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.)

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.