Work History Report

OMB 0960-0578

SSA collects the information to document an applicant's work history. The Disability Determination Services adjudicators use the information to make a decision about the alleged disability. The respondents are applicants for disability benefits.

The latest form for Work History Report expires 2021-01-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form SSA-3369 Work History Report Form and Instruction
Addendum - 0578.docx Supplementary Document
Supporting Statement - 0578.docx Supporting Statement A
Work History Report Form and Instruction
Work History Report (EDCS) Other-EDCS

All Historical Document Collections

202009-0960-011	Revision of a currently approved collection	2020-12-09
201701-0960-017 Approved without change	Revision of a currently approved collection	2017-05-17
201311-0960-009 Approved without change	Revision of a currently approved collection	2014-03-10
201007-0960-005 Approved without change	Revision of a currently approved collection	2010-12-10
200803-0960-002 Approved without change	No material or nonsubstantive change to a currently approved collection	2008-03-06
200702-0960-002 Approved with change	Revision of a currently approved collection	2007-07-25
200406-0960-004 Approved with change	Extension without change of a currently approved collection	2004-06-10
200106-0960-007 Approved without change	Revision of a currently approved collection	2001-06-14
199806-0960-001 Approved without change	Reinstatement with change of a previously approved collection	1998-06-02
199707-0960-008 Approved without change	New collection (Request for a new OMB Control Number)	1997-07-23

OMB Details

Work History Report

Federal Enterprise Architecture: Income Security - General Retirement and Disability

Form SSA-3369

Work History Report

Paper Only

Form and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.