - Using hands to seize/hold/grasp/turn (One Hand, Both Hands, Hours)
Eighth Activity - Using hands to seize/hold/grasp/turn — One Hand	Checkbox	Check this box if, in a typical workday, you use only one hand to seize, hold, grasp, or turn objects (for example, holding a small box, hammer, or bottle) for any portion of your workday.
Eighth Activity - Using hands to seize/hold/grasp/turn — Both Hands	Checkbox	Check this box if, in a typical workday, you use both hands to seize, hold, grasp, or turn objects (for example, holding a large envelope, a box, or using two hands on a tool) for any portion of your workday.
Eighth Activity - Using hands to seize/hold/grasp/turn (Hours)	Time	Enter the amount of time in a typical workday, using hours and minutes, that you spend using your hands to seize, hold, grasp, or turn objects.
Eighth Job Entry (Row 8) - Job Title, Type of Business, Dates Worked
Eighth Job — Job Title	Text	Enter the job title you held for the eighth listed job (for example, Cashier).
Eighth Job — Type of Business	Text	Enter the type of business or industry for the employer of the eighth listed job (for example, Grocery Store).
Eighth Job — Dates Worked From	Date	Enter the date when you began working in the eighth listed job.
Eighth Job — Dates Worked To	Date	Enter the date when you stopped working in the eighth listed job or indicate that you are still employed there.
Eleventh Activity Row - Climbing stairs or ramps
Eleventh — Climbing stairs or ramps (Hours/Minutes)	Text	Enter the typical amount of time per workday you spend climbing stairs or ramps, using hours and/or minutes (for example: "1 hour" or "30 minutes").
Explain how medical conditions affect ability to do this job
Explain how medical conditions affect ability to do this job	Text	Describe your medical condition(s) and explain how each one limits or affects your ability to perform the job’s tasks, including what activities are affected, how often or for how long, and any accommodations or help you need.
Explain how medical conditions affect ability to do this job (text)
How medical conditions affect ability to do this job	Text	Describe any medical conditions, symptoms, or limitations and explain specifically how each affects your ability to perform the job tasks (for example: what you cannot do, what you can do only with difficulty, how often limitations occur, and any accommodations that help).
Explain how medical conditions would affect ability to do this job
How medical conditions affect ability to do this job	Text	Describe how your medical conditions limit or affect your ability to perform job tasks, including specific activities you cannot do or have difficulty with, how often the limitations occur, any assistive devices or restrictions you need, and any accommodations that help you perform the work.
Exposure details (how often exposed)
Exposure description and frequency	Text	Describe which of the checked job exposures applied to you and state how often you were exposed to each one (for example: daily, several times per day, hourly, weekly) including any relevant details about duration or typical situations. Fill only if 'Outdoors', 'Extreme heat (non-weather related)', 'Extreme cold (non-weather related)', 'Wetness', 'Humidity', 'Hazardous substances', 'Moving mechanical parts', 'High, exposed places', 'Heavy vibrations', 'Loud noises', 'Other' is 'Yes' (any). Depends on: Outdoors, Extreme heat (non-weather related), Extreme cold (non-weather related), Wetness, Humidity, Hazardous substances, Moving mechanical parts, High, exposed places, Heavy vibrations, Loud noises, Other
Exposure details (text)
Exposure details and frequency	Text	Describe the workplace exposures you encountered (for example: outdoors, heat, cold, wetness, hazardous substances, loud noises, moving mechanical parts, etc.) and explain how often and under what circumstances you were exposed to each. Fill only if 'Outdoors', 'Extreme heat (non-weather related)', 'Extreme cold (non-weather related)', 'Wetness', 'Humidity', 'Hazardous substances', 'Moving mechanical parts', 'High, exposed places', 'Heavy vibrations', 'Loud noises', 'Other' is 'Yes' for any. Depends on: Outdoors, Extreme heat (non-weather related), Extreme cold (non-weather related), Wetness, Humidity, Hazardous substances, Moving mechanical parts, High, exposed places, Heavy vibrations, Loud noises, Other
Exposure details (what and how often)
Exposure details and frequency	Text	Describe each exposure you experienced on this job (for example, outdoors, extreme heat, hazardous substances, loud noises, etc.), and explain how often and under what circumstances you were exposed in a typical workday. Fill only if 'Outdoors', 'Extreme heat (non-weather related)', 'Extreme cold (non-weather related)', 'Wetness', 'Humidity', 'Hazardous substances', 'Moving mechanical parts', 'High, exposed places', 'Heavy vibrations', 'Loud noises', 'Other (specify)' is 'Yes' on any. Depends on: Outdoors, Extreme heat (non-weather related), Extreme cold (non-weather related), Wetness, Humidity, Hazardous substances, Moving mechanical parts, High, exposed places, Heavy vibrations, Loud noises, Other (specify)
Exposure details and frequency
Exposure details and frequency	Text	Describe any workplace exposures you checked above and explain what each exposure was, how often you were exposed (e.g., daily, hourly, occasionally), typical duration, and any relevant context or location for the exposure. Fill only if 'Outdoors', 'Extreme heat (non-weather related)', 'Extreme cold (non-weather related)', 'Wetness', 'Humidity', 'Hazardous substances', 'Moving mechanical parts', 'High, exposed places', 'Heavy vibrations', 'Loud noises', 'Other' is 'Yes' (any). Depends on: Outdoors, Extreme heat (non-weather related), Extreme cold (non-weather related), Wetness, Humidity, Hazardous substances, Moving mechanical parts, High, exposed places, Heavy vibrations, Loud noises, Other
Fifth Activity Row - Crouching (bending legs & back down & forward)
Fifth - Crouching (bending legs & back down & forward) — Time per workday	Time	Enter the amount of time during a typical workday you spend crouching (bending legs and back down and forward).
Fifth Job Entry (Row 5) - Job Title, Type of Business, Dates Worked
Fifth Job (Row 5) — Job Title	Text	Enter the job title you held for the fifth job listed (for example, Cashier).
Fifth Job (Row 5) — Type of Business	Text	Enter the type of business or industry where you worked for the fifth job listed (for example, Grocery Store).
Fifth Job (Row 5) — Dates Worked From	Date	Provide the month and year you started working in this job for the fifth job listed.
Fifth Job (Row 5) — Dates Worked To	Date	Provide the month and year you stopped working in this job for the fifth job listed, or indicate that you still work there.
First Activity Row - Standing and walking (combined)
1st — Standing and walking (combined) Hours/Minutes	Text	Enter the amount of time you typically spend standing and walking during a workday, using hours and/or minutes (for example, "2 hours", "30 minutes", or "1").
First Job Entry (Row 1) - Job Title, Type of Business, Dates Worked
First Job - Job Title	Text	Enter the job title or position name you held for the first listed job (for example, Cashier or Software Engineer).
First Job - Type of Business	Text	Enter the type of business, employer, or industry where you worked for this job (for example, Grocery Store, Retail, Healthcare).
First Job - Dates Worked (From)	Date	Enter the date you started working in this job.
First Job - Dates Worked (To)	Date	Enter the date you stopped working in this job or indicate that you currently still work there.
Form Page Number
Page Number	Text	Enter the page number for this form page as it appears on the document (e.g., '3' for page 3).
Fourth Activity Row - Kneeling (bending legs to rest on knees)
Fourth Activity — Kneeling (Hours/Minutes)	Time	Enter how much time you typically spend kneeling (bending legs to rest on knees) during a normal workday.
