Form SSA-3369-BK, Work History Report Instructions

Enter how much time you typically spend in a workday climbing ladders, ropes, or scaffolds.

Enter how much time you typically spend during a workday climbing stairs or ramps.

Enter how much time you spend crawling (moving on hands and knees) during a typical workday.

Enter the total amount of time you spend crouching during a typical workday.

Enter the total amount of time you spend kneeling during a typical workday.

Check this box if, during your workday, you reached at or below shoulder level using one arm.

Check this box if, during your workday, you reached at or below shoulder level using both arms.

Enter the total amount of time you spend in a typical workday reaching at or below shoulder level, considering whether you used one arm or both arms. Fill only if 'One Arm', 'Both Arms' is 'Yes' (any).

Check this box if, during a typical workday, you reached overhead using one arm.

Check this box if, during a typical workday, you reached overhead using both arms.

Enter how much time you spent in a typical workday reaching overhead (above the shoulder), using either one arm or both arms. Fill only if 'Reaching overhead (above the shoulder) - One Arm', 'Reaching overhead (above the shoulder) - Both Arms' is 'Yes' (any).

Enter how much time you typically spend sitting during a workday (in hours and/or minutes).

Enter the total time you typically spend standing and walking combined during a workday.

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

Check this box if, in a typical workday, you used the fingers of one hand to touch, pick, or pinch (e.g., mouse/keyboard, turning pages, buttoning).

Check this box if, in a typical workday, you used the fingers of both hands to touch, pick, or pinch (e.g., mouse/keyboard, turning pages, buttoning).

Enter how much time you typically spend in a workday using your fingers to touch, pick, or pinch (for example, using a mouse/keyboard, turning pages, or buttoning a shirt). Fill only if 'Using fingers — One Hand', 'Using fingers — Both Hands' is 'Yes' (any).

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

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

Enter how much time you spent in a typical workday using your hands to seize, hold, grasp, or turn objects (e.g., holding a large envelope, small box, hammer, or water bottle). Fill only if 'One Hand', 'Both Hands' is 'Yes' (any).

Enter the total time you typically spend in a workday climbing ladders, ropes, or scaffolds.

Enter the total time you typically spend in a workday climbing ladders, ropes, or scaffolds.

Enter the total time you typically spend in a workday climbing ladders, ropes, or scaffolds.

Enter the total time you typically spend climbing stairs or ramps during a usual workday.

Enter how much time you spend climbing stairs or ramps during a typical workday.

Enter how much time you typically spend climbing stairs or ramps during a typical workday.

Enter the daytime phone number where you can be reached or where a message may be left, including area code and any international/country codes if outside the USA or Canada. Fill only if 'Someone else (Complete the information below)' is 'Yes'.

Enter the phone extension for the daytime phone number, if applicable.

Enter the completer's mailing street address or PO Box, including any apartment or unit number if applicable. Fill only if 'Someone else (Complete the information below)' is 'Yes'.

Enter the city for the completer's mailing address. Fill only if 'Someone else (Complete the information below)' is 'Yes'.

Enter the state or province for the completer's mailing address. Fill only if 'Someone else (Complete the information below)' is 'Yes'.

Enter the ZIP code or postal code for the completer's mailing address. Fill only if 'Someone else (Complete the information below)' is 'Yes'.

Enter the country for the completer's mailing address if it is outside the United States. Fill only if 'Someone else (Complete the information below)' is 'Yes'.

Enter the full name (first, middle initial, last) of the person completing this report. Fill only if 'Someone else (Complete the information below)' is 'Yes'.

Enter the completer’s relationship to the person listed in item 1.A. Fill only if 'Someone else (Complete the information below)' is 'Yes'.

Enter how much time you spend crawling (moving on hands and knees) during a typical workday.

Enter how much time you spend crawling (moving on hands and knees) during a typical workday.

Enter the amount of time you typically spend crawling (moving on hands and knees) during a workday, in hours and/or minutes.

Enter the total amount of time you spend crouching in a typical workday.

Enter how much time you spend crouching (bending legs and back down and forward) during a typical workday.

Enter the total amount of time you typically spend crouching during a normal workday.

Enter the date on which this report was completed.

Check this box if, for this activity, you typically use one hand to seize, hold, grasp, or turn objects during your workday.

Check this box if, for this activity, you typically use both hands to seize, hold, grasp, or turn objects during your workday.

Enter how much time you spend in a typical workday using your hands to seize, hold, grasp, or turn objects. Fill only if 'One Hand', 'Both Hands' is 'Yes' (any).

