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pdfSocial Security Administration
Retirement, Survivors and Disability Insurance
Supplemental Security Income
Date:
Claim Number:
Social Security Number:
Worker's Name:
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 or was an unsuccessful work
attempt 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.
Form SSA-3033 (02-2011) ef (02-2011)
Page 1
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. 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
Enclosure:
Work Activity Questionnaire
Form SSA·3033 (02-2011) ef (02-2011)
Page 2
Privacy Act Statement
Collection and Use of Personal Information
Sections 201, 223(d)(4), 1612(b)(4) and1614(a)(3)(D) of the Social Security Act as amended, [42 U.S.C. 401,
423(d)(4), 1382a(b)(4) and 1382c(a)(3)(D)] authorize us to collect this information. We will use the information
you provide to help us in determining if your employee or former employee's work activity islwas subsidized or
was an unsuccessful work attempt under the Social Security rules. The information you provide on this form is
voluntary. However, failure to provide all or part of the requested information may prevent us from making an
accurate and timely decision concerning this person's entitlement to benefit payments.
See below for
We rarely use the information you provide on this form forrevised
any purpose
other
than for the reasons explained
Privacy
Act
above. However, we may use it for the administration and
integrity
of Social Security programs. We may also
and
Paperwork
disclose information to another person or to another agency in accordance with approved routine uses, which
Reduction Act
include but are not limited to the following:
Statements.
1. To enable a third party or an agency to assist Social Security in establishing rights to
Social Security benefits or coverage;
2. To comply with Federal laws requiring the release of information from Social Security
records to other agencies.
3. To make determinations for eligibility in similar health and income maintenance programs
at the Federal, State, and local level; and
4. To facilitate statistical research, audit, or investigative activities necessary to assure the
integrity of Social Security programs.
We may also use the information you provide in computer matching programs. Matching programs compare
our records with records kept by other Federal, State, or local government agencies. Information from these
matching agencies can be used to establish or verity a person's eligibility for Federally-funded or administered
benefit programs and for repayment of payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in our Systems of Records Notices entitled,
Claims Folder System, 60-0089 and Supplemental Security Income Record and Special Veterans Benefits,
60-0103. The notices, additional information regarding this form, and information regarding our system and
programs, are available on-line at www.sQcialsecurity.gov or at any local Social Security office.
Paperwork Reduction Act Statement
This 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 Budget control number. We estimate that it will take about 15 minutes to read the
instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO
YOUR LOCAL SOCIAL SECURITY OFFICE. The office is listed under U. S. Government agencies in your
telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778) . You may
send comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send
only comments relating to our time estimate to this address, not the completed form.
Form SSA-3033 (02-2011) ef (02-2011)
Page 3
Social Security Adminstration
Form Approved
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?
DYes
2. Is the employee able to complete all of the job duties
without special assistance?
DYes
3. Does the employee regularly report for work as scheduled?
4. On average, does the employee complete his/her work
in the same amount of time as employees in similar positions?
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
_
Frequent absences
_
Irregular hours
_
Lower production standards
_
Special transportation
Less hours
More breaks/rest periods
_
Extra help/supervision
_
Lower quality standards
Special equipment
_
Form SSA-3033 (02-2011) ef (02-2011)
Page 4
D
D
No
No
DYes
D
No
DYes
D
No
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
0
0
0
0
0
0
7. Are you paying the employee more per hour than you would another
employee in a similar position?
DYes
No
D
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?
DYes
No
2. Did the person do the work under special conditions
DYes
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?
D
o
No
DYes
o
No
Section 3
--.-------------~.-----
(Signature and Title)
(Telephone Number)
Form SSA·3033 (02-2011) et (02-2011)
Page 5
(Date)
SSA will insert the following revised Privacy Act Statement into the form at its
next scheduled reprinting:
Privacy Act Statement
Collection and Use of Personal Information
Sections 221, 223(d)(4), 1612(b)(4)(B), and 1614(a)(3)(D) of the Social Security Act, as
amended, authorize us to collect this information. We will use the information you provide to
determine whether the employee’s work activity was an unsuccessful work attempt or whether it
is/was subsidized.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information may prevent an accurate and timely decision on any claim filed.
We rarely use the information you supply us for any purpose other than to make a determination
regarding benefit eligibility. However, we may use the information for the administration of our
programs including sharing information:
1. To comply with Federal laws requiring the release of information from our records (e.g.,
to the Government Accountability Office and Department of Veterans Affairs); and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure the
integrity and improvement of our programs (e.g., to the Bureau of the Census and to
private entities under contract with us).
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notices 60-0089, entitled, Claims Folder System
and 60-0103, entitled, Supplemental Security Income Record and Special Veterans Benefits.
Additional information about these and other system of records notices and our programs are
available online at www.socialsecurity.gov or at your local Social Security office.
We may share the information you provide to other health agencies through computer matching
programs. Matching programs compare our records with records kept by other Federal, State, or
local government agencies. We use the information from these programs to establish or verify a
person’s eligibility for federally funded or administered benefit programs and for repayment of
incorrect payments or delinquent debts under these programs.
SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
Paperwork Reduction Act Statement - This 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 Budget (OMB) control number. We estimate that it will take about
60 minutes to read the instructions, gather the facts, and answer the questions. Send only
comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-6401.
| File Type | application/pdf |
| File Modified | 2013-12-23 |
| File Created | 2011-03-23 |