The SSA SSA-3380-BK form is a crucial document used by the Social Security Administration to evaluate an individual's ability to work due to mental impairments. This form gathers essential information about the applicant's daily activities, social functioning, and cognitive limitations. To ensure a thorough assessment, it is important to fill out the form accurately and completely; start the process by clicking the button below.
The SSA SSA-3380-BK form is an important document used in the Social Security Administration's disability determination process. This form, also known as the "Function Report - Adult," serves to gather detailed information about an individual's daily activities, capabilities, and limitations. It plays a crucial role in evaluating how a person's impairments affect their ability to work and perform routine tasks. Individuals are asked to provide insights into various aspects of their life, including personal care, household chores, social interactions, and recreational activities. The information collected through this form helps the SSA assess the severity of the applicant's condition and its impact on their overall functioning. Completing the SSA-3380-BK accurately and thoroughly is essential, as it can significantly influence the outcome of a disability claim. Understanding the form's requirements and the type of information needed can enhance the chances of a successful application for benefits.
Form SSA-3380 (06-2020)
Discontinue Prior Editions
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Social Security Administration
OMB No. 0960-0635
FUNCTION REPORT - ADULT - THIRD PARTY Form SSA-3380-BK
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 (TTY 1-800-325-0778).
HOW TO COMPLETE THIS FORM
The information that you give on this form will be used to make a decision on the disabled person's claim. You can help by completing as much of the form as you can. When a question refers to the "disabled person," it refers to the person who is applying for or receiving disability benefits.
It is important that you tell us what you know about the disabled person's activities and abilities.
DO NOT ASK THE DISABLED PERSON TO GIVE YOU ANSWERS
•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 you need more space to answer any questions, use the "REMARKS" section on Page 10, and show the number of the question being answered.
Function Report - Adult - Third Party Form SSA-3380-BK
REMEMBER TO GIVE US THE NAME AND ADDRESS OF THE PERSON
COMPLETING THIS FORM ON PAGE 10
Form SSA-3380-BK (06-2020)
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Privacy Act and Paperwork Reduction Act Statements
Sections 205(a), 223(d), and 1631 of the Social Security Act (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 make a determination of eligibility for benefits. We may also share your information for the following purposes, called routine uses:
•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; and
•To applicants, claimants, prospective applicants or claimants, other than the data subject, their authorized representatives or representative payees to the extent necessary to pursue Social Security claims and to representative payees when the information pertains to individuals for whom they serve as representative payees, for the purpose of assisting SSA in administering its representative payment responsibilities under the Act and assisting the representative payees in performing their duties as payees, including receiving and accounting for benefits for individuals for whom they serve as payees.
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 Systems, as published in the Federal Register (FR) on April 1, 2003, at 68 FR 15784, and 60-0320, entitled Electronic Disability Claim File, as published in the FR December 22, 2003, at 68 FR 71210. Additional information, and a full listing of all of our SORNs, is available on our website at https://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 on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.
PLEASE REMOVE THIS SHEET BEFORE RETURNING
THE COMPLETED FORM.
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FUNCTION REPORT- ADULT - THIRD PARTY
How the disabled person's illnesses, injuries, or conditions limit his/her 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, Last)
2.YOUR NAME (Person completing the form)
3.RELATIONSHIP (To disabled person)
4.DATE (MM/DD/YYYY)
5.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.)
-
Area Code
Phone Number
Your Number
Message Number
None
6.a. How long have you known the disabled person?
b. How much time do you spend with the disabled person and what do you do together?
7. a. Where does the disabled person live? (Check one.)
House
Apartment
Boarding House
Shelter
Group Home
Other (What?)
Nursing Home
b. With whom does he/she live? (Check one.)