Enter the job title for your eighth job in the work history list.

Enter the type of business or industry where you worked for your eighth job.

Enter the date you started working at your eighth job.

Enter the date you stopped working at your eighth job.

Enter the total amount of time you typically spend in a workday climbing stairs or ramps.

Describe any job-related exposures you had (such as outdoors, extreme heat/cold, wetness, humidity, hazardous substances, moving mechanical parts, heights, heavy vibrations, loud noise, or other) and explain how often 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' (any fields).

Describe the types of workplace exposures you had (based on the items checked above) and how often you were exposed during this job. 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).

Describe the specific workplace exposure(s) you had (for any items checked above) and how often you were exposed in this job. 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).

Describe the exposure(s) you checked above and explain how often you were exposed during this job. 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 fields).

Describe the workplace exposure(s) you had (based on the checked items above) and explain how often you were exposed during this job. Fill only if 'Odours', '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).

Enter the total amount of time you spend crouching during a typical workday.

Enter the job title you held for your fifth listed job.

Enter the type of business or industry for your fifth listed job (for example, grocery store or construction company).

Enter the date you started working at your fifth listed job.

Enter the date you stopped working at your fifth listed job.

Enter the total amount of time you spend standing and walking combined during a typical workday.

Enter the job title for your first listed job in your work history.

Enter the type of business or industry where you worked for your first listed job.

Enter the date you started working at this job.

Enter the date you stopped working at this job.

Enter the Social Security number associated with the person completing this Work History Report.

Enter the total time you typically spend kneeling during a workday.

Enter the job title you held for your fourth listed job.

Enter the type of business or industry for your fourth listed job (for example, grocery store, restaurant, construction).

Enter the month and year you started working at your fourth listed job.

Enter the month and year you stopped working at your fourth listed job.

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

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

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

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

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

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

Check this box if the heaviest weight you lifted in this job does not fit the listed options (and specify the weight on the line).

If you selected "Other" for the heaviest weight you lifted, enter the weight amount and units. Fill only if 'Other' is 'Yes'.

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

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

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

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

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

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

Check this box if the heaviest weight you lifted does not match the listed options, and write the weight on the provided line.

Enter the heaviest weight you lifted if it is not covered by the listed choices. Fill only if 'Other' is 'Yes'.

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

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

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

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

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

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

Check this box if none of the listed weights match the heaviest weight you lifted in this job, and write the weight on the line provided.

Enter the heaviest weight you lifted if it is not one of the listed options. Fill only if 'Other' is 'Yes'.

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

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

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

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

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

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

Check this box if the heaviest weight you lifted does not match the listed options and enter the weight on the line provided.

Enter the heaviest weight you lifted if it is not one of the listed options. Fill only if 'Other' is 'Yes'.

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

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

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

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

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

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

Check this box if the heaviest weight you lifted in this job does not match the listed options, and write the weight on the line provided.

Enter the heaviest weight you lifted in this job if it is not covered by the listed options. Fill only if 'Other' is 'Yes'.

Enter the typical number of hours you worked per day at Job Title No. 2. Fill only if 'Job Title (Job No. 2) listed in Section 2' is provided.

Enter the typical number of days you worked per week at Job Title No. 2. Fill only if 'Job Title (Job No. 2) listed in Section 2' is provided.

Explain how your medical conditions would affect your ability to perform this job, including any limitations on tasks, pace, stamina, or required accommodations.

Describe how your medical conditions would affect your ability to perform this job’s duties.

Enter the document title text printed vertically along the right margin.

Enter the OMB control number printed in the page header.

Enter the form number text printed vertically along the right margin.

Enter the current page number shown in the page header.

Check this box if this job required you to interact with coworkers, the general public, or anyone else. Fill only if 'Job Title (Job No. 2) listed in Section 2' is provided.

Check this box if this job did not require you to interact with coworkers, the general public, or anyone else. Fill only if 'Job Title (Job No. 2) listed in Section 2' is provided.

Describe who you interacted with at this job (coworkers, the public, or others), the purpose and method of the interaction, and how much time you spent doing it per workday or workweek. Fill only if 'Yes' is 'Yes'.

Check this box if this job required you to interact with coworkers, the general public, or anyone else. Fill only if 'Job No. 5 (Job Title) in Section 2 - Work History' is provided.

Check this box if this job did not require you to interact with coworkers, the general public, or anyone else. Fill only if 'Job No. 5 (Job Title) in Section 2 - Work History' is provided.

Describe whether this job required interaction with coworkers, the general public, or others, including who you interacted with, the purpose and method of the interaction, and how much time you spent interacting per workday or workweek. Fill only if 'YES' is 'Yes'.

