Article Structure
The SSA SSA-3380-BK form plays a crucial role in the Social Security Administration's process for evaluating claims related to mental disorders. Designed to gather comprehensive information about an individual's functional limitations, this form helps the SSA assess how a person's mental health impacts their daily life and ability to work. It prompts applicants to provide detailed insights into their daily activities, social interactions, and cognitive capabilities. By focusing on aspects such as concentration, social functioning, and the ability to complete tasks, the SSA-3380-BK form ensures that the evaluation process is thorough and personalized. Completing this form accurately is essential for individuals seeking disability benefits, as it directly influences the decision-making process regarding their eligibility. Understanding the importance of each section can significantly enhance the chances of a successful claim, making it a vital component of the application journey.
Form Sample
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Social Security Administration |
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FUNCTION REPORT - ADULT - THIRD PARTY Form
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
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
REMEMBER TO GIVE US THE NAME AND ADDRESS OF THE PERSON
COMPLETING THIS FORM ON PAGE 10
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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)
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
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.)
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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
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? |
Yes |
No |
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If "YES," how? |
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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?
Yes No
Yes No
16. MEALS |
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a. Does the disabled person prepare his/her own meals? |
Yes |
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.
No
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?
Yes
No
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d. If the disabled person doesn't do house or yard work, explain why not. |
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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.) |
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Walk |
Drive a car |
Ride in a car |
Ride a bicycle |
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Use public transportation |
Other (Explain) |
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c. When going out, can he/she go out alone? |
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Yes |
No |
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If "NO," explain why he/she can't go out alone. |
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d. Does the disabled person drive?
If he/she doesn't drive, explain why not.
Yes
No
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: |
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Pay bills |
Yes |
Count change |
Yes |
Explain all "NO" answers. |
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No |
Handle a savings account |
No |
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 |
Yes |
No |
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the illnesses, injuries, or conditions began? |
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If "YES," explain how the ability to handle money has changed. |
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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.) |
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In person |
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Video Chat (for example Skype or Facetime) |
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Other (Explain) |
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b. Describe the kinds of things he/she does with others. |
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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?
Yes
No
Does he/she need someone to accompany him/her?
Yes
No
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d. Does this person have any problems getting along with family, friends, neighbors, or others?
If "YES," explain.
Yes
No
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, |
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chores, reading, watching a movie.) |
Yes |
No |
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? |
Yes |
No |
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 |
Other (Explain) |
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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?
Yes
Yes
No
No
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
Document Specifications
| Fact Name | Details |
|---|---|
| Form Purpose | The SSA-3380-BK form is used to collect information about a person's ability to work and function in daily life due to a disability. |
| Target Audience | This form is primarily for individuals applying for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI). |
| Information Required | Applicants must provide detailed information about their medical conditions, daily activities, and work history. |
| Filing Method | The form can be submitted online, by mail, or in person at a local Social Security office. |
| Processing Time | After submission, processing times can vary, but it typically takes several weeks to receive a decision. |
| Supplemental Documentation | Applicants are encouraged to include supporting documents, such as medical records and treatment history. |
| Legal Basis | This form is governed by the Social Security Act, which outlines the requirements for disability benefits. |
| Confidentiality | Information provided on the SSA-3380-BK form is kept confidential and used solely for determining eligibility for benefits. |
| Assistance Available | Applicants can seek assistance from Social Security representatives or legal aid organizations when filling out the form. |
| Updates and Changes | It is important to check for any updates to the form or process, as regulations may change periodically. |
Steps to Filling Out SSA SSA-3380-BK
Filling out the SSA-3380-BK form is an important step in the process of applying for Social Security benefits. Once you have completed the form, you will need to submit it to the Social Security Administration along with any required documentation. Here are the steps to help you accurately fill out the form.
- Begin by carefully reading the instructions provided with the form. This will give you an overview of what information is needed.
- Gather all necessary personal information, including your name, Social Security number, and contact details.
- Complete the section regarding your medical history. Be thorough and accurate, as this information is crucial for your application.
- Provide details about your daily activities and how your condition affects them. Use specific examples to illustrate your situation.
- Fill out the section on any treatments or medications you are currently receiving. Include names, dosages, and the frequency of use.
- Review the form for any errors or missing information. Double-check your contact details to ensure they are correct.
- Sign and date the form at the designated area. This confirms that all the information provided is true and complete.
- Make a copy of the completed form for your records before submitting it.
- Submit the form to the Social Security Administration, either by mail or through your local office, as instructed.
More About SSA SSA-3380-BK
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 information about an individual's daily activities and how their disability affects their ability to function. This form helps the SSA assess the impact of a disability on daily living and work-related activities.
Who needs to fill out the SSA SSA-3380-BK form?
This form is typically required for individuals applying for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) benefits. If you have a disability that affects your ability to work or perform daily tasks, you may be asked to complete this form as part of your application process.
What kind of information is requested on the form?
