The SSA SSA-3373-BK form is a crucial document used by the Social Security Administration to assess an individual's ability to work due to disability. Completing this form accurately is essential for those seeking disability benefits, as it provides detailed information about daily activities and limitations. Ready to get started? Fill out the form by clicking the button below!
The SSA SSA-3373-BK form is a critical document used by the Social Security Administration (SSA) to evaluate an individual's capacity for work and assess their eligibility for disability benefits. This form plays a vital role in the disability claims process, as it collects essential information about an applicant's daily activities, work history, and limitations caused by their medical conditions. Applicants are required to provide detailed descriptions of their physical and mental impairments, including how these impairments affect their ability to perform basic work-related tasks. The SSA uses this information to determine the severity of the applicant's condition and how it impacts their functional abilities. Completing the SSA-3373-BK accurately is crucial, as it can significantly influence the outcome of a disability claim. Understanding the form's components and the information it seeks can help applicants present a stronger case for their eligibility for benefits.
Form SSA-3373 (02-2024) UF
Discontinue Prior Editions
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Social Security Administration
OMB No. 0960-0681
FUNCTION REPORT - ADULT
READ ALL OF THIS INFORMATION BEFORE
YOU BEGIN COMPLETING THIS FORM
IF YOU NEED HELP
If you need help with this form, complete as much of it as you can and call the phone number provided on the letter sent with the form, or contact the person who asked you to complete the form. If you need the address or phone number for the office that provided the form, you can get it by calling Social Security at 1-800-772-1213.
HOW TO COMPLETE THIS FORM
The information that you give us on this form will be used by the office that makes the disability decision on your disability claim. You can help them by completing as much of the form as you can.
It is important that you tell us about your activities and abilities.
•Print or type.
•DO NOT LEAVE ANSWERS BLANK. If you do not know the answer or the answer is "none" or "does not apply," please write "don't know" or "none" or "does not apply."
•Do not ask a doctor or hospital to complete this form.
•Be sure to explain an answer if the question asks for an explanation, or if you think you need to explain an answer.
•If more space is needed to answer any questions, use the "REMARKS" section on Page 10, and show the number of the question being answered.
•If a specific activity is performed with the help of others, please indicate that.
Function Report - Adult - Form SSA-3373-BK
REMEMBER TO GIVE US THE NAME AND ADDRESS OF THE PERSON
COMPLETING THIS FORM ON PAGE 10
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Privacy Act Statements
Collection and Use of Personal Information
Sections 205(a), 223(d), and 1631 of the Social Security Act, as amended, allow us to collect this information. Furnishing us this information is voluntary. However, failing to provide all or part of the information may prevent an accurate and timely decision on any claim filed.
We will use the information you provide to determine benefits eligibility. We may also share the information for the following purposes, called routine uses:
•To third party contacts (e.g., employers and private pension plans) in situations where the party to be contacted has, or is expected to have, information relating to the individual's capability to manage his or her benefits or payments, or his or her eligibility for entitlement to benefits or eligibility for payments, under the Social Security program; and
•To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social Security Administration (SSA) in the efficient administration of its programs. We will disclose information under this routine use only in situations in which we may enter into a contractual or similar agreement to obtain assistance in accomplishing an SSA function relating to this system record.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where authorized, we may use and disclose this information in computer matching programs, in which our records are compared with other records to establish or verify a person's eligibility for Federal benefit programs and for repayment of incorrect or delinquent debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices (SORN) 60-0089, entitled Claims Folders System, as published in the Federal Register (FR) on October 31, 2019, at 84 FR 58422, and 60-0320, entitled Electronic Disability Claim File, as published in the FR on June 6, 2020 at 85 FR 34477. Additional information, and a full listing of all of our SORNs, is available on our website at www.ssa.gov/privacy.
Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take about 61 minutes to read the instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO
YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your local Social Security office through SSA's website at www.socialsecurity.gov. Offices are also listed under U. S.
Government agencies in your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). You may send comments regarding this burden
estimate or any other aspect of this collection, including suggestions for reducing this burden to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to
our time estimate or other aspects of this collection to this address, not the completed form.
PLEASE REMOVE THIS SHEET BEFORE RETURNING
THE COMPLETED FORM.
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How your illnesses, injuries, or conditions limit your activities
For SSA Use Only
Do not write in this box.
