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.

FREE CASE EVALUTION

  • We accept California Social Security disability cases at all stages. If you are thinking about applying for disability benefits or have had your application denied, please answer the questions below if you would like us to review your case. Asterisks(*) indicate required fields.

Areas Served:

We handle California Social Security disability claims for claimants from San Diego and nearby areas, including these counties and cities:

Counties


Imperial, Orange, Riverside, and San Diego.

Cities

Imperial County: Brawley, Calexico, and El Centro.
Orange County: Anaheim, Buena Park, Costa Mesa, Fountain Valley, Fullerton, Garden Grove, Huntington Beach, Irvine, La Habra, Laguna Niguel, Lake Forest, Mission Viejo, Newport Beach, Orange, Santa Ana, Tustin, Westminster, and Yorba Linda.
Riverside County: Corona, Hemet, Moreno Valley, Palm Desert, Palm Springs, Riverside, and Temecula.
San Diego County: Carlsbad, Chula Vista, El Cajon, Encinitas, Escondido, La Mesa, National City, Oceanside, Poway, Ramona, San Diego, San Marcos, Santee, and Vista.

Experienced disability lawyers in other regions :

Tampa Social Security disability attorney, Denver Social Security disability lawyer, Boston Social Security attorney, Chambersburg Social Security lawyer, Licking County disability attorney, North Carolina disability lawyer, Milwaukee Personal Injury Lawyer, Pensacola Family Lawyer, Long View Law Firm, San Mateo DUI Lawyer, Riverside DUI Attorney, Riverside Personal Injury Lawyer, San Jose DUI Attorney, Arizona Disability Lawyer