Employee Work Activity Questionnaire

SSA will insert the following revised Privacy Act Statement into the form as soon as possible:
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, allow us to collect this information. Furnishing us this information is voluntary.
However, failing to provide all or part of the information may prevent us from properly
evaluating unsuccessful work attempts and subsidized work and prevent an accurate and timely
decision on any claim filed.
We will use the information to make a determination of eligibility for benefits. We may also
share your information for the following purposes, called routine uses:
1. To third party contacts, where necessary, to establish or verify information provided
by representative payees or payee applicants.
2. To employers or former employers for correcting or reconstructing earnings records
and for Social Security tax purposes only.
In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice
(SORN) 60-0089, entitled Claims Folders Systems. Additional information and a full listing of
all our SORNs are available on our website at www.socialsecurity.gov/foia/bluebook.