Fourth Job Entry (Row 4) - Job Title, Type of Business, Dates Worked
Fourth Job - Job Title	Text	Enter the job title or position you held for this employment (for example, Cashier or Delivery Driver).
Fourth Job - Type of Business	Text	Enter the type of business or industry where you worked (for example, Grocery Store, Restaurant, or Construction).
Fourth Job - Dates Worked From	Date	Enter the month and year you started working in this job.
Fourth Job - Dates Worked To	Date	Enter the month and year you stopped working in this job or indicate if you are still employed there.
Header field (top-right) - ID 1
Header - Page Number	Text	Enter the page number or header identifier that appears in the top-right corner of the form (e.g., '1').
Heaviest weight lifted (choices + Other text)
Less than 1 lb.	Checkbox	Check this box if the heaviest weight you lifted in this job during a typical workday was less than 1 pound.
Less than 10 lbs.	Checkbox	Check this box if the heaviest weight you lifted in this job during a typical workday was under 10 pounds.
10 lbs.	Checkbox	Check this box if the heaviest weight you lifted in this job during a typical workday was about 10 pounds.
20 lbs.	Checkbox	Check this box if the heaviest weight you lifted in this job during a typical workday was about 20 pounds.
50 lbs.	Checkbox	Check this box if the heaviest weight you lifted in this job during a typical workday was about 50 pounds.
100 lbs. or more	Checkbox	Check this box if the heaviest weight you lifted in this job during a typical workday was 100 pounds or more.
Other	Checkbox	Check this box if the heaviest weight you lifted in this job does not match the listed options and write the specific weight on the line provided.
Heaviest weight lifted — Other (specify)	Number	Enter the numeric weight in pounds for the heaviest weight you lifted when selecting the 'Other' option. Fill only if 'Other' is 'Yes'. Depends on: Other
Heaviest weight lifted (choices + Other)
Less than 1 lb.	Checkbox	Check this box if the heaviest weight you lifted in this job was less than 1 pound.
Less than 10 lbs.	Checkbox	Check this box if the heaviest weight you lifted in this job was less than 10 pounds.
10 lbs.	Checkbox	Check this box if the heaviest weight you lifted in this job was about 10 pounds.
20 lbs.	Checkbox	Check this box if the heaviest weight you lifted in this job was about 20 pounds.
50 lbs.	Checkbox	Check this box if the heaviest weight you lifted in this job was about 50 pounds.
100 lbs. or more	Checkbox	Check this box if the heaviest weight you lifted in this job was 100 pounds or more.
Other	Checkbox	Check this box if the heaviest weight you lifted does not fit the listed choices and write the specific weight on the line provided.
Heaviest weight lifted — Other (specify)	Number	Enter the weight amount for the 'Other' selection that represents the heaviest weight you lifted in this job. Fill only if 'Other' is 'Yes'. Depends on: Other
Heaviest weight lifted (options + Other)
Less than 1 lb.	Checkbox	Check this box if the heaviest weight you lifted in a typical workday was less than 1 pound.
Less than 10 lbs.	Checkbox	Check this box if the heaviest weight you lifted in a typical workday was less than 10 pounds.
10 lbs.	Checkbox	Check this box if the heaviest weight you lifted in a typical workday was about 10 pounds.
20 lbs.	Checkbox	Check this box if the heaviest weight you lifted in a typical workday was about 20 pounds.
50 lbs.	Checkbox	Check this box if the heaviest weight you lifted in a typical workday was about 50 pounds.
100 lbs. or more	Checkbox	Check this box if the heaviest weight you lifted in a typical workday was 100 pounds or more.
Other	Checkbox	Check this box if the heaviest weight you lifted is not listed and write the exact weight on the line provided.
Heaviest weight lifted — Other	Number	Enter the numeric value for the heaviest weight you lifted when selecting the 'Other' option. Fill only if 'Other' is 'Yes'. Depends on: Other
Less than 1 lb.	Checkbox	Check this box if the heaviest weight you lifted in this job was less than 1 pound.
Less than 10 lbs.	Checkbox	Check this box if the heaviest weight you lifted in this job was less than 10 pounds.
10 lbs.	Checkbox	Check this box if the heaviest weight you lifted in this job was about 10 pounds.
20 lbs.	Checkbox	Check this box if the heaviest weight you lifted in this job was about 20 pounds.
50 lbs.	Checkbox	Check this box if the heaviest weight you lifted in this job was about 50 pounds.
100 lbs. or more	Checkbox	Check this box if the heaviest weight you lifted in this job was 100 pounds or more.
Other (specify)	Checkbox	Check this box if the heaviest weight you lifted does not match the listed options and write the specific weight on the line provided.
Heaviest weight lifted — Other	Number	Enter the weight (in pounds) for the 'Other' option when the heaviest weight you lifted in this job does not match the listed choices. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Heaviest weight lifted (select one)
Less than 1 lb.	Checkbox	Check this box if the heaviest weight you lifted in this job was less than 1 pound.
Less than 10 lbs.	Checkbox	Check this box if the heaviest weight you lifted in this job was less than 10 pounds.
10 lbs.	Checkbox	Check this box if the heaviest weight you lifted in this job was about 10 pounds.
20 lbs.	Checkbox	Check this box if the heaviest weight you lifted in this job was about 20 pounds.
50 lbs.	Checkbox	Check this box if the heaviest weight you lifted in this job was about 50 pounds.
100 lbs. or more	Checkbox	Check this box if the heaviest weight you lifted in this job was 100 pounds or more.
Other (specify)	Checkbox	Check this box if the heaviest weight you lifted is not listed and write the specific weight on the line provided.
Heaviest weight lifted — Other (specify)	Number	Enter the heaviest weight you lifted in this job and specify the amount in pounds if it is not one of the listed options. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
How medical conditions would affect ability to do this job
How medical conditions affect ability to do this job	Text	Describe how your medical condition(s) limit or change your ability to perform the tasks of this job, including specific activities affected, severity, frequency, and any accommodations or restrictions needed.
Interaction with Others (Yes/No and Description) (Job No. 5)
Job No. 5 - Interaction with Others: YES	Checkbox	Check this box if the job required you to interact with coworkers, the general public, or anyone else. Fill only if 'Job No. 5 (Section 2 - Work History)' is listed. Depends on: Fifth Job (Row 5) — Job Title
Job No. 5 - Interaction with Others: NO	Checkbox	Check this box if the job did not require you to interact with coworkers, the general public, or anyone else. Fill only if 'Job No. 5 (Section 2 - Work History)' is listed. Depends on: Fifth Job (Row 5) — Job Title
Job No. 5 — Interaction With Others Description	Text	If this job required interaction with coworkers, the public, or others, describe who you interacted with, the purpose of the interaction, how you interacted (in person, by phone, etc.), and how much time you spent doing it per workday or per workweek. Fill only if 'Job No. 5 - Interaction with Others: YES' is 'Yes'. Depends on: Job No. 5 - Interaction with Others: YES
Job exposure checkboxes and Other (Did this job expose you to any of the following?)
Outdoors	Checkbox	Check this box if your job required you to work outdoors or exposed you to outdoor conditions as part of your duties.
Extreme heat (non-weather related)	Checkbox	Check this box if your job exposed you to extreme heat from non-weather sources (for example, furnaces, ovens, molten metal, or similar workplace heat sources).
Extreme cold (non-weather related)	Checkbox	Check this box if your job exposed you to extreme cold from non-weather sources (for example, cold storage, freezers, or refrigeration equipment).
Wetness	Checkbox	Check this box if your job exposed you to frequent wet conditions or regular contact with water or dampness.
