SSA Form SSA-3369-BK

2025 Printable Template

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Form last updated: 03/2024. Please verify this is the current version before use.

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What is a SSA-3369-BK used for?

Form SSA-3369-BK, the Work History Report, is used by the Social Security Administration (SSA) to gather detailed information about your work history over the past 15 years. This information helps the SSA determine eligibility for disability benefits by assessing how your past work experience relates to your current disability claim.

Who needs to fill out a SSA-3369-BK form

Individuals applying for Social Security Disability benefits who have worked in the past 15 years.

How to fill out a SSA-3369-BK online?

Follow these steps to complete your SSA-3369-BK form online.

Step 1
Step 1
Begin by entering your name, Social Security number, and daytime phone number in Section 1.
Step 2
Step 2
List all jobs from the past 15 years in Section 2, detailing job titles, employers, and employment dates.
Step 3
Step 3
Provide detailed descriptions of job duties and any limitations in Section 3.
Step 4
Step 4
Indicate who is completing the form in Section 4 and include their contact details.
Step 5
Step 5
Retain any additional documents for your records.
Social Security Administration

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Frequently Asked Questions

Find quick answers to common questions about our PDF editor.

It is the Work History Report used by the SSA to assess your work history for disability claims.

It is not required if you haven't worked in the last 15 years or if your claim is solely based on medical records.

No, this form does not require a signature for submission.

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