Form Ssa-821-Bk - Work Activity Report - Employee Page 6
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12Claim #:
5. For any job(s) that you told us about in Question 3, have you worked under any special conditions listed below?
Date
Yes
Special Condition
Employer Name
(MM/YYYY to
Please Describe
MM/YYYY)
Had extra help, extra
supervision or a job coach
Worked irregular or fewer
hours than other workers
Given special equipment
because of my condition
Took more rest periods than
other workers
Given special transportation
to and from work
Had fewer or easier duties
than other workers
Allowed to produce less work
than other workers
Hired through special training
or therapy program
Given work that was suited to
my condition
Given special help getting
ready for work
Other (explain)
Other (explain)
None of the above apply. Go to Question 6A.
Form SSA-821-BK (04-2012) ef (04-2012)
Page 4
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Parent category: Legal