Form SSA-3033 Work Activity Questionnaire

Social Security Administration
Retirement, Survivors and Disability Insurance
Supplemental Security Income

Employer Name
Address
Address

Claimant’s name
Claim Number:
Address:
Address:

Dear Sir or Madam:
We are writing to you about
. Please assist us by completing the
enclosed questionnaire. We are requesting this information in order to determine
whether
work activity is/was subsidized
under the Social Security rules. The information you provide will not be shared with
other agencies and is in no way a negative reflection on the employee, or you as the
employer.
Information About Subsidy
A subsidy exists when an employer willingly pays more in wages than the value of
the actual services performed. This is usually for humanitarian reasons. A subsidy
can be reflected by giving the employee:
•
•
•

extra assistance,
full wages for lower quality or quantity than standard, or
fewer and/or easier duties than usual for that position.

Information about Unsuccessful Work Attempt
An unsuccessful work attempt may exist if the employee had frequent absences,
performed unsatisfactorily, and worked for six months or less.
What We Need You To Do
Please have
direct supervisor or another person having direct
knowledge of the employee's work activity complete the work activity questionnaire.
Form SSA-3033-BK (7-2005)

We would appreciate it if you would complete, sign and return the questionnaire to
this office within 7 days using the enclosed envelope. If you have any questions, or if
you would rather provide this information over the telephone, please call
and
ask for
.
Thank you for your time and assistance.

Manager/Adjudicator Name
Position title

Form SSA-3033-BK (7-2005)

PRIVACY ACT/PAPERWORK REDUCTION ACT NOTICE

We are authorized to collect the information on this form under sections 221,
223(d)(4), 1612(b)(4) and 1614(a)(3)(D) of the Social Security Act. We need the
information to make a decision on your employee or former employee's claim. Giving
us the information on this form is voluntary. However, if you do not give us part or all
of the information, this person may lose benefits.
We give out the facts on this form without your consent only in certain situations that
are explained in the Federal Register. For example, we must give out this information
if Federal law requires us to, if your Congressman or Senator needs the information
to answer questions you ask them, or if the Justice Department needs it to
investigate and prosecute violations of the Social Security Act.
We may also use the information you give us when we match records by computer.
Matching programs compare our records with those of other Federal, State, or local
government agencies. Many agencies may use matching programs to find or prove
that a person qualifies for benefits paid by the Federal government. The law allows
us to do this even if you do not agree to it.
These and other reasons why information about you may be used or given out are
explained in the Federal Register. If you want to learn more about this, contact any
Social Security office.
The information collection meets the requirements of 44 U.S.C> § 3507, as amended
by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer
these questions unless we display a valid Office of Management and Budge control
number.
Time It Takes To Complete This Form
We estimate that it will take you about 15 minutes to complete this form. This
includes the time it will take to read the instructions, gather the necessary facts and
fill out the form. If you have comments or suggestions on this estimate, write to the
Social Security Administration, 1338 Annex Building, Baltimore, MD 21235-6401.
ATTN: Reports Clearance Officer. Only comments relating to our time estimate
should be provided, not the completed form.

Form SSA-3033-BK (7-2005)

OMB No. 0960-0483
WORK ACTIVITY QUESTIONNAIRE

Business Name: _______________________________________________
Job Title: _______________________________
Hourly Wage________ Hours per Week_____________
Date Work Started ______________

Date Work Stopped______________
Section 1

1. Does the employee complete all the usual duties required for
his/her position?

Yes
No

2. Is the employee able to complete all of the job duties without
special assistance?

Yes
No

3. Does the employee regularly report for work as scheduled?

Yes
No

4. On average, does the employee complete his/her work in the
same amount of time as employees in similar positions?

Yes
No

5. Please indicate the type(s) of special assistance, if any, the employee receives on
the job that is not regularly given to other employees. (Check all that apply.)
____Fewer or easier duties
____Irregular hours
____Special transportation
____Less hours
____More breaks/rest periods
____Frequent absences

Form SSA-3033-BK (7-2005)

____Lower production standards
____Extra help/supervision
____Lower quality standards
____Frequent absences
____Special Equipment

6. Based on the information above, approximately how would you rate the
productivity of the employee compared to other employees in similar positions and
similar pay rates?
50% or less of other employees’ productivity
60% of other employees’ productivity
70% of other employees’ productivity
80% of other employees’ productivity
90% of other employees’ productivity
100% of other employees’ productivity
7. Are you paying the employee more per hour than you would another employee in a
similar position?
Yes
No
If Yes, what would you pay another employee in a similar position per hour?
$___________________________

Section 2
Unsuccessful Work Attempt
1. Was the person frequently absent from work?

Yes
No

2. Did the person do the work under special conditions such as
with extra help/supervision, fewer/easier duties, frequent rest
periods, or lower production?
3. Was the person’s work satisfactory when compared to another
employee who worked in a similar position?

Yes
No

Form SSA-3033-BK (7-2005)

Yes
No

Section 3

_____________________________________ __________________
(Signature and Title)
(Date)
_____________________________________
(Telephone Number)

Form SSA-3033-BK (7-2005)