Check this box if Job Title No. 1 required you to interact with coworkers, the general public, or anyone else. Fill only if 'Job Title 1 (Section 2 job list)' is provided.

Check this box if Job Title No. 1 did not require you to interact with coworkers, the general public, or anyone else. Fill only if 'Job Title 1 (Section 2 job list)' is provided.

If the job required interaction with coworkers, the general public, or anyone else, describe who you interacted with, the purpose and method of the interaction, and how much time you spent doing it per workday or workweek. Fill only if 'Yes' is 'Yes'.

List the machines, tools, and equipment you used regularly for Job 1 and briefly explain what you used each item for. Fill only if 'Job Title 1 (Section 2 job list)' is provided.

Describe the types of reports or written documents you prepared or completed for Job No. 1 and how much time you typically spent on this writing per workday or per workweek. Fill only if 'Typical Workday Tasks (Job 1)' includes writing or completing reports.

Describe who or what you supervised in Job 1 and explain the supervisory duties you performed (for example, evaluating employees, making schedules, or maintaining time records). Fill only if 'Typical Workday Tasks (Job 1)' includes supervising others.

Enter the job title for Job No. 1. Fill only if 'Job Title 1 (Section 2 job list)' is provided.

Enter the amount you were paid for Job No. 1 for the pay period you select (hour, day, week, month, or year). Fill only if 'Job Title 1 (Section 2 job list)' is provided.

Check this box if the rate of pay you entered is paid per hour. Fill only if 'Job Title 1 (Section 2 job list)' is provided.

Check this box if the rate of pay you entered is paid per day. Fill only if 'Job Title 1 (Section 2 job list)' is provided.

Check this box if the rate of pay you entered is paid per week. Fill only if 'Job Title 1 (Section 2 job list)' is provided.

Check this box if the rate of pay you entered is paid per month. Fill only if 'Job Title 1 (Section 2 job list)' is provided.

Check this box if the rate of pay you entered is paid per year. Fill only if 'Job Title 1 (Section 2 job list)' is provided.

Enter the typical number of hours you worked per day at Job No. 1. Fill only if 'Job Title 1 (Section 2 job list)' is provided.

Enter the typical number of days per week you worked at Job No. 1. Fill only if 'Job Title 1 (Section 2 job list)' is provided.

Describe in detail the tasks you performed during a typical workday for Job Title No. 1. Fill only if 'Job Title 1 (Section 2 job list)' is provided.

Check this box if this job required you to work outdoors.

Check this box if this job exposed you to extreme heat from sources other than the weather (for example, ovens, furnaces, or industrial heat).

Check this box if this job exposed you to extreme cold from sources other than the weather (for example, freezers or refrigerated areas).

Check this box if this job frequently exposed you to wet conditions (water or other liquids).

Check this box if this job exposed you to high-humidity conditions.

Check this box if this job exposed you to hazardous substances (such as chemicals, fumes, dusts, solvents, or similar materials).

Check this box if this job exposed you to moving mechanical parts (such as machinery with moving components).

Check this box if this job required you to work at heights or in exposed high places.

Check this box if this job exposed you to heavy vibrations (for example, from power tools, machinery, or vehicles).

Check this box if this job exposed you to loud noise levels.

Check this box if this job exposed you to another condition not listed, and write the exposure on the line provided.

Describe any other type of exposure you had on this job that is not listed in the checklist. Fill only if 'Other' is 'Yes'.

Check this box if this job required you to work outdoors and you were exposed to outdoor conditions.

Check this box if this job exposed you to extreme heat from non-weather sources (for example, furnaces, ovens, boilers, hot equipment, or hot indoor environments).

Check this box if this job exposed you to extreme cold from non-weather sources (for example, freezers, refrigerated areas, or cold industrial processes).

Check this box if you were frequently wet or worked in wet conditions during this job.

Check this box if you were exposed to high humidity or very damp air while doing this job.

Check this box if this job exposed you to hazardous substances (such as chemicals, fumes, dusts, solvents, or other dangerous materials).

Check this box if you worked around moving mechanical parts (such as machinery with moving components) during this job.

Check this box if this job required working at heights or in exposed high places (such as rooftops, platforms, scaffolds, or open edges).

Check this box if this job exposed you to heavy vibration (for example, from power tools, machinery, or vehicles).

Check this box if this job exposed you to loud noise levels that could affect hearing or required hearing protection.

Check this box if this job exposed you to other conditions not listed, and be prepared to describe the exposure and how often it occurred.