Anyone who makes or causes to be made a false statement or representation of material fact for use in determining a payment under the Social Security Act, or knowingly conceals or fails to disclose an event with an intent to affect an initial or continued right to payment, commits a crime punishable under Federal law by fine, imprisonment, or both, and may be subject to administrative sanctions.
SECTION A - GENERAL INFORMATION
1. NAME OF DISABLED PERSON (First, Middle Initial, Last)
2. SOCIAL SECURITY NUMBER
3.YOUR DAYTIME TELEPHONE NUMBER (If there is no telephone number where you can be reached, please give us a daytime number where we can leave a message for you.)
Your Number
Message Number
None
Area Code Phone Number
4. a. Where do you live? (Check one.)
House
Apartment
Boarding House
Nursing Home
Shelter
Group Home
Other (What?)
b. With whom do you live? (Check one.)
Alone
With Family
With Friends
Other (Describe relationship.)
SECTION B - INFORMATION ABOUT YOUR ILLNESSES, INJURIES, OR CONDITIONS
5.How do your illnesses, injuries, or conditions limit your ability to work?
____________________________________________________________________________________________________
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SECTION C - INFORMATION ABOUT DAILY ACTIVITIES
6.Describe what you do from the time you wake up until going to bed.
7. Do you take care of anyone else such as a wife/husband, children, grandchildren,
Yes
No
parents, friend, other?
If "YES," for whom do you care, and what do you do for them?
8. Do you take care of pets or other animals?
If "YES," what do you do for them?
9. Does anyone help you care for other people or animals?
If "YES," who helps, and what do they do to help?
10.
What were you able to do before your illnesses, injuries, or conditions that you can't do now?
11.
Do the illnesses, injuries, or conditions affect your sleep?
If "YES," how?
12.
PERSONAL CARE (Check here
if NO PROBLEM with personal care.)
a. Explain how your illnesses, injuries, or conditions affect your ability to:
Dress
Bathe
Care for hair
Shave
Feed self
Use the toilet
Other
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b. Do you need any special reminders to take care of personal
needs and grooming?
If "YES," what type of help or reminders are needed?
__________________________________________________________________________________________________
c. Do you need help or reminders taking medicine?
If "YES," what kind of help do you need?
13. MEALS
a. Do you prepare your own meals?
If "Yes," what kind of food do you prepare? (For example, sandwiches, frozen dinners, or complete meals with several courses.)
How often do you prepare food or meals? (For example, daily, weekly, monthly.)
How long does it take you?
Any changes in cooking habits since the illness, injuries, or conditions began?
b. If "No," explain why you cannot or do not prepare meals.
14.HOUSE AND YARD WORK
a.List household chores, both indoors and outdoors, that you are able to do. (For example, cleaning, laundry, household repairs, ironing, mowing, etc.)
b. How much time does it take you, and how often do you do each of these things?
c. Do you need help or encouragement doing these things?
If "YES," what help is needed?
d. If you don't do house or yard work, explain why not.
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15.GETTING AROUND
a. How often do you go outside?
If you don't go out at all, explain why not.
b.
When going out, how do you travel? (Check all that apply.)
Walk
Drive a car
Ride in a car
Ride a bicycle
Use public transportation
Other (Explain)
c. When going out, can you go out alone?
If "NO," explain why you can't go out alone.
d. Do you drive?
If you don't drive, explain why not.
16.SHOPPING
a. If you do any shopping, do you shop: (Check all that apply.)
In stores
By phone
By mail
By computer
b. Describe what you shop for.
c. How often do you shop and how long does it take?
17. MONEY
a. Are you able to:
Pay bills
Handle a savings account
Count change
Use a checkbook/money orders
Explain all "NO" answers.
b. Has your ability to handle money changed since the illnesses,
injuries, or conditions began?
If "YES," explain how the ability to handle money has changed.
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18.HOBBIES AND INTERESTS
a. What are your hobbies and interests? (For example, reading, watching TV, sewing, playing sports, etc.)
b. How often and how well do you do these things?
c. Describe any changes in these activities since the illnesses, injuries, or conditions began.
19.SOCIAL ACTIVITIES
a. How do you spend time with others? (Check all that apply.)