Humidity	Checkbox	Check this box if your job exposed you to high humidity or consistently humid working conditions.
Hazardous substances	Checkbox	Check this box if your job exposed you to hazardous substances such as chemicals, fumes, dusts, gases, or asbestos.
Moving mechanical parts	Checkbox	Check this box if your job exposed you to moving machine or mechanical parts that could cause injury.
High, exposed places	Checkbox	Check this box if your job required you to work in high or exposed locations (for example, roofs, scaffolds, or elevated platforms).
Heavy vibrations	Checkbox	Check this box if your job exposed you to strong or prolonged vibrations (for example, using jackhammers or heavy vibrating equipment).
Loud noises	Checkbox	Check this box if your job exposed you to loud noise levels (for example, regular exposure requiring hearing protection).
Other	Checkbox	Check this box if your job exposed you to any other hazards not listed above, and provide details about the exposure(s) and frequency.
Other exposures (describe)	Text	Enter a brief description of any other job exposures not listed above and explain how often you were exposed to them in a typical workday. Fill only if 'Other' is 'Yes'. Depends on: Other
Job exposures - check all that apply (choices + Other)
Outdoors	Checkbox	Check this box if your job required you to work outdoors or exposed you regularly to outdoor conditions.
Extreme heat (non-weather related)	Checkbox	Check this box if you were regularly exposed to extreme heat from sources such as ovens, furnaces, or industrial processes (not weather-related).
Extreme cold (non-weather related)	Checkbox	Check this box if you were regularly exposed to extreme cold from sources such as refrigerated areas or cold storage (not weather-related).
Wetness	Checkbox	Check this box if your work regularly exposed you to wet conditions, frequent contact with water, or constant dampness.
Humidity	Checkbox	Check this box if your job regularly exposed you to high humidity or consistently moist air conditions.
Hazardous substances	Checkbox	Check this box if you were regularly exposed to hazardous chemicals, fumes, gases, solvents, or other dangerous substances.
Moving mechanical parts	Checkbox	Check this box if your job exposed you to machinery or equipment with moving parts that could cause injury.
High, exposed places	Checkbox	Check this box if you worked at heights or in locations where you were exposed to fall hazards or high, unguarded edges.
Heavy vibrations	Checkbox	Check this box if you were regularly exposed to strong or sustained vibrations from tools, equipment, or machinery.
Loud noises	Checkbox	Check this box if your job regularly exposed you to loud noise levels (e.g., requiring hearing protection or shouting to be heard).
Other (specify)	Checkbox	Check this box if you were exposed to other job hazards not listed above and provide a brief description of the exposure.
Other job exposure (specify)	Text	Enter a brief description of any other workplace exposure not listed in the boxes (and, if relevant, indicate how often you were exposed). Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Job exposures (check all that apply + Other text)
Outdoors	Checkbox	Check this box if your job required you to work outside or be regularly exposed to outdoor conditions.
Extreme heat (non-weather related)	Checkbox	Check this box if you were exposed to extreme heat from sources other than normal weather (for example, near furnaces, ovens, boilers, or hot machinery).
Extreme cold (non-weather related)	Checkbox	Check this box if you were exposed to extreme cold from non-weather sources (for example, refrigerated rooms, freezers, or cold-processing equipment).
Wetness	Checkbox	Check this box if your work often involved getting wet or working in wet conditions (for example, frequent contact with water or other liquids).
Humidity	Checkbox	Check this box if you were regularly exposed to high humidity or very damp working conditions.
Hazardous substances	Checkbox	Check this box if you were exposed to hazardous materials such as chemicals, fumes, dusts, gases, or biological agents.
Moving mechanical parts	Checkbox	Check this box if you worked near or operated machinery with moving parts that could cause injury (for example, conveyors, rollers, or exposed gears).
High, exposed places	Checkbox	Check this box if your job required working at heights or on elevated, exposed surfaces where there was a fall risk.
Heavy vibrations	Checkbox	Check this box if you were regularly exposed to strong vibrations from tools or equipment (for example, jackhammers or heavy machinery).
Loud noises	Checkbox	Check this box if you were regularly exposed to loud noise levels (for example, requiring hearing protection or making normal conversation difficult).
Other	Checkbox	Check this box if your job exposed you to a hazard not listed above, and write a brief description of that exposure on the provided line.
Other job exposure description	Text	Describe any other workplace exposures not listed above, including what the exposure was and how often or how long you were exposed during a typical workday. Fill only if 'Other' is 'Yes'. Depends on: Other
Job exposures (check all that apply)
Outdoors	Checkbox	Check this box if the job required you to work outdoors or be regularly exposed to outside environmental conditions.
Extreme heat (non-weather related)	Checkbox	Check this box if you were regularly exposed to extreme heat not caused by weather (for example, heat from industrial processes or equipment).
Extreme cold (non-weather related)	Checkbox	Check this box if you were regularly exposed to extreme cold not caused by weather (for example, refrigeration or cold-storage environments).
Wetness	Checkbox	Check this box if the job regularly exposed you to wet conditions or frequent contact with water or moisture.
Humidity	Checkbox	Check this box if you were regularly exposed to high humidity or persistently damp/muggy conditions at work.
Hazardous substances	Checkbox	Check this box if you were regularly exposed to hazardous substances such as chemicals, fumes, dusts, gases, or biological agents.
Moving mechanical parts	Checkbox	Check this box if you worked near or operated machinery with moving parts that could cause injury or contact.
High, exposed places	Checkbox	Check this box if the job required working at heights or in unprotected, exposed elevated locations.
Heavy vibrations	Checkbox	Check this box if you were regularly exposed to heavy vibrations from tools or machinery (hand‑arm or whole‑body vibration).
Loud noises	Checkbox	Check this box if you were regularly exposed to loud noises (levels requiring shouting or the use of hearing protection).
Other	Checkbox	Check this box if the job exposed you to other conditions not listed above, and describe the exposure(s) and frequency in the space provided.
Exposure details	Text	Describe the job exposure(s) you checked above and explain how often and under what conditions you were exposed during a typical workday. Fill only if 'Other' is 'Yes'. Depends on: Other
Job exposures (check all that apply) + Other (specify) and exposure details
Outdoors	Checkbox	Check this box if the job required working outdoors or you were regularly exposed to outdoor conditions.
Extreme heat (non-weather related)	Checkbox	Check this box if you were regularly exposed to extreme heat at work (not due to weather), such as from furnaces, ovens, or hot equipment.
Extreme cold (non-weather related)	Checkbox	Check this box if you were regularly exposed to extreme cold at work (not due to weather), such as in freezers, cold storage, or cold-processing areas.
Wetness	Checkbox	Check this box if your job routinely involved getting wet or working in consistently wet or damp conditions.
Humidity	Checkbox	Check this box if your work regularly exposed you to high humidity or very moist environments.
Hazardous substances	Checkbox	Check this box if you were regularly exposed to hazardous substances such as chemicals, solvents, fumes, asbestos, or other toxic materials.
Moving mechanical parts	Checkbox	Check this box if your work involved being near or operating moving machinery or mechanical parts that could present a hazard.
High, exposed places	Checkbox	Check this box if the job required working at elevated or otherwise exposed high places (for example, on rooftops, scaffolds, or ladders without full protection).
Heavy vibrations	Checkbox	Check this box if you were routinely exposed to strong or heavy vibrations from tools, equipment, or vehicles.
Loud noises	Checkbox	Check this box if you were regularly exposed to loud noise levels at work that could affect hearing or require hearing protection.