Describe any other workplace exposure not listed in the checklist. Fill only if 'Other' is 'Yes'.

Check this box if this job exposed you to outdoor conditions as part of your work.

Check this box if this job exposed you to extreme heat from sources other than normal weather (e.g., furnaces, ovens, hot equipment).

Check this box if this job exposed you to extreme cold from sources other than normal weather (e.g., freezers, refrigerated areas).

Check this box if this job exposed you to wet conditions (water, liquids, or consistently wet environments).

Check this box if this job exposed you to high humidity or very damp air conditions.

Check this box if this job exposed you to hazardous substances (such as chemicals, fumes, dusts, gases, or toxic materials).

Check this box if this job exposed you to moving mechanical parts (such as machinery with moving components).

Check this box if this job required work at heights or in high, exposed places (e.g., rooftops, scaffolds, elevated platforms).

Check this box if this job exposed you to heavy vibrations (such as from power tools, machinery, or vehicles).

Check this box if this job exposed you to loud noise levels during your work.

Check this box if this job exposed you to a type of exposure not listed here and provide the exposure in the space provided.

Describe any other type of exposure you had in this job that is not listed among the check-all-that-apply options. Fill only if 'Other' is 'Yes'.

Check this box if Job No. 3 required you to interact with coworkers, the general public, or anyone else (then provide the requested description below). Fill only if 'Job Title' for Job No. 3 (listed in Section 2) is provided.

Check this box if Job No. 3 did not require you to interact with coworkers, the general public, or anyone else. Fill only if 'Job Title' for Job No. 3 (listed in Section 2) is provided.

Describe who you interacted with on this job (coworkers, the public, or others), the purpose and method of the interaction, and how much time you spent interacting per workday or workweek. Fill only if 'Yes' is 'Yes'.

List the machines, tools, and equipment you used regularly in Job No. 3 and explain what you used each item for. Fill only if 'Job Title' for Job No. 3 (listed in Section 2) is provided.

Enter the job title for Job No. 3. Fill only if 'Job Title' for Job No. 3 (listed in Section 2) is provided.

Enter the amount you were paid for Job No. 3 for the selected pay period (hour, day, week, month, or year). Fill only if 'Job Title' for Job No. 3 (listed in Section 2) is provided.

Check this box if the rate of pay you entered is paid per hour. Fill only if 'Job Title' for Job No. 3 (listed in Section 2) is provided.

Check this box if the rate of pay you entered is paid per day. Fill only if 'Job Title' for Job No. 3 (listed in Section 2) is provided.

Check this box if the rate of pay you entered is paid per week. Fill only if 'Job Title' for Job No. 3 (listed in Section 2) is provided.

Check this box if the rate of pay you entered is paid per month. Fill only if 'Job Title' for Job No. 3 (listed in Section 2) is provided.

Check this box if the rate of pay you entered is paid per year. Fill only if 'Job Title' for Job No. 3 (listed in Section 2) is provided.

Enter the typical number of hours you worked per day at Job No. 3. Fill only if 'Job Title' for Job No. 3 (listed in Section 2) is provided.

Enter the typical number of days per week you worked at Job No. 3. Fill only if 'Job Title' for Job No. 3 (listed in Section 2) is provided.

Describe who or what you supervised in Job No. 3 and explain the specific supervisory duties you performed. Fill only if 'Typical Workday Tasks (Job 3)' mentions supervising others.

Describe in detail the tasks you performed during a typical workday for Job No. 3. Fill only if 'Job Title' for Job No. 3 (listed in Section 2) is provided.

Describe the type of reports or written materials you prepared for Job No. 3 and how much time you spent on this writing or reporting work per workday or workweek. Fill only if 'Typical Workday Tasks (Job 3)' mentions writing or completing reports.

Check this box if Job No. 4 required you to interact with coworkers, the general public, or anyone else. Fill only if 'Job No. 4' is listed in Section 2 - Work History.

Check this box if Job No. 4 did not require you to interact with coworkers, the general public, or anyone else. Fill only if 'Job No. 4' is listed in Section 2 - Work History.

Describe who you interacted with on Job No. 4 (coworkers, the public, or others), the purpose and method of the interaction, and approximately how much time you spent interacting per workday or workweek. Fill only if 'YES' is 'Yes'.

List the machines, tools, and equipment you regularly used in Job No. 4 and briefly explain what you used each item for. Fill only if 'Job No. 4' is listed in Section 2 - Work History.

Describe who or what you supervised in Job No. 4 and the supervisory duties you performed. Fill only if 'Job No. 4' is listed in Section 2 - Work History.