In person
On the phone
Email
Texting
Mail
Video Chat (for example Skype or Facetime)
b. Describe the kinds of things you do with others.
How often do you do these things?
c. List the places you go on a regular basis. (For example, church, community center, sports events, social groups, etc.)
Do you need to be reminded to go places?
How often do you go and how much do you take part?
Do you need someone to accompany you?
If "YES", explain.
d. Do you have any problems getting along with family, friends, neighbors, or others?
If "YES," explain.
e. Describe any changes in social activities since the illnesses, injuries, or conditions began.
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SECTION D - INFORMATION ABOUT ABILITIES
20. a. Check any of the following items that your illnesses, injuries, or conditions affect:
Lifting
Walking
Stair Climbing
Understanding
Squatting
Sitting
Seeing
Following Instructions
Bending
Kneeling
Memory
Using Hands
Standing
Talking
Completing Tasks
Getting Along With Others
Reaching
Hearing
Concentration
Please explain how your illnesses, injuries, or conditions affect each of the items you checked. (For example, you can only lift [how many pounds], or you can only walk [how far])
b. Are you:
Right Handed?
Left Handed?
c. How far can you walk before needing to stop and rest?
If you have to rest, how long before you can resume walking?
d. For how long can you pay attention?
e. Do you finish what you start? (For example, a conversation, chores,
reading, watching a movie.)
f. How well do you follow written instructions? (For example, a recipe.)
g. How well do you follow spoken instructions?
h. How well do you get along with authority figures? (For example, police, bosses, landlords or teachers.)
i. Have you ever been fired or laid off from a job because of problems getting
along with other people?
If "YES," please explain.
If "YES," please give name of employer.
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j. How well do you handle stress?
k. How well do you handle changes in routine?
l. Have you noticed any unusual behavior or fears?
21. Do you use any of the following? (Check all that apply.)
Crutches
Cane
Hearing Aid
Walker
Brace/Splint
Glasses/Contact Lenses
Wheelchair
Artificial Limb
Artificial Voice Box
Which of these were prescribed by a doctor?
When was it prescribed?
When do you need to use these aids?
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22. Do you currently take any medicines for your illnesses, injuries, or conditions?
If "YES, "do any of your medicines cause side effects?
If "YES," please explain. (Do not list all of the medicines that you take. List only the medicines that cause side effects.)
NAME OF MEDICINE
SIDE EFFECTS YOU HAVE
SECTION E - REMARKS
Use this section for any added information you did not show in earlier parts of this form. When you are done with this section (or if you didn't have anything to add), be sure to complete the fields at the bottom of this page.
______________________________________________________________________________________________________
Name of person completing this form (Please print)
Date (MM/DD/YYYY)
Address (Number and Street)
Email address (optional)
City
State
ZIP Code
Once you have the SSA-3373-BK form in hand, you are ready to provide the necessary information about your daily activities and limitations. This form is crucial for gathering details that will help assess your situation. Follow these steps to complete the form accurately.
What is the SSA SSA-3373-BK form?
The SSA SSA-3373-BK form, also known as the Function Report - Adult, is a document used by the Social Security Administration (SSA) to gather information about how a person's medical condition affects their daily life and ability to work. It helps the SSA assess an individual's functional limitations and determine eligibility for disability benefits.
Who needs to fill out the SSA SSA-3373-BK form?
This form is typically required from individuals applying for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI). If you have a medical condition that significantly impairs your ability to perform daily activities or work, you may be asked to complete this form as part of your application process.
What kind of information is required on the form?
The SSA-3373-BK form requests detailed information about your daily activities, including how your condition affects your ability to perform tasks like cooking, cleaning, shopping, and personal care. It also asks about your social interactions, hobbies, and any assistance you may need from others. Providing thorough and accurate responses is crucial for your application.
How do I submit the SSA SSA-3373-BK form?
You can submit the completed form online through the SSA's website if you are applying for benefits online. Alternatively, you can print the form and mail it to your local SSA office. It's important to keep a copy for your records and ensure it is sent to the correct address to avoid delays in processing your application.
Can someone help me fill out the form?
Yes, you can receive assistance from family members, friends, or professionals, such as attorneys or advocates, when completing the SSA-3373-BK form. They can help you understand the questions and provide accurate information based on your situation. However, it is essential that the information you provide is truthful and reflects your personal experience.
