Form Ssa-821-Bk - Work Activity Report - Employee Page 7
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12Claim #:
6A. For any job that you told us about in Question 3, did you make any of the changes below since the DATE shown in
the Identification section (Check all that apply).
Date
Yes
Special Condition
Employer Name
Reasons for Changes in Work Activity
(MM/DD/YYYY)
My physical and/or mental condition(s)
Special conditions that allowed me to
Stopped working
work were removed
Other reasons (please explain in 6B)
My physical and/or mental condition(s)
Special conditions that allowed me to
Reduced my work hours
work were removed
Other reasons (please explain in 6B)
My physical and/or mental condition(s)
Special conditions that allowed me to
Reduced my earnings
work were removed
Other reasons (please explain in 6B)
My physical and/or mental condition(s)
Changed to a lighter or
Special conditions that allowed me to
easier type of work
work were removed
Other reasons (please explain in 6B)
No, I did not make any changes since the date shown in the Identification section. Go to Question 7.
6B. Use this space to provide any additional information about your work changes.
Form SSA-821-BK (04-2012) ef (04-2012)
Page 5
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