Alone
With Family
Other (describe relationship)
With Friends
SECTION B - INFORMATION ABOUT ILLNESSES, INJURIES, OR CONDITIONS
8. How does this person's illnesses, injuries, or conditions limit his/her ability to work?
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SECTION C - INFORMATION ABOUT DAILY ACTIVITIES
9. Describe what the disabled person does from the time he/she wakes up until going to bed.
10.Does this person take care of anyone else such as a wife/husband, children, grandchildren, parents, friend, other?
If "YES," for whom does he/she care, and what does he/she do for them?
Yes
No
11.Does he/she take care of pets or other animals? If "YES," what does he/she do for them?
12.Does anyone help this person care for other people or animals? If "YES," who helps, and what do they do to help?
Yes No
13. What was the disabled person able to do before his/her illnesses, injuries, or conditions that he/she can't do now?
14. Do the illnesses, injuries, or conditions affect his/her sleep?
If "YES," how?
15. PERSONAL CARE (Check here if NO PROBLEM with personal care.)
a.Explain how the illnesses, injuries, or conditions affect this person's ability to: Dress
Bathe
Care for hair
Shave
Feed self
Use the toilet
Other
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b. Does he/she need any special reminders to take care of personal needs and grooming?
If "YES," what type of help or reminders are needed?
c. Does he/she need help or reminders taking medicine? If "YES," what kind of help does he/she need?
16. MEALS
a. Does the disabled person prepare his/her own meals?
If "Yes," what kind of food is prepared? (For example, sandwiches, frozen dinners, or complete meals with several courses.)
How often does he/she prepare food or meals? (For example, daily, weekly, monthly.)
How long does it take him/her?
Any changes in cooking habits since the illness, injuries, or conditions began?
b. If "No," explain why he/she cannot or does not prepare meals.
17.HOUSE AND YARD WORK
a . List household chores, both indoors and outdoors, that the disabled person is able to do . (For example, cleaning, laundry, household repairs, ironing, mowing, etc.)
b. How much time do chores take, and how often does he/she do each of these things?
c. Does he/she need help or encouragement doing these things? If "YES," what help is needed?
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d. If the disabled person doesn't do house or yard work, explain why not.
18.GETTING AROUND
a. How often does this person go outside?
If he/she doesn't go out at all, explain why not.
b. When going out, how does he/she 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 he/she go out alone?
If "NO," explain why he/she can't go out alone.
d. Does the disabled person drive?
If he/she doesn't drive, explain why not.
19.SHOPPING
a. If the disabled person does any shopping, does he/she shop: (Check all that apply.)
In stores By phone By mail By computer b. Describe what he/she shops for.
c. How often does he/she shop and how long does it take?
20. MONEY
a. Is he/she able to:
Pay bills
Count change
Explain all "NO" answers.
Handle a savings account
Use a checkbook/money orders
Yes Yes
No No
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b. Has the disabled person's ability to handle money changed since
the illnesses, injuries, or conditions began?
If "YES," explain how the ability to handle money has changed.
21.HOBBIES AND INTERESTS
a. What are his/her hobbies and interests? (For example, reading, watching TV, sewing, playing sports, etc.)
b. How often and how well does he/she do these things?
c. Describe any changes in these activities since the illnesses, injuries, or conditions began.
22.SOCIAL ACTIVITIES
a. How does the disabled person 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 he/she does with others.
How often does he/she do these things?
c. List the places he/she goes on a regular basis. (For example, church, community center, sports events, social groups, etc.)
Does he/she need to be reminded to go places?
How often does he/she go and how much does he/she take part?
Does he/she need someone to accompany him/her?
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d. Does this person 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.
SECTION D - INFORMATION ABOUT ABILITIES
23. a. Check any of the following items the disabled person's illnesses, injuries, or conditions affect:
Lifting
Squatting
Bending
Standing
Reaching
Walking
Sitting
Kneeling
Talking
Hearing
Stair Climbing
Seeing
Memory
Completing Tasks
Concentration
Understanding Following Instructions Using Hands
Getting Along with Others
Please explain how his/her illnesses, injuries, or conditions affect each of the items you checked. (For example, he/she can only lift [how many pounds], or he/she can only walk [how far])
b. Is the disabled person:
Right Handed?
