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  • Social Security Disability Employment Questionnaire

    When an issue in your Social Security disability benefits case is whether your brief work qualifies as an unsuccessful work attempt, especially if the work lasted more than three months but less than six months, it may be useful to send your former employer this questionnaire to complete. You can also download and print the full PDF version of the Social Security Disability Employment Questionnaire.

    To: _________________________________

    Re: _________________________________

    SSN: _________________________________

    Please answer the following questions.

    Did you grant any of the following special considerations to allow this employee to work? (Check all that apply.)

    SSD employment questionnaire

    Please explain any items checked above and describe any other special considerations granted:

    ____________________________________________________________________

    ____________________________________________________________________

    Was the employee hired because of family relationship, past association with the employer or other altruistic reason? Yes ___ No ___

    Explain Yes answer: ____________________________________________________________________

    ____________________________________________________________________

    Did the employee have trouble relating to co-workers? Yes ___ No ___

    Explain Yes answer: ____________________________________________________________________

    ____________________________________________________________________

    Did the employee have trouble relating to the public? Yes ___ No ___

    Explain Yes answer: ____________________________________________________________________

    ____________________________________________________________________

    Did the employee have trouble dealing with normal work stress? Yes ___ No ___

    Explain Yes answer: ____________________________________________________________________

    ____________________________________________________________________

    Did the employee have trouble following directions? Yes ___ No ___

    Explain Yes answer: ____________________________________________________________________

    ____________________________________________________________________

    Did the employee have trouble maintaining attention and concentration? Yes ___ No ___

    Explain Yes answer: _____________________________________________________________________

    _____________________________________________________________________

    Was the employee frequently absent from work? Yes ___ No ___

    Was the employee’s work satisfactory? Yes ___ No ___

    If the employee no longer works for you, when did his/her employment end and why?

    ______________________________________________________________________

    ______________________________________________________________________

    ______________________________________________________________________

    Space for any additional remarks you may wish to provide:

    ______________________________________________________________________

    ______________________________________________________________________

    ______________________________________________________________________

    ______________________________________________________________________

    Signature: ______________________________

    Title: ______________________________

    Date: ______________________________

    Telephone Number: __________________________

    Continue to the full PDF version of the Social Security Disability Employment Questionnaire.

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