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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.
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: __________________________