Enter the job title for Job No. 4. Fill only if 'Job No. 4' is listed in Section 2 - Work History.

Enter the amount you were paid for this job at the selected pay period (hour, day, week, month, or year). Fill only if 'Job No. 4' is listed in Section 2 - Work History.

Check this box if the rate of pay you entered is paid per hour for Job Title No. 4. Fill only if 'Job No. 4' is listed in Section 2 - Work History.

Check this box if the rate of pay you entered is paid per day for Job Title No. 4. Fill only if 'Job No. 4' is listed in Section 2 - Work History.

Check this box if the rate of pay you entered is paid per week for Job Title No. 4. Fill only if 'Job No. 4' is listed in Section 2 - Work History.

Check this box if the rate of pay you entered is paid per month for Job Title No. 4. Fill only if 'Job No. 4' is listed in Section 2 - Work History.

Check this box if the rate of pay you entered is paid per year for Job Title No. 4. Fill only if 'Job No. 4' is listed in Section 2 - Work History.

Enter the typical number of hours you worked per day in this job. Fill only if 'Job No. 4' is listed in Section 2 - Work History.

Enter the typical number of days you worked per week in this job. Fill only if 'Job No. 4' is listed in Section 2 - Work History.

Describe in detail the tasks you performed during a typical workday for Job No. 4. Fill only if 'Job No. 4' is listed in Section 2 - Work History.

Describe the types of reports or written work you completed for Job No. 4 and how much time you spent on them per workday or workweek. Fill only if 'Job No. 4' is listed in Section 2 - Work History.

Enter the title of the second job listed in Section 2. Fill only if 'Job Title (Job No. 2) listed in Section 2' is provided.

Enter the job title for Job No. 5 as it was listed in your work history. Fill only if 'Job No. 5 (Job Title) in Section 2 - Work History' is provided.

Enter the amount of time you typically spend kneeling during a workday.

Enter how much time you typically spend kneeling during a normal workday (in hours/minutes).

Enter the total amount of time you typically spend kneeling during a workday.

Describe the lifting and carrying required in this job, including what you lifted, how far you carried it, and how often you did it in a typical workday.

Describe what you lifted, how far you carried it, and how often you did this during a typical workday for this job.

Describe what you lifted, how far you carried it, and how often you did this in a typical workday for this job.

Describe what you lifted, how far you carried it, and how often you did this during a typical workday for this job.

Describe what you lifted, how far you carried it, and how often you did this during a typical workday.

List the machines, tools, and equipment you regularly used in this job and explain what you used each item for. Fill only if 'Job Title (Job No. 2) listed in Section 2' is provided.

List the machines, tools, and equipment you used regularly for this job and explain what you used each item for. Fill only if 'Job No. 5 (Job Title) in Section 2 - Work History' is provided.

Describe how your medical condition(s) would affect your ability to perform this job’s duties.

Describe how your medical conditions would affect your ability to perform the duties of this job.

Describe how your medical conditions affect your ability to perform this job, including any limitations, difficulties, or tasks you cannot do.

Check this box if, when reaching at or below shoulder level during your workday, you typically use one arm.

Check this box if, when reaching at or below shoulder level during your workday, you typically use both arms.

Enter the total amount of time during a typical workday that you spend reaching at or below shoulder level (using one arm or both arms). Fill only if 'One Arm', 'Both Arms' is 'Yes' (any).

Enter the job title you held for the ninth job listed in your work history.

Enter the type of business or industry for the employer for the ninth job listed.

Enter the date you started working at the ninth job listed.

Enter the date you stopped working at the ninth job listed.

Check this box if the rate of pay amount you entered is paid per hour. Fill only if 'Job No. 5 (Job Title) in Section 2 - Work History' is provided.

Check this box if the rate of pay amount you entered is paid per day. Fill only if 'Job No. 5 (Job Title) in Section 2 - Work History' is provided.

Check this box if the rate of pay amount you entered is paid per week. Fill only if 'Job No. 5 (Job Title) in Section 2 - Work History' is provided.

Check this box if the rate of pay amount you entered is paid per month. Fill only if 'Job No. 5 (Job Title) in Section 2 - Work History' is provided.

Check this box if the rate of pay amount you entered is paid per year. Fill only if 'Job No. 5 (Job Title) in Section 2 - Work History' is provided.

Enter the dollar amount you were paid for Job Title No. 2 for the pay period selected (e.g., per hour, day, week, month, or year). Fill only if 'Job Title (Job No. 2) listed in Section 2' is provided.

Check this box if the pay rate you entered for Job Title No. 2 is paid per hour. Fill only if 'Job Title (Job No. 2) listed in Section 2' is provided.

Check this box if the pay rate you entered for Job Title No. 2 is paid per day. Fill only if 'Job Title (Job No. 2) listed in Section 2' is provided.

Check this box if the pay rate you entered for Job Title No. 2 is paid per week. Fill only if 'Job Title (Job No. 2) listed in Section 2' is provided.

Check this box if the pay rate you entered for Job Title No. 2 is paid per month. Fill only if 'Job Title (Job No. 2) listed in Section 2' is provided.

Check this box if the pay rate you entered for Job Title No. 2 is paid per year. Fill only if 'Job Title (Job No. 2) listed in Section 2' is provided.

Enter the amount you were paid for Job No. 5 for the pay period you select (e.g., per hour, day, week, month, or year). Fill only if 'Job No. 5 (Job Title) in Section 2 - Work History' is provided.

Enter the typical number of hours you worked per day at Job No. 5. Fill only if 'Job No. 5 (Job Title) in Section 2 - Work History' is provided.

Enter the typical number of days you worked per week at Job No. 5. Fill only if 'Job No. 5 (Job Title) in Section 2 - Work History' is provided.

Check this box if, when reaching at or below shoulder level during your workday, you typically used one arm.

Check this box if, when reaching at or below shoulder level during your workday, you typically used both arms.

Enter the total amount of time you spend in a typical workday reaching at or below shoulder level (using one or both arms).

Check this box if, when reaching at or below shoulder level during the job, you typically used one arm.

Check this box if, when reaching at or below shoulder level during the job, you typically used both arms.

Enter the total amount of time in a typical workday you spent reaching at or below shoulder level (with one arm or both arms).

Check this box if, when reaching at or below shoulder level during a typical workday, you used one arm.

Check this box if, when reaching at or below shoulder level during a typical workday, you used both arms.

Enter the total time you spend in a typical workday reaching at or below shoulder level using one arm or both arms.

Check this box if, when reaching overhead (above the shoulder) during a typical workday, you usually use one arm.

Check this box if, when reaching overhead (above the shoulder) during a typical workday, you usually use both arms.

Enter how much time you spent in a typical workday reaching overhead (above shoulder level), using either one arm or both arms.

Check this box if, in this job, you reached overhead using one arm (not both) during a typical workday.

Check this box if, in this job, you reached overhead using both arms during a typical workday.

Enter how much time you spent in a typical workday reaching overhead (above the shoulder), whether done with one arm or both arms.

Check this box if reaching overhead (above the shoulder) in this job was typically done using one arm.

Check this box if reaching overhead (above the shoulder) in this job was typically done using both arms.

Enter the total amount of time you spend in a typical workday reaching overhead (above the shoulder), whether using one arm or both arms.

Describe the type of reports you wrote or completed for Job Title No. 5 and how much time you spent on them per workday or workweek. Fill only if 'Typical Workday Tasks (Job 5)' mentions writing or completing reports.

Enter how much time you typically spend sitting during a workday (in hours and/or minutes).

Enter the job title for your second most recent job in the work history list.

Enter the type of business or industry of the employer for your second most recent job.

Enter the date when you started working at your second most recent job.

Enter the date when you stopped working at your second most recent job.

Enter your name, including first name, middle initial, last name, and any suffix.

Enter your Social Security number.

Enter your primary daytime phone number where you can be reached or where a message can be left.

Enter a secondary daytime phone number where you can be reached or where a message can be left, if available.

Enter any additional remarks or information not provided elsewhere in the report, including the job title number and question you are referencing if applicable.

Check this box if you used fingers to touch, pick, or pinch (e.g., using a mouse/keyboard, turning pages, buttoning) with one hand during a typical workday.

Check this box if you used fingers to touch, pick, or pinch (e.g., using a mouse/keyboard, turning pages, buttoning) with both hands during a typical workday.

Enter how much of your typical workday you spend using your fingers to touch, pick, or pinch (such as using a mouse or keyboard, turning pages, or buttoning a shirt). Fill only if 'One Hand', 'Both Hands' is 'Yes' (any).

Enter the job title for your seventh job in your work history list.

Enter the type of business or industry for your seventh job (for example, grocery store or construction).

Enter the date you started working at your seventh job.

Enter the date you stopped working at your seventh job.

Enter the amount of time you typically spend sitting during a workday, in hours and minutes.

Enter the total amount of time you typically spend sitting during a workday (in hours and/or minutes).

Enter the amount of time you typically spend sitting during a workday.

Enter how much time you spend crawling (moving on hands and knees) during a typical workday.

Enter the job title you held for your sixth listed job.

Enter the type of business or industry for your sixth listed job (for example, grocery store or construction).

Enter the date you started working at your sixth listed job.

Enter the date you stopped working at your sixth listed job.

Enter the total time you typically spend standing and walking combined during a workday.

Enter the total time you spend standing and walking combined during a typical workday (in hours and/or minutes).

Enter the total amount of time you spend standing and walking combined during a typical workday.

Enter how much time you typically spend stooping (bending down and forward at the waist) during a normal workday.

Enter how much time you typically spend stooping (bending down and forward at the waist) during a workday.

Enter how much time you typically spend stooping (bending down and forward at the waist) during a workday.

Describe who or what you supervised in this job and the specific supervisory duties you performed. Fill only if 'Typical Workday Tasks (Job 5)' mentions supervising others.

Describe who or what you supervised in this job and the supervisory duties you performed. Fill only if 'Typical Workday Tasks Description (Job Title No. 2)' described tasks include supervising others.

Check this box if, when reaching overhead (above the shoulder) during a typical workday, you usually reach with one arm.

Check this box if, when reaching overhead (above the shoulder) during a typical workday, you usually reach with both arms.

Enter how much time you typically spend in a workday reaching overhead (above the shoulder), whether using one arm or both arms. Fill only if 'One Arm', 'Both Arms' is 'Yes' (any).

Enter the job title you held for your tenth listed job.

Enter the type of business or industry for your tenth listed job (for example, grocery store or construction company).

Enter the date you started working at your tenth listed job.

Enter the date you stopped working at your tenth listed job.

Enter how much time you typically spend stooping (bending down and forward at the waist) during a typical workday, in hours and/or minutes.

Enter the job title for your third listed job.

Enter the type of business or industry for the employer of your third listed job.

Enter the start date when you began working at your third listed job.

Enter the end date when you stopped working at your third listed job.

Enter how much time you typically spend in a workday climbing ladders, ropes, or scaffolds.

Describe in detail the tasks you performed during a typical workday for Job Title No. 2. Fill only if 'Job Title (Job No. 2) listed in Section 2' is provided.

Describe in detail the tasks you performed during a typical workday for Job Title No. 5. Fill only if 'Job No. 5 (Job Title) in Section 2 - Work History' is provided.

Check this box if, in a typical workday, you used the fingers of one hand to touch, pick, or pinch (for example, using a mouse/keyboard, turning pages, or buttoning a shirt).

Check this box if, in a typical workday, you used the fingers of both hands to touch, pick, or pinch (for example, using a mouse/keyboard, turning pages, or buttoning a shirt).

Enter how much time you spend in a typical workday using your fingers to touch, pick, or pinch items (e.g., using a mouse or keyboard, turning pages, buttoning a shirt).

Check this box if, when using your fingers to touch, pick, or pinch (e.g., using a mouse/keyboard, turning pages, buttoning a shirt), you typically do this with one hand.

Check this box if, when using your fingers to touch, pick, or pinch (e.g., using a mouse/keyboard, turning pages, buttoning a shirt), you typically do this with both hands.

Enter the total amount of time in a typical workday that you spent using your fingers to touch, pick, or pinch with one or both hands.

Check this box if the job required using fingers to touch, pick, or pinch (e.g., mouse/keyboard/turning pages/buttoning) with one hand.

Check this box if the job required using fingers to touch, pick, or pinch (e.g., mouse/keyboard/turning pages/buttoning) with both hands.

Enter how much time you spend in a typical workday using your fingers to touch, pick, or pinch (for example, using a mouse/keyboard, turning pages, or buttoning a shirt).

Check this box if the activity “Using hands to seize, hold, grasp, or turn” is typically done with one hand during your workday.

Check this box if the activity “Using hands to seize, hold, grasp, or turn” is typically done with both hands during your workday.

Enter how much time you spend in a typical workday using your hands to seize, hold, grasp, or turn objects.

Check this box if, in this job, you used one hand to seize, hold, grasp, or turn objects (e.g., holding a large envelope, small box, hammer, or water bottle).

Check this box if, in this job, you used both hands to seize, hold, grasp, or turn objects (e.g., holding a large envelope, small box, hammer, or water bottle).

Enter how much time you typically spend during a workday using one or both hands to seize, hold, grasp, or turn objects.

Check this box if you typically used one hand to seize, hold, grasp, or turn objects during your workday.