Left Handed?
c. How far can he/she walk before needing to stop and rest?
If he/she has to rest, how long before he/she can resume walking?
d. For how long can the disabled person pay attention?
e. Does the disabled person finish what he/she starts? ( For example, a
conversation,
chores, reading, watching a movie.)
f. How well does the disabled person follow written instructions? (For example, a recipe.)
g. How well does the disabled person follow spoken instructions?
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h. How well does the disabled person get along with authority figures? (For example, police, bosses, landlords or teachers.)
i. Has he/she ever been fired or laid off from a job because of problems
getting along with other people? Yes No If "YES," please explain.
If "YES," please give name of employer.
j . How well does the disabled person handle stress?
k. How well does he/she handle changes in routine?
l. Have you noticed any unusual behavior or fears in the disabled person?
If "YES," please explain.
24. Does the disabled person 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 does this person need to use these aids?
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25.Does the disabled person currently take any medicines for his/her illnesses, injuries, or conditions?
If " YES," do any of the medicines cause side effects?
If "YES," please explain. (Do not list all of the medicines that the disabled person takes. List only the medicines that cause side effects for the disabled person.)
NAME OF MEDICINE
SIDE EFFECTS PERSON HAS
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)
Address (Number and Street)
Date (MM/DD/YYYY)
Email address (optional)
City
State
ZIP Code
Completing the SSA SSA-3380-BK form is a straightforward process that requires careful attention to detail. After filling out this form, you will submit it to the Social Security Administration as part of your application or appeal process. Ensure that all information is accurate and complete to avoid delays.
What is the SSA SSA-3380-BK form?
The SSA SSA-3380-BK form, also known as the "Function Report - Adult," is a document used by the Social Security Administration (SSA) to gather detailed information about an individual's daily activities and functional limitations. This form is typically required when someone applies for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) benefits. It helps the SSA assess how a person’s condition affects their ability to perform everyday tasks.
Who needs to fill out the SSA SSA-3380-BK form?
This form is generally filled out by individuals who are applying for disability benefits due to physical or mental impairments. If you are an adult seeking assistance through SSDI or SSI, you may be asked to complete this form to provide the SSA with a comprehensive view of your functional capabilities and limitations.
How do I complete the SSA SSA-3380-BK form?
Completing the SSA SSA-3380-BK form involves providing information about various aspects of your life, including your ability to perform daily activities, your social interactions, and how your condition impacts your work. The form consists of several sections, and you should answer each question as thoroughly and honestly as possible. Use specific examples to illustrate how your condition affects your daily life.
Where can I obtain the SSA SSA-3380-BK form?
The SSA SSA-3380-BK form can be obtained directly from the Social Security Administration's website or by visiting a local SSA office. You may also request the form through a phone call to the SSA. Ensure you have the most recent version of the form, as updates can occur periodically.
What should I do if I need help completing the form?
If you find yourself struggling to complete the SSA SSA-3380-BK form, you can seek assistance from various sources. Friends or family members may help you articulate your experiences. Additionally, community organizations, legal aid services, or disability advocacy groups often offer guidance in filling out such forms. Professional assistance from an attorney specializing in disability claims can also be beneficial.
What happens after I submit the SSA SSA-3380-BK form?
Once you submit the SSA SSA-3380-BK form, the Social Security Administration will review the information provided alongside your disability application. They may contact you for further clarification or additional information. The SSA uses the details from this form to determine your eligibility for benefits, so it is crucial that the information is accurate and complete.
Can I make changes to my SSA SSA-3380-BK form after submission?
If you need to make changes to your SSA SSA-3380-BK form after you have submitted it, you should contact the SSA as soon as possible. They may allow you to provide updated information or corrections, especially if it significantly impacts your claim. It’s important to keep the SSA informed about any changes in your condition or circumstances.