What happens after I submit the form?
Once you submit the SSA-3373-BK form, the SSA will review your application, including the information provided in the form. They may contact you for additional information or clarification. The review process can take time, so it’s important to be patient and respond promptly to any requests from the SSA.
What if I need to update my information after submitting the form?
If your situation changes after you submit the SSA-3373-BK form, you should inform the SSA as soon as possible. You can do this by contacting your local SSA office. Providing updated information is important, as it can affect your eligibility for benefits and the assessment of your case.
Where can I find the SSA SSA-3373-BK form?
The SSA-3373-BK form can be found on the Social Security Administration's official website. You can download it directly from their forms section. If you prefer, you can also request a paper copy by visiting your local SSA office or calling their customer service line.
When filling out the SSA-3373-BK form, many individuals inadvertently make mistakes that can affect their Social Security Disability benefits application. One common error is providing insufficient detail in the descriptions of daily activities. This form requires a thorough account of how a disability impacts your daily life. Simply stating that you can’t work isn’t enough; you should explain how your condition affects your ability to perform routine tasks, like cooking, cleaning, or socializing.
Another frequent mistake is neglecting to include all relevant medical information. Applicants sometimes forget to mention specific diagnoses, treatments, or medications. It’s crucial to provide a complete picture of your health history. This includes not only current conditions but also past surgeries or treatments that may still affect your functioning. Omitting this information can lead to delays or denials in the application process.
Additionally, people often overlook the importance of consistency in their responses. Inconsistencies between the SSA-3373-BK form and other documentation, such as medical records or previous applications, can raise red flags. Review your answers carefully to ensure they align with what your doctors have documented. This consistency helps build credibility in your application.
Finally, failing to seek assistance can be a significant mistake. Many individuals attempt to complete the form on their own without fully understanding the requirements. Utilizing resources, such as legal aid services or disability advocates, can provide valuable guidance. They can help clarify questions, ensure that all necessary information is included, and ultimately improve the chances of a successful application.
The SSA-3373-BK form, also known as the Function Report, is a critical document used in the Social Security Administration's disability evaluation process. It provides detailed information about an individual's daily activities, limitations, and how their condition affects their ability to function. Several other forms and documents are often submitted alongside the SSA-3373-BK to support a disability claim. Below is a list of these commonly used documents.
Submitting these forms and documents along with the SSA-3373-BK can enhance the chances of a successful disability claim. Each document serves a specific purpose, contributing to a comprehensive understanding of the applicant's situation and needs.
The SSA-3373-BK form is used by the Social Security Administration to gather information about an individual's daily functioning and limitations. Several other documents serve similar purposes in assessing disability or providing information about a person's condition. Here are seven documents that share similarities with the SSA-3373-BK form:
Filling out the SSA SSA-3373-BK form can be a crucial step in your application process. To ensure that your submission is complete and accurate, here are some essential dos and don'ts to keep in mind.
By following these guidelines, you can help facilitate a smoother process and increase the likelihood of a favorable outcome. Your attention to detail matters.
The SSA SSA-3373-BK form is an important document used in the Social Security Administration's disability determination process. However, several misconceptions exist about this form. Here are seven common misunderstandings:
Many people believe that the SSA-3373-BK form applies only to physical conditions. In reality, it is designed to assess both physical and mental impairments.
Some assume that filling out the form correctly will automatically result in receiving benefits. Approval depends on the overall evaluation of medical evidence and other factors.
While medical professionals provide valuable input, individuals can and should contribute their own experiences and insights when completing the form.
Some think that brief answers are sufficient. However, detailed and specific information about daily activities and limitations is crucial for a thorough evaluation.
Many people believe the SSA-3373-BK is only needed at the start of the application process. In fact, it can also be required during appeals or reviews of existing claims.
Some think that once the form is submitted, it cannot be altered. However, you can submit additional information or corrections if new evidence arises.
Many assume that this form alone suffices for a disability claim. In reality, other forms and documentation may also be necessary to support the claim.
Understanding these misconceptions can help individuals navigate the disability application process more effectively.
The SSA SSA-3373-BK form is an important document for individuals seeking Social Security Disability benefits. Understanding how to fill it out correctly can significantly impact the outcome of your application. Here are key takeaways to keep in mind: