SSA-3033 - Current

Form SSA-3033 (08-2021) UF
Discontinue Prior Editions
Social Security Administration

Page 1 of 5
OMB No. 0960-0483

Social 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

. This individual has indicated to us

(s)he worked for your organization, but that the work was either limited in nature, subsidized, or ultimately
unsuccessful. (S)he has given us permission to reach out to you to help us determine whether his or her
work activity is/was subsidized or was an unsuccessful work attempt as described in our Social Security
regulations. Please assist us by completing the enclosed questionnaire. The information you provide will not
be shared with other agencies and is 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 (08-2021) UF

Page 2 of 5

Social Security Number:
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 phone,
please call

and ask for

.

Thank you for your time and assistance.

Manager/Adjudicator Name
Position Title
Enclosure:
Work Activity Questionnaire

Form SSA-3033 (08-2021) UF

Page 3 of 5

Social Security Number:
Privacy Act Statement
Collection and Use of Personal Information
Sections 221, 223(d), 1612(b)(4), and 1614(a)(3) 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 an accurate and timely decision on any claim filed.
We will use the information you provide to validate unsuccessful work attempts and subsidies, and to
determine benefits eligibility. We may also share the information for the following purposes, called routine
uses:
• To contractors and other Federal agencies, as necessary, for the purpose of assisting us in the
efficient administration of our programs. We will disclose information under this routine use only in
situations in which we may enter into a contractual or similar agreement to obtain assistance in
accomplishing an SSA function relating to this system of records, and
• To claimants, prospective claimants (other than the data subject), and their authorized
representatives or representative payees, to the extent necessary to pursue Social Security claims;
to representative payees, when the information pertains to individuals for whom they serve as
representative payees, for the purpose of assisting us in administering representative payment
responsibilities under the Social Security Act; and to representative payees, for the purpose of
assisting them in performing their duties as payees, including receiving and accounting for benefits
for individuals for whom they as payees.
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 Notices (SORN) 60-0089,
Claims Folders System, as published in the Federal Register (FR) on October 31, 2019, at 84 FR 58422;
60-0090, Master Beneficiary Record, as published in the FR on January 11, 2006, at 71 FR 1826; and
60-0103, Supplemental Security Income Record and Special Veterans Benefits, at 71 FR 1830. Additional
information, and a full listing of all of our SORNs, is available on our website at www.ssa.gov/privacy.

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 15 minutes to read the instructions, gather the facts, and answer the
questions. Send only comments regarding this burden estimate or any other aspect of this collection,
including suggestions for reducing this burden to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

Form SSA-3033 (08-2021) UF
Discontinue Prior Editions
Social Security Administration

Page 4 of 5
OMB No. 0960-0483

Social Security Number:

Work Activity Questionnaire
Business Name:
Employee's
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

Lower production standards

Extra help/supervision

Lower quality standards

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

80% of other employees' productivity

60% of other employees' productivity

90% of other employees' productivity

70% 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?
If Yes, what would you pay another employee in a similar position per hour?

Yes

No

Form SSA-3033 (08-2021) UF

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Social Security Number:
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?

Yes

No

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

Yes

No

Section 3
Signature and Title
Date:

(Telephone Number):