Is there a deadline for submitting the SSA SSA-3380-BK form?
Yes, there is a deadline for submitting the SSA SSA-3380-BK form. Typically, this form should be submitted along with your disability application or as directed by the SSA during the claims process. It is essential to adhere to any deadlines provided by the SSA to avoid delays in your claim. If you are unsure about the deadlines, contacting the SSA directly will provide clarity.
What if I don’t have all the information requested on the form?
If you do not have all the information requested on the SSA SSA-3380-BK form, it is still important to complete the form to the best of your ability. You can indicate that certain information is unavailable or unknown. Providing as much detail as possible, even if incomplete, is better than leaving sections blank. The SSA will take into account the information you provide when making their determination.
When filling out the SSA SSA-3380-BK form, individuals often make several common mistakes that can delay their Social Security Disability benefits. Understanding these pitfalls can help ensure a smoother application process.
One frequent error is providing incomplete information. Applicants sometimes skip questions or leave sections blank, thinking that the details are not crucial. However, every piece of information is important for the Social Security Administration (SSA) to assess the claim accurately.
Another mistake involves vague descriptions of medical conditions. When detailing impairments, it’s essential to be specific. Instead of saying "I have pain," a more effective approach would be to describe the type, location, and frequency of the pain. This clarity helps the SSA understand the severity of the condition.
Some individuals fail to include relevant medical records or documentation. The SSA requires evidence to support claims. Without proper documentation, the application may be denied or delayed. It’s advisable to gather all necessary medical records before submitting the form.
Inaccurate personal information can also lead to complications. This includes misspellings of names, incorrect Social Security numbers, or outdated addresses. These errors can cause confusion and may result in the SSA being unable to process the application efficiently.
Additionally, applicants sometimes underestimate the importance of listing all medications. Failing to include prescribed medications can create a misleading picture of one’s health status. It’s crucial to provide a comprehensive list of all medications, including dosages and purposes.
Many people overlook the significance of signature and date. An unsigned form or one that lacks a date can be considered incomplete. This oversight can lead to unnecessary delays in processing the application.
Lastly, some individuals do not follow up after submitting the form. Checking the status of an application is important. If there are any issues or additional information needed, being proactive can help address them quickly.
The SSA-3380-BK form, also known as the Function Report, is a key document used by the Social Security Administration (SSA) to assess an individual's ability to perform daily activities. When submitting this form, there are several other documents that may be required or helpful in supporting a claim for Social Security Disability benefits. Below is a list of these forms and documents, each serving a specific purpose in the evaluation process.
Each of these documents plays a vital role in the Social Security Disability application process. Together, they help create a comprehensive picture of the claimant’s situation, allowing the SSA to make informed decisions regarding eligibility for benefits.
The SSA-3380-BK form is used by the Social Security Administration (SSA) to gather information about a person's functioning and daily activities, particularly when assessing disability claims. Several other forms serve similar purposes, focusing on gathering information about an individual's condition, limitations, and needs. Here are eight documents that are similar to the SSA-3380-BK form:
When filling out the SSA SSA-3380-BK form, it’s important to approach the process with care. Here are some key dos and don’ts to keep in mind:
By following these guidelines, you can help ensure that your SSA SSA-3380-BK form is completed correctly and processed efficiently.
The SSA-3380-BK form is often misunderstood. Here are nine common misconceptions about this form, along with clarifications.
Understanding these misconceptions can help applicants navigate the process more effectively and ensure they provide the necessary information for their case.
The SSA SSA-3380-BK form is an important document used to evaluate an individual's ability to work due to mental impairments. Here are some key takeaways to keep in mind when filling out and using this form:
Taking the time to carefully complete the SSA SSA-3380-BK form can significantly impact the evaluation of your case. Ensure that your information is clear and well-supported to facilitate a smoother review process.