Other (specify)	Checkbox	Check this box if you were exposed to other conditions not listed; provide a brief description of the exposure(s) and how often you were exposed in the space provided.
Other exposure (specify)	Text	Enter the name or short description of any other job exposure not listed in the checkboxes. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Exposure details and frequency	Text	Describe the exposure(s) you selected and explain how often and for how long you were exposed to each in a typical workday. Fill only if 'Outdoors', 'Extreme heat (non-weather related)', 'Extreme cold (non-weather related)', 'Wetness', 'Humidity', 'Hazardous substances', 'Moving mechanical parts', 'High, exposed places', 'Heavy vibrations', 'Loud noises', 'Other (specify)' is 'Yes' (any). Depends on: Outdoors, Extreme heat (non-weather related), Extreme cold (non-weather related), Wetness, Humidity, Hazardous substances, Moving mechanical parts, High, exposed places, Heavy vibrations, Loud noises, Other (specify)
Job No. 3 Interaction (Yes/No) and Details
Job No. 3 - Interaction: YES	Checkbox	Check this box if the job listed as Job No. 3 required you to interact with coworkers, the general public, or anyone else.
Job No. 3 - Interaction: NO	Checkbox	Check this box if the job listed as Job No. 3 did not require you to interact with coworkers, the general public, or anyone else.
Job No. 3 — Interaction Details	Text	If this job required interaction with coworkers, the public, or others, describe who you interacted with, the purpose and method of the interactions, and how much time you spent doing it per workday or workweek. Fill only if 'Job No. 3 - Interaction: YES' is 'Yes'. Depends on: Job No. 3 - Interaction: YES
Job No. 3 Machines, Tools, and Equipment
Job No. 3 — Machines, Tools, and Equipment	Text	List the machines, tools, and equipment you used regularly for Job No. 3 and briefly explain what you used each item for.
Job No. 3 Main Tasks Description
Job No. 3 — Main Tasks Description	Text	Describe in detail the tasks you performed in a typical workday for Job No. 3 (for example, stocking shelves, greeting customers, scheduling appointments, or maintaining records).
Job No. 3 Reports Description
Job No. 3 — Reports Description	Text	Describe any reports you wrote or completed for Job No. 3, including the type of report and how much time you spent on them per workday or per workweek. Fill only if 'Job No. 3 — Main Tasks Description' includes writing or completing reports. Depends on: Job No. 3 — Main Tasks Description
Job No. 3 Supervisory Description
Job No. 3 - Supervisory Duties Description	Text	Describe in detail any supervisory responsibilities you had for Job No. 3, including who or what you supervised, the specific supervisory tasks you performed (for example evaluating performance, making schedules, or maintaining time records), and how often or how much time you spent on those duties. Fill only if 'Job No. 3 — Main Tasks Description' includes supervising others. Depends on: Job No. 3 — Main Tasks Description
Job No. 3 Title and Pay/Hours
Job No. 3 - Job Title	Text	Enter the job title or position name for Job No. 3 as listed by the employer.
Job No. 3 - Rate of Pay	Number	Enter the rate of pay received for Job No. 3.
Job No. 3: Per Hour	Checkbox	Check this box if the rate of pay you entered for Job Title No. 3 is paid per hour.
Job No. 3: Per Day	Checkbox	Check this box if the rate of pay you entered for Job Title No. 3 is paid per day.
Job No. 3: Per Week	Checkbox	Check this box if the rate of pay you entered for Job Title No. 3 is paid per week.
Job No. 3: Per Month	Checkbox	Check this box if the rate of pay you entered for Job Title No. 3 is paid per month.
Job No. 3: Per Year	Checkbox	Check this box if the rate of pay you entered for Job Title No. 3 is paid per year.
Job No. 3 - Hours per Day	Number	Enter the typical number of hours worked per day for Job No. 3.
Job No. 3 - Days per Week	Text	Enter the typical number of days worked per week for Job No. 3 (for example, 5 or 'varies').
Job No.4 - Basic Info (Job Title, Rate, Pay Period, Hours)
Job No. 4 — Job Title	Text	Enter the job title or position name for Job No. 4.
Job No. 4 — Rate of Pay	Number	Enter the rate of pay for Job No. 4 in dollars for the pay period indicated.
Job No. 4 - Per Hour	Checkbox	Check this box if the rate of pay you entered for Job No. 4 is an hourly rate.
Job No. 4 - Per Day	Checkbox	Check this box if the rate of pay you entered for Job No. 4 is a daily rate.
Job No. 4 - Per Week	Checkbox	Check this box if the rate of pay you entered for Job No. 4 is a weekly rate.
Job No. 4 - Per Month	Checkbox	Check this box if the rate of pay you entered for Job No. 4 is a monthly rate.
Job No. 4 - Per Year	Checkbox	Check this box if the rate of pay you entered for Job No. 4 is an annual (yearly) rate.
Job No. 4 — Hours per Day	Number	Enter the typical number of hours worked per day for Job No. 4.
Job No. 4 — Days per Week	Text	Enter the typical number of days worked per week for Job No. 4.
Job No.4 - Interaction with Others (Yes/No and Details)
Job No. 4 — Interaction with Others: YES	Checkbox	Check this box if the job listed as Job No. 4 required you to interact with coworkers, the general public, or anyone else.
Job No. 4 — Interaction with Others: NO	Checkbox	Check this box if the job listed as Job No. 4 did not require you to interact with coworkers, the general public, or anyone else.
Job No. 4 — Interaction with Others (Details)	Text	Describe who you interacted with (coworkers, public, clients, etc.), the purpose and nature of those interactions, how you interacted (in person, phone, email, etc.), and an estimate of how much time you spent doing each activity per workday or workweek. Fill only if 'Job No. 4 — Interaction with Others: YES' is 'Yes'. Depends on: Job No. 4 — Interaction with Others: YES
Job No.4 - Machines/Tools/Equipment Used
Job No.4 - Machines, Tools, and Equipment Used	Text	List the machines, tools, and equipment you used regularly in Job No. 4 and briefly explain what you used each one for.
Job No.4 - Reports Description (type and time spent)
Job No.4 — Reports: type and time spent	Text	Describe the type(s) of reports you wrote or completed for Job No. 4 and explain how much time you spent on them (per workday or per workweek). Fill only if 'Job No. 4 - Typical Tasks Description' involved writing or completing reports. Depends on: Job No. 4 - Typical Tasks Description
Job No.4 - Supervisory Duties Description
Job No. 4 - Supervisory Duties Description	Text	Describe who or what you supervised for Job No. 4 and the specific supervisory duties you performed (for example, evaluating employee performance, making schedules, maintaining time records), including any details about how much time you spent on those duties. Fill only if 'Job No. 4 - Typical Tasks Description' involved supervising others. Depends on: Job No. 4 - Typical Tasks Description
Job No.4 - Tasks Description
Job No. 4 - Typical Tasks Description	Text	Describe in detail the tasks you performed in a typical workday for Job No. 4, including specific duties (for example: stocking shelves, greeting customers, scheduling appointments, maintaining records) and any routine responsibilities.
Job Title No. 1 - Basic Info (title, pay, rate, hours/days)
Job Title No. 1	Text	Enter the job title for Job No. 1 as you would describe the position (for example, "Cashier" or "Administrative Assistant").
Rate of Pay (Job No. 1)	Number	Enter the rate of pay you received for Job No. 1 in dollars.
Job Title No. 1 - Per Hour	Checkbox	Check this box if the rate of pay you entered for Job No. 1 is an hourly rate (paid per hour).
