Current Version (unrevised) SSA-3033

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
. Please assist us by
completing the enclosed questionnaire. We are requesting this information in order to determine
work activity is/was subsidized or was an unsuccessful work
whether
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-BK (5-2009) ef (5-2009)

What We Need You To Do
direct supervisor or another person having direct knowledge of
Please have
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

PRIVACY ACT
See revised
Act
We are authorized to collect the information onPrivacy
this form
under sections 221,
Statement
below.
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.

Paperwork Reduction Act
Statement
See revised
This information collection meets the requirements
of 44 U.S.C. § 3507, as amended by Section
Paperwork
2 of the Paperwork Reduction Act of 1995 . YouReduction
do not needAct
to answer
and these questions unless we
display a valid Office of Management and Budget
control
number.
We estimate that it will take
Privacy Act
about 15 minutes to read the instructions, gatherStatements
the facts, andbelow.
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-BK (5-2009) ef (5-2009)

Form Approved
OMB No. 0960-0483

Social Security Adminstration

WORK ACTIVITY QUESTIONNAIRE

Business Name:
Job Title:
Hourly Wage
Date Work Started

Hours per Week
Date Work Stopped
Section 1

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

Yes

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

Yes

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 similiar 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
Irregular hours
Special transportation
Less hours
More breaks/rest periods

Form SSA-3033-BK (5-2009) ef (5-2009)

Frequent absences
Lower production standards
Extra help/supervision
Lower quality standards
Special equipment

No

No
Yes
No
Yes
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
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?

Yes

3. Was the person's work satisfactory when compared
to another employee who worked in a similar position?

Yes

No

No

Section 3

(Signature and Title)

( ) (Telephone Number)

Form SSA-3033-BK (5-2009) ef (5-2009)

(Date)