Check this box if you typically used both hands to seize, hold, grasp, or turn objects during your workday.

Enter how much time during a typical workday you spend using one or both hands to seize, hold, grasp, or turn objects.

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

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

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

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

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

Check this box if the weight you frequently lifted (about 1/3 to 2/3 of the workday) is not listed, and write the weight on the line provided.

If you selected “Other” for the weight you frequently lifted, enter the weight amount you most often lifted in this job. Fill only if 'Other' is 'Yes'.

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

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

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

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

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

Check this box if the weight you frequently lifted/carried for this job (about 1/3 to 2/3 of the workday) is not listed, and write the weight in the space provided.

Enter the weight you frequently lifted during this job if it is not listed among the provided choices. Fill only if 'Other (specify)' is 'Yes'.

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

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

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

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

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

Check this box if the weight you frequently lifted in this job (about 1/3 to 2/3 of the workday) does not match the listed options and specify the weight.

Enter the weight amount you frequently lifted if you selected "Other" for the weight frequently lifted option. Fill only if 'Other' is 'Yes'.

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

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

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

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

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

Check this box if the weight you frequently lifted does not match the options listed, and write the weight on the line provided.

If you selected "Other" for the weight you frequently lifted, enter the weight amount and units you most often lifted during the workday. Fill only if 'Other' is 'Yes'.

Check this box if, for about 1/3 to 2/3 of the workday, you frequently lifted less than 1 pound.

Check this box if, for about 1/3 to 2/3 of the workday, you frequently lifted less than 10 pounds.

Check this box if, for about 1/3 to 2/3 of the workday, you frequently lifted 10 pounds.

Check this box if, for about 1/3 to 2/3 of the workday, you frequently lifted 25 pounds.

Check this box if, for about 1/3 to 2/3 of the workday, you frequently lifted 50 pounds or more.

Check this box if the weight you frequently lifted (about 1/3 to 2/3 of the workday) is not listed, and write the weight on the line provided.

Enter the weight you frequently lifted if it is not one of the listed options. Fill only if 'Other' is 'Yes'.

Check this box if the person named in item 1.A. is the one completing this report.

Check this box if someone other than the person in item 1.A. is completing this report and you will provide their name, relationship, and mailing address below.

Check this box if this job exposed you to working outdoors.

Check this box if this job exposed you to extreme heat not caused by outdoor weather (for example, heat from equipment or indoor conditions).

Check this box if this job exposed you to extreme cold not caused by outdoor weather (for example, freezers or refrigerated areas).

Check this box if this job exposed you to wet conditions (such as frequent water or damp environments).

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

Check this box if this job exposed you to hazardous substances (such as chemicals, fumes, dusts, or similar materials).

Check this box if this job exposed you to moving mechanical parts (such as machinery with moving components).

Check this box if this job exposed you to working in high or exposed places (such as heights or open edges).

Check this box if this job exposed you to heavy vibrations (such as from power tools, vehicles, or machinery).

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

Check this box if this job exposed you to a different type of exposure not listed, and write what it was in the space provided.

Enter any other work exposure(s) not listed that the job involved. Fill only if 'Other' is 'Yes'.

Check this box if this job exposed you to strong or unpleasant odors (for example, fumes, smells, or vapors) during your work.

Check this box if this job exposed you to very hot temperatures from indoor or work-process sources (not outdoor weather).

Check this box if this job exposed you to very cold temperatures from indoor or work-process sources (not outdoor weather).

Check this box if this job exposed you to wet conditions (for example, water, liquids, or consistently damp environments) during your work.

Check this box if this job exposed you to high humidity or persistently moist air while working.

Check this box if this job exposed you to hazardous substances such as chemicals, solvents, dusts, fumes, or other toxic materials.

Check this box if this job exposed you to moving machine parts (for example, rotating, cutting, or conveyor components) that could cause injury.

Check this box if this job required you to work at heights or in exposed high places where falling was a risk.

Check this box if this job exposed you to heavy vibration (for example, from power tools, machinery, or vehicles) during your work.

Check this box if this job exposed you to loud noise levels (for example, machinery or equipment noise) during your work.

Check this box if this job exposed you to a work condition not listed above, and describe it in the space provided.

Describe any other type of exposure you had on this job that is not listed in the checkboxes. Fill only if 'Other' is 'Yes'.

Describe any writing or reports you completed for Job Title No. 2, including the type of report and how much time you spent on it per workday or workweek. Fill only if 'Typical Workday Tasks Description (Job Title No. 2)' described tasks include writing or completing reports.