Job Title No. 1 - Per Day	Checkbox	Check this box if the rate of pay you entered for Job No. 1 is a daily rate (paid per day).
Job Title No. 1 - Per Week	Checkbox	Check this box if the rate of pay you entered for Job No. 1 is a weekly rate (paid per week).
Job Title No. 1 - Per Month	Checkbox	Check this box if the rate of pay you entered for Job No. 1 is a monthly rate (paid per month).
Job Title No. 1 - Per Year	Checkbox	Check this box if the rate of pay you entered for Job No. 1 is an annual rate (paid per year).
Hours per Day (Job No. 1)	Number	Enter the typical number of hours you worked per day in Job No. 1.
Days per Week (Job No. 1)	Text	Enter the typical number of days per week you worked in Job No. 1 (for example, 5).
Job Title No. 1 - Interaction with others (yes/no and description)
Job Title No. 1 - Interaction with others: YES	Checkbox	Check this box if the job required you to interact with coworkers, the general public, or anyone else (and you will provide the required description of who you interacted with, the purpose, how you interacted, and how much time you spent).
Job Title No. 1 - Interaction with others: NO	Checkbox	Check this box if the job did not require you to interact with coworkers, the general public, or anyone else.
Job Title No. 1 — Interaction description	Text	If this job required interacting with coworkers, the public, or others, describe who you interacted with, the purpose and manner of the interactions, and how much time you spent doing it per workday or workweek. Fill only if 'Job Title No. 1 - Interaction with others: YES' is 'Yes'. Depends on: Job Title No. 1 - Interaction with others: YES
Job Title No. 1 - Machines, tools, and equipment used
Job Title No. 1 - Machines, Tools, and Equipment Used	Text	List the machines, tools, and equipment you used regularly in this job and briefly explain what you used each item for.
Job Title No. 1 - Reports (type and time spent)
Job 1 — Reports (type and time spent)	Text	Describe any reports you wrote or completed for Job Title No. 1, including the type of report and how much time you spent on it per workday or per workweek. Fill only if 'Job Title No. 1 – Typical Tasks' involved writing or completing reports. Depends on: Job Title No. 1 – Typical Tasks
Job Title No. 1 - Supervisory duties (describe who/what supervised)
Job Title No. 1 - Supervisory duties (who/what supervised)	Text	Describe who or what you supervised in this job and the supervisory duties you performed, including specific tasks such as evaluating employee performance, making schedules, maintaining time records, or other management responsibilities. Fill only if 'Job Title No. 1 – Typical Tasks' involved supervising others. Depends on: Job Title No. 1 – Typical Tasks
Job Title No. 1 - Tasks (describe typical tasks)
Job Title No. 1 – Typical Tasks	Text	Describe in detail the tasks you performed in a typical workday for Job Title No. 1 (for example: stocking shelves, greeting customers, scheduling appointments, maintaining records), using complete sentences and as much detail as needed.
Job Title No. 2 - Detailed Tasks
Job 2 — Detailed Tasks	Text	Describe in detail the tasks and duties you performed in a typical workday for Job No. 2, including specific activities, responsibilities, and examples (for example: stocking shelves, greeting customers, scheduling appointments, or maintaining records).
Job Title No. 2 - Interaction with Others (Yes/No + Details)
Job Title No. 2 - Interaction with others: YES	Checkbox	Check this box if the job required you to interact with coworkers, the general public, or anyone else.
Job Title No. 2 - Interaction with others: NO	Checkbox	Check this box if the job did not require you to interact with coworkers, the general public, or anyone else.
Job Title No. 2 - Interaction Details	Text	If you answered whether the job required interaction with others, describe who you interacted with, the purpose of the interaction, how you interacted (in person, by phone, etc.), and how much time you spent doing it per workday or workweek. Fill only if 'Job Title No. 2 - Interaction with others: YES' is 'Yes'. Depends on: Job Title No. 2 - Interaction with others: YES
Job Title No. 2 - Machines/Tools/Equipment
Job No. 2 - Machines, Tools, and Equipment Used	Text	Enter the machines, tools, and equipment you used regularly for Job No. 2 and briefly explain what you used each item for.
Job Title No. 2 - Reports
Job Title No. 2 — Reports (type and time)	Text	Describe any reports you wrote or completed for Job Title No. 2, including the type of report and how much time you spent on it per workday or per workweek. Fill only if 'Job 2 — Detailed Tasks' involved writing or completing reports. Depends on: Job 2 — Detailed Tasks
Job Title No. 2 - Supervisory Duties
Job 2 Supervisory Duties Description	Text	Describe who or what you supervised in Job No. 2 and detail the supervisory duties you performed (for example, evaluating employee performance, making schedules, maintaining time records), including how often or how much supervision you provided. Fill only if 'Job 2 — Detailed Tasks' involved supervising others. Depends on: Job 2 — Detailed Tasks
Job Title No. 2 - Title and Pay
Job Title No. 2 - Title	Text	Enter the job title for Job No. 2 (for example, 'Cashier' or 'Office Manager').
Job Title No. 2 - Rate of Pay	Number	Enter the rate of pay for Job No. 2 in dollars.
Job Title No. 2 - Per Hour	Checkbox	Check this box if the rate of pay shown for Job Title No. 2 is an hourly rate (paid per hour).
Job Title No. 2 - Per Day	Checkbox	Check this box if the rate of pay shown for Job Title No. 2 is a daily rate (paid per day).
Job Title No. 2 - Per Week	Checkbox	Check this box if the rate of pay shown for Job Title No. 2 is a weekly rate (paid per week).
Job Title No. 2 - Per Month	Checkbox	Check this box if the rate of pay shown for Job Title No. 2 is a monthly rate (paid per month).
Job Title No. 2 - Per Year	Checkbox	Check this box if the rate of pay shown for Job Title No. 2 is an annual rate (paid per year).
Job Title No. 2 - Hours per Day	Number	Enter the typical number of hours you worked per day in Job No. 2.
Job Title No. 2 - Days per Week	Text	Enter the typical number of days per week you worked in Job No. 2 (for example, '5').
Job Title No. 5
Job Title No. 5	Text	Enter the name of the job you held for Job Title No. 5 as listed in Section 2 (e.g., 'Cashier', 'Office Manager'), using the same title you provided previously. Fill only if 'Job No. 5 (Section 2 - Work History)' is listed. Depends on: Fifth Job (Row 5) — Job Title
Kneeling (bending legs to rest on knees) - Hours/Minutes
Kneeling — Hours/Minutes	Text	Enter the amount of time you typically spend kneeling (bending legs to rest on knees) during a normal workday, using hours and minutes (for example “1:30” or “1 hr 30 min”).
Lifting and carrying description
Lifting and carrying description	Text	Describe the lifting and carrying you did in this job in a typical workday, including what you lifted, how far you carried it, how often you did it, and any other relevant details (weights, frequency, and distances).
Lifting and carrying description	Text	Enter a detailed description of the lifting and carrying you did in this job, including what items you lifted, how far you carried them, how often or how many times per typical workday, and any other relevant details (weights, frequency, and typical distances).
Lifting and carrying description	Text	Describe what you lifted and carried in this job, how far you carried each item, and how often you performed those lifting/carrying tasks in a typical workday.
Lifting and carrying description (tell us what you lifted, how far, how often)
Lifting and carrying description	Text	Describe what you lifted and carried in this job, including approximate weight or object, how far you carried it, and how often you did this in a typical workday.
Machines, Tools, and Equipment Used (Job No. 5)
Job No. 5 — Machines, Tools, and Equipment (Item 1)	Text	Enter the machines, tools, or equipment you used regularly for Job No. 5 and briefly explain what you used each one for (for example: 'forklift — moved pallets', 'computer — inventory and scheduling'). Fill only if 'Job No. 5 (Section 2 - Work History)' is listed. Depends on: Fifth Job (Row 5) — Job Title
Mailing Address - City / State / ZIP / Country
City	Text	Enter the city or town for your mailing address. Fill only if 'Someone else (Complete the information below)' is 'Yes'. Depends on: Someone else (Complete the information below)
State/Province	Text	Enter the state or province for your mailing address using the full name or the standard abbreviation. Fill only if 'Someone else (Complete the information below)' is 'Yes'. Depends on: Someone else (Complete the information below)
ZIP/Postal Code	Text	Enter the ZIP or postal code for your mailing address (include ZIP+4 if available). Fill only if 'Someone else (Complete the information below)' is 'Yes'. Depends on: Someone else (Complete the information below)
Country (if not USA)	Text	Enter the country name only if your mailing address is outside the United States; leave blank if your address is in the USA. Fill only if 'Someone else (Complete the information below)' is 'Yes'. Depends on: Someone else (Complete the information below)
Mailing Address (Street or PO Box)
Mailing Address (Street or PO Box)	Text	Enter the full mailing address where you receive mail (street address or PO Box), including apartment or unit number if applicable. Fill only if 'Someone else (Complete the information below)' is 'Yes'. Depends on: Someone else (Complete the information below)
Medical conditions impact explanation
1. Medical conditions impact explanation	Text	Describe how your medical conditions, symptoms, or limitations affect your ability to perform the job tasks listed above, including specific activities you cannot do or have difficulty with, how often the limitations occur, and any accommodations or changes that help you perform the work.
Name (First, Middle Initial, Last) and Relationship to Person in 1.A.
Name (First, Middle Initial, Last)	Text	Enter the full name of the person completing this report, including first name, middle initial (if any), and last name. Fill only if 'Someone else (Complete the information below)' is 'Yes'. Depends on: Someone else (Complete the information below)
Relationship to Person in 1.A.	Text	Enter the relationship of the person completing this report to the individual listed in question 1.A. (for example, spouse, parent, friend, legal representative). Fill only if 'Someone else (Complete the information below)' is 'Yes'. Depends on: Someone else (Complete the information below)
Ninth Activity Row - Reaching at or below the shoulder (One Arm, Both Arms, Hours)
Ninth Row - Reaching at or below the shoulder: One Arm	Checkbox	Check this box if, during a typical workday, you reach at or below shoulder level using only one arm.
Ninth Row - Reaching at or below the shoulder: Both Arms	Checkbox	Check this box if, during a typical workday, you reach at or below shoulder level using both arms.
9th Activity — Reaching at/below shoulder (Hours)	Text	Enter the amount of time (hours and/or minutes) you spent reaching at or below shoulder level in a typical workday for this activity.
Ninth Job Entry (Row 9) - Job Title, Type of Business, Dates Worked
Row 9 — Job Title	Text	Enter the job title you held for the ninth listed job (for example, Cashier).
Row 9 — Type of Business	Text	Enter the type of business or industry for that job or the employer name (for example, Grocery Store or Retail).
Row 9 — Dates Worked (From)	Date	Enter the date when you started working in this position.
Row 9 — Dates Worked (To)	Date	Enter the date when you stopped working in this position or indicate if you are still employed there.
Paperwork Reduction Act statement marker
Paperwork Reduction Act (PRA) Marker	Text	Enter the short PRA marker or identifier shown on the form page for the Paperwork Reduction Act statement (typically a small control or page marker).
Pay Rate and Frequency (Job No. 5)
Job 5 - Rate of Pay	Number	Enter the pay rate you received for Job No. 5 (the amount you were paid). Fill only if 'Job No. 5 (Section 2 - Work History)' is listed. Depends on: Fifth Job (Row 5) — Job Title
Job No. 5 - Per Hour	Checkbox	Check this box if the rate of pay you entered for Job No. 5 is paid per hour. Fill only if 'Job No. 5 (Section 2 - Work History)' is listed. Depends on: Fifth Job (Row 5) — Job Title
Job No. 5 - Per Day	Checkbox	Check this box if the rate of pay you entered for Job No. 5 is paid per day. Fill only if 'Job No. 5 (Section 2 - Work History)' is listed. Depends on: Fifth Job (Row 5) — Job Title
Job No. 5 - Per Week	Checkbox	Check this box if the rate of pay you entered for Job No. 5 is paid per week. Fill only if 'Job No. 5 (Section 2 - Work History)' is listed. Depends on: Fifth Job (Row 5) — Job Title
Job No. 5 - Per Month	Checkbox	Check this box if the rate of pay you entered for Job No. 5 is paid per month. Fill only if 'Job No. 5 (Section 2 - Work History)' is listed. Depends on: Fifth Job (Row 5) — Job Title
Job No. 5 - Per Year	Checkbox	Check this box if the rate of pay you entered for Job No. 5 is paid per year. Fill only if 'Job No. 5 (Section 2 - Work History)' is listed. Depends on: Fifth Job (Row 5) — Job Title
Job 5 - Hours per Day	Number	Enter the average number of hours you worked per day for Job No. 5. Fill only if 'Job No. 5 (Section 2 - Work History)' is listed. Depends on: Fifth Job (Row 5) — Job Title
Job 5 - Days per Week	Text	Enter the number of days per week you worked in Job No. 5. Fill only if 'Job No. 5 (Section 2 - Work History)' is listed. Depends on: Fifth Job (Row 5) — Job Title
Primary Job Tasks (Job No. 5)
Job No. 5 - Primary Job Tasks	Text	Describe in detail the tasks you performed in a typical workday for the job listed as Job Title No. 5 (for example: stocking shelves, greeting customers, scheduling appointments, or maintaining records). Fill only if 'Job No. 5 (Section 2 - Work History)' is listed. Depends on: Fifth Job (Row 5) — Job Title
Reaching at or below the shoulder (One Arm / Both Arms + Hours)
Reaching at or below the shoulder — One Arm	Checkbox	Check this box if, during a typical workday, you reach at or below shoulder level using only one arm (not both) for the activities you perform.
Reaching at or below the shoulder — Both Arms	Checkbox	Check this box if, during a typical workday, you reach at or below shoulder level using both arms for the activities you perform.
Reaching at or below the shoulder — Hours per day	Time	Enter the typical amount of time per workday you spend reaching at or below shoulder level.
Reaching overhead (above the shoulder) (One Arm / Both Arms + Hours)
Reaching overhead (above the shoulder) — One Arm	Checkbox	Check this box if during a typical workday you reach overhead (above shoulder level) using one arm.
Reaching overhead (above the shoulder) — Both Arms	Checkbox	Check this box if during a typical workday you reach overhead (above shoulder level) using both arms.
Reaching overhead (above the shoulder) — Time	Time	Enter how much time you spend reaching overhead (above the shoulder) during a typical workday.
Report Completion Date (MM/DD/YYYY)
Report Completion Date	Date	Enter the date when this report was completed.
Reports Written or Completed (Job No. 5)
Job No. 5 — Reports Written or Completed	Text	Describe any reports you wrote or completed for Job No. 5, including the type of report and how much time you spent on each report per workday or per workweek. Fill only if 'Job No. 5 - Primary Job Tasks' include writing or completing reports. Depends on: Job No. 5 - Primary Job Tasks
Right margin field (mid-right) - ID 2
Right margin note 1	Text	Enter a short identifier or note to appear in the mid-right margin of the page (for example a page-specific code, marker, or brief comment).
Second Activity Row - Sitting
2nd Activity - Sitting (Hours/Minutes)	Text	Enter the amount of time you spend sitting during a typical workday using hours and/or minutes (for example, '6 hours', '1 hour 30 minutes', or '1:30').
Second Job Entry (Row 2) - Job Title, Type of Business, Dates Worked
Second Job (Row 2) - Job Title	Text	Enter the job title you held for your second listed job (Row 2), for example, 'Cashier' or 'Teacher'.
Second Job (Row 2) - Type of Business	Text	Enter the type of business or industry for this job (Row 2), for example, 'Grocery store', 'Restaurant', or 'Construction'.
Second Job (Row 2) - Dates Worked From	Date	Enter the month and year when you began working in this job for your second listed job (Row 2).
Second Job (Row 2) - Dates Worked To	Date	Enter the month and year when you stopped working in this job for your second listed job (Row 2).
Section 1 - Applicant Name, SSN, Daytime Phones
Section 1 - Name (First, Middle Initial, Last, Suffix)	Text	Enter the applicant's full name (first name, middle initial, last name, and suffix if any) exactly as it appears on legal documents.
Section 1 - Social Security Number	Text	Enter the applicant's Social Security Number (SSN), using all nine digits and including dashes if you normally record them.
Section 1 - Primary Daytime Phone	Text	Enter the applicant's primary daytime telephone number, including area code or international country code if calling from outside the USA or Canada.
Section 1 - Secondary Daytime Phone (if available)	Text	Enter an alternate or secondary daytime telephone number for the applicant, including area code or international country code if applicable; leave blank if not available.
Section 3 - Remarks
Section 3 Remarks (Additional Information)	Text	Enter any additional information not provided elsewhere in this report, including the job title number and question you are referring to if applicable; use this space to continue answers for earlier sections or add details about added jobs.
Seventh Activity Row - Using fingers to touch/pick/pinch (One Hand, Both Hands, Hours)
Seventh Activity - Using fingers to touch/pick/pinch: One Hand	Checkbox	Check this box if, in a typical workday, you use one hand to touch, pick, or pinch (e.g., using a mouse, turning pages, buttoning) for the reported amount of time.
Seventh Activity - Using fingers to touch/pick/pinch: Both Hands	Checkbox	Check this box if, in a typical workday, you use both hands to touch, pick, or pinch (e.g., typing, handling small objects) for the reported amount of time.
Seventh Activity - Using fingers to touch/pick/pinch (Hours/Minutes)	Text	Enter how much time you typically spend per workday using your fingers to touch, pick, or pinch (for example, using a mouse, keyboard, turning pages, or buttoning a shirt) as hours and minutes (e.g., "2 hours", "15 minutes", or "2:30").
Seventh Job Entry (Row 7) - Job Title, Type of Business, Dates Worked
Seventh Job Title	Text	Enter the job title you held for the seventh listed job (for example, Cashier or Software Engineer).
Seventh Type of Business	Text	Enter the type of business or industry for the employer of the seventh listed job (for example, Grocery Store, Construction, or Healthcare).
Seventh Dates Worked - From	Date	Enter the date you started working in this job.
Seventh Dates Worked - To	Date	Enter the date you stopped working in this job, or indicate if you are still employed in this job.
Sitting - Hours/Minutes
Sitting	Time	Enter the amount of time you typically spend sitting during a usual workday.
Sixth Activity Row - Crawling (moving on hands and knees)
Sixth Activity — Crawling (hours/minutes)	Text	Enter how much time you typically spend crawling (moving on hands and knees) in a usual workday, e.g., "1 hour" or "15 minutes".
Sixth Job Entry (Row 6) - Job Title, Type of Business, Dates Worked
Sixth Job - Job Title	Text	Enter the job title you held for the sixth listed job (for example, Cashier).
Sixth Job - Type of Business	Text	Enter the type of business or industry for the sixth listed job (for example, Grocery Store).
Sixth Job - Dates Worked From	Date	Enter the month and year when you started working in the sixth listed job.
Sixth Job - Dates Worked To	Date	Enter the month and year when you stopped working in the sixth listed job or indicate if you are still employed there.
Standing and walking (combined) - Hours/Minutes
Standing and walking (combined) - Hours/Minutes	Text	Enter the typical amount of time you spend standing and walking combined during a normal workday, using hours and minutes (for example “2:30” for two hours and thirty minutes).
Stooping (bending down & forward at waist) - Hours/Minutes
Stooping — Hours/Minutes	Text	Enter the amount of time you typically spend stooping (bending down and forward at the waist) during a workday, using hours and minutes (for example: 1 hour 30 minutes or 1:30).
Supervisory Duties (Job No. 5)
Supervisory Duties — Job No. 5	Text	Describe in detail who or what you supervised for Job No. 5 and the specific supervisory duties you performed (for example, evaluating employee performance, making schedules, maintaining time records); provide a clear, complete description of your supervisory responsibilities. Fill only if 'Job No. 5 - Primary Job Tasks' include supervising others. Depends on: Job No. 5 - Primary Job Tasks
Tenth Activity Row - Reaching overhead (above the shoulder) (One Arm, Both Arms, Hours)
Tenth - Reaching overhead (above the shoulder) — One Arm	Checkbox	Check this box if, in a typical workday, you reach overhead (above the shoulder) using one arm.
Tenth - Reaching overhead (above the shoulder) — Both Arms	Checkbox	Check this box if, in a typical workday, you reach overhead (above the shoulder) using both arms.
Tenth — Reaching overhead (above the shoulder) — Hours/Minutes	Time	Enter the amount of time (hours and/or minutes) per typical workday you spend reaching overhead (above shoulder level).
Tenth Job Entry (Row 10) - Job Title, Type of Business, Dates Worked
10th Job Title	Text	Enter the job title or position you held for the tenth listed job.
10th Type of Business	Text	Provide the type of business or industry of the employer for the tenth listed job (for example, grocery store, office, or hospital).
10th Dates Worked - From	Date	Enter the month and year you started working in the tenth listed job.
10th Dates Worked - To	Date	Enter the month and year you stopped working in the tenth listed job, or leave blank if you are still employed.
Third Activity Row - Stooping (bending down & forward at waist)
3rd Activity - Stooping (Hours/Minutes)	Text	Enter the amount of time you typically spend stooping (bending down and forward at the waist) during a normal workday, using hours and/or minutes (for example, "15 minutes" or "1 hour").
Third Job Entry (Row 3) - Job Title, Type of Business, Dates Worked
Third Job Title	Text	Enter the job title you held for this position (for example, Cashier or Delivery Driver).
Third Type of Business	Text	Enter the primary type of business or industry for this job (for example, Grocery Store, Restaurant, or Construction).
Third Dates Worked - From	Date	Enter the date you started working in this position.
Third Dates Worked - To	Date	Enter the date you stopped working in this position, or the date up to which you currently work if still employed.
Top-right page marker
Page marker 1	Text	Enter the small top-right page marker or identifier shown on the form (the single-digit number or code printed in the highlighted box).
Twelfth Activity Row - Climbing ladders, ropes, or scaffolds
Twelfth Activity — Climbing ladders, ropes, or scaffolds (Hours/Minutes)	Time	Enter the amount of time you typically spend during a normal workday climbing ladders, ropes, or scaffolds.
Using fingers to touch/pick/pinch (One Hand / Both Hands + Hours)
Using fingers to touch, pick, or pinch — One Hand	Checkbox	Check this box if, in a typical workday, you perform finger activities (e.g., using a mouse, keyboard, turning pages, buttoning a shirt) using only one hand.
Using fingers to touch, pick, or pinch — Both Hands	Checkbox	Check this box if, in a typical workday, you perform finger activities (e.g., using a mouse, keyboard, turning pages, buttoning a shirt) using both hands.
Using fingers to touch/pick/pinch — One Hand (Hours/Minutes)	Text	Enter the typical amount of time in a workday you use fingers with one hand (e.g., using a mouse, keyboard, turning pages, buttoning) as hours and minutes.
Using hands to seize/hold/grasp/turn (One Hand / Both Hands + Hours)
Using hands to seize, hold, grasp, or turn — One Hand	Checkbox	Check this box if, in a typical workday, you perform seizing/holding/grasping/turning tasks using only one hand (then enter the hours/minutes spent).
Using hands to seize, hold, grasp, or turn — Both Hands	Checkbox	Check this box if, in a typical workday, you perform seizing/holding/grasping/turning tasks using both hands (then enter the hours/minutes spent).
Using hands to seize/hold/grasp/turn — Hours per day	Time	Enter the amount of time in a typical workday you spend using your hands to seize, hold, grasp, or turn objects (for example, holding a large envelope, small box, hammer, or water bottle) as hours and minutes.
Weight frequently lifted (choices + Other text)
Less than 1 lb.	Checkbox	Check this box if the weight you frequently lift during a typical workday (about 1/3 to 2/3 of the day) is less than 1 pound.
Less than 10 lbs.	Checkbox	Check this box if the weight you frequently lift during a typical workday (about 1/3 to 2/3 of the day) is less than 10 pounds.
10 lbs.	Checkbox	Check this box if the weight you frequently lift during a typical workday (about 1/3 to 2/3 of the day) is 10 pounds.
25 lbs.	Checkbox	Check this box if the weight you frequently lift during a typical workday (about 1/3 to 2/3 of the day) is 25 pounds.
50 lbs. or more	Checkbox	Check this box if the weight you frequently lift during a typical workday (about 1/3 to 2/3 of the day) is 50 pounds or more.
Other (specify)	Checkbox	Check this box if you frequently lift a weight not listed above (about 1/3 to 2/3 of the workday) and write the specific weight on the line provided.
Weight frequently lifted — Other	Text	Enter the weight you frequently lift for the 'Other' option as a text string, including the unit (for example, "15 lbs" or "7 kg"). Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Weight frequently lifted (choices + Other)
Less than 1 lb.	Checkbox	Check this box if the weight you most frequently lift during a typical workday (about 1/3 to 2/3 of the day) is less than 1 pound.
Less than 10 lbs.	Checkbox	Check this box if the weight you most frequently lift during a typical workday (about 1/3 to 2/3 of the day) is less than 10 pounds.
10 lbs.	Checkbox	Check this box if the weight you most frequently lift during a typical workday (about 1/3 to 2/3 of the day) is approximately 10 pounds.
25 lbs.	Checkbox	Check this box if the weight you most frequently lift during a typical workday (about 1/3 to 2/3 of the day) is approximately 25 pounds.
50 lbs. or more	Checkbox	Check this box if the weight you most frequently lift during a typical workday (about 1/3 to 2/3 of the day) is 50 pounds or more.
Other (specify)	Checkbox	Check this box if the weight you most frequently lift during a typical workday is not listed, and write the specific weight on the line provided.
Weight frequently lifted — Other	Text	If you selected "Other" for the weight you frequently lifted, enter that weight here (include units, e.g., "15 lbs"). Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Weight frequently lifted (options + Other)
Less than 1 lb.	Checkbox	Check this box if the weight you frequently lifted (about one-third to two-thirds of the workday) was less than 1 pound.
Less than 10 lbs.	Checkbox	Check this box if the weight you frequently lifted (about one-third to two-thirds of the workday) was less than 10 pounds.
10 lbs.	Checkbox	Check this box if you frequently lifted items weighing about 10 pounds for roughly one-third to two-thirds of your typical workday.
25 lbs.	Checkbox	Check this box if you frequently lifted items weighing about 25 pounds for roughly one-third to two-thirds of your typical workday.
50 lbs. or more	Checkbox	Check this box if you frequently lifted items weighing 50 pounds or more for about one-third to two-thirds of your typical workday.
Other	Checkbox	Check this box if the weight you frequently lifted is not listed, and write the specific weight in the provided space.
Frequently Lifted Weight (Other)	Number	If you selected 'Other' for the weight frequently lifted, enter the weight you typically lifted in this job during a typical workday (in pounds). Fill only if 'Other' is 'Yes'. Depends on: Other
Less than 1 lb.	Checkbox	Check this box if the weight you most frequently lifted during a typical workday (about 1/3 to 2/3 of the workday) was less than 1 pound.
Less than 10 lbs.	Checkbox	Check this box if the weight you most frequently lifted during a typical workday (about 1/3 to 2/3 of the workday) was less than 10 pounds.
10 lbs.	Checkbox	Check this box if the weight you most frequently lifted during a typical workday (about 1/3 to 2/3 of the workday) was approximately 10 pounds.
25 lbs.	Checkbox	Check this box if the weight you most frequently lifted during a typical workday (about 1/3 to 2/3 of the workday) was approximately 25 pounds.
50 lbs. or more	Checkbox	Check this box if the weight you most frequently lifted during a typical workday (about 1/3 to 2/3 of the workday) was 50 pounds or more.
Other	Checkbox	Check this box if the weight you most frequently lifted during a typical workday (about 1/3 to 2/3 of the workday) is not listed, and write the approximate weight on the line provided.
Weight frequently lifted - Other (Specify)	Text	Enter the other weight or a brief description of the weight you frequently lifted (for example, a specific number of pounds or a description like 'child/carpet roll') that is not listed among the checkboxes. Fill only if 'Other' is 'Yes'. Depends on: Other
Weight frequently lifted (select one)
Less than 1 lb.	Checkbox	Check this box if the weight you frequently lift (about 1/3 to 2/3 of the workday) is less than 1 pound.
Less than 10 lbs.	Checkbox	Check this box if the weight you frequently lift (about 1/3 to 2/3 of the workday) is less than 10 pounds.
10 lbs.	Checkbox	Check this box if the weight you frequently lift (about 1/3 to 2/3 of the workday) is approximately 10 pounds.
25 lbs.	Checkbox	Check this box if the weight you frequently lift (about 1/3 to 2/3 of the workday) is approximately 25 pounds.
50 lbs. or more	Checkbox	Check this box if the weight you frequently lift (about 1/3 to 2/3 of the workday) is 50 pounds or more.
Other	Checkbox	Check this box if the weight you frequently lift (about 1/3 to 2/3 of the workday) is not listed, and write the specific weight in the provided blank.
Weight frequently lifted — Other	Text	If you checked Other for the weight frequently lifted (about 1/3 to 2/3 of the workday), enter the specific weight or brief description here (e.g., "35 lbs", "boxes up to 40 lbs"). Fill only if 'Other' is 'Yes'. Depends on: Other
Who is completing this report - options
The person listed in 1.A.	Checkbox	Check this box if the person who completed this report is the same person listed in item 1.A.
Someone else (Complete the information below)	Checkbox	Check this box if someone other than the person listed in 1.A. completed the report, and you will provide that person's name and relationship below.

Form SSA-3369-BK, Work History Report Instructions