The SSA SSA-3380-BK form asks for detailed information about your daily life. This includes questions about how you manage personal care, household tasks, social activities, and your ability to work. The form also inquires about any assistance you may need and how your disability affects your overall functioning.
How should I complete the SSA SSA-3380-BK form?
It is essential to be as thorough and honest as possible when filling out the form. Take your time to reflect on your daily activities and the challenges you face due to your disability. Use specific examples to illustrate your limitations. If you require assistance, consider asking a family member or friend to help you complete the form.
What happens after I submit the SSA SSA-3380-BK form?
Once you submit the form, the SSA will review the information provided along with your application. They may contact you for additional details or clarification. The information on this form plays a crucial role in determining your eligibility for benefits, so ensure that it is accurate and complete.
Can I appeal if my application is denied after submitting the form?
Yes, if your application for benefits is denied, you have the right to appeal the decision. The appeal process allows you to present additional evidence or clarify any misunderstandings. It is advisable to seek assistance from a legal professional or an advocate who specializes in Social Security cases during this process.
Is there a deadline for submitting the SSA SSA-3380-BK form?
Yes, there are deadlines associated with your application for benefits. It is important to submit the SSA SSA-3380-BK form as soon as possible after you receive a request from the SSA. Delays in submission could affect your eligibility for benefits, so be sure to adhere to any timelines provided.
Can I get help with filling out the SSA SSA-3380-BK form?
Absolutely! There are various resources available to assist you with completing the SSA SSA-3380-BK form. You can reach out to local disability advocacy organizations, social workers, or legal professionals who specialize in Social Security matters. They can provide guidance and support throughout the process.
What should I do if I have questions about the form?
If you have questions about the SSA SSA-3380-BK form, you can contact the Social Security Administration directly. They have representatives available to assist you. Additionally, reviewing the SSA's official website may provide helpful information and resources related to the form and the application process.
Common mistakes
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Incomplete Information: One of the most common mistakes is failing to provide all necessary details. Each section of the SSA-3380-BK form requires specific information. Omitting any part can lead to delays or even denials of benefits.
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Inaccurate Descriptions of Limitations: When describing how your condition affects daily activities, vague or inaccurate descriptions can hinder the assessment process. It is essential to be as precise as possible about limitations.
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Neglecting to Include Supporting Documentation: Many individuals forget to attach relevant medical records or other documents that support their claims. This oversight can significantly impact the evaluation of the application.
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Not Reviewing for Errors: Before submission, it is crucial to review the form for any typographical errors or inconsistencies. Even minor mistakes can raise questions about the credibility of the information provided.
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Missing Deadlines: Timeliness is vital in the application process. Failing to submit the SSA-3380-BK form within the required timeframe can lead to complications or a complete rejection of the claim.
Documents used along the form
The SSA SSA-3380-BK form is an important document used in the Social Security Administration process, particularly for disability claims. To ensure a comprehensive evaluation of a claim, several other forms and documents are often submitted alongside it. Below are some commonly used forms that may accompany the SSA SSA-3380-BK.
- SSA-3368-BK: This form is the Disability Report – Adult. It collects detailed information about an individual's medical condition, work history, and daily activities. It helps the SSA understand the extent of the disability and its impact on the individual's life.
- SSA-827: The Authorization to Disclose Information to the Social Security Administration form allows the SSA to obtain medical records and other relevant information from healthcare providers. This is crucial for verifying the claims made in the disability report.
- SSA-3373-BK: Known as the Function Report – Adult, this form provides insights into how a disability affects daily living and functioning. It includes questions about the individual's ability to perform various tasks and their overall quality of life.
- Medical Records: These documents are essential in supporting a disability claim. They provide evidence of the medical condition, treatment history, and the prognosis from healthcare professionals, helping to substantiate the claims made in the SSA forms.
Submitting these forms along with the SSA SSA-3380-BK can significantly enhance the chances of a successful disability claim. Each document plays a vital role in painting a complete picture of the individual's situation, ensuring that the SSA has all the necessary information to make an informed decision.
Similar forms
The SSA-3380-BK form, also known as the Adult Function Report, is used by the Social Security Administration to gather information about an individual's daily activities and how their condition affects their ability to function. Similar to the SSA-3380-BK, the SSA-3373-BK, or the Adult Disability Report, collects detailed information about the applicant's medical history, work history, and how their impairments limit their daily life. Both forms require the applicant to provide comprehensive insights into their functional capabilities, though the SSA-3373-BK focuses more on medical evidence and diagnosis.
The SSA-827 form, or the Authorization to Disclose Information to the Social Security Administration, is another document that complements the SSA-3380-BK. While the SSA-3380-BK gathers subjective information about daily activities, the SSA-827 allows the SSA to obtain medical records and other relevant documents from healthcare providers. This form ensures that the SSA has the necessary medical evidence to support the claims made in the Adult Function Report.
The SSA-3369-BK, or the Work History Report, serves a purpose similar to the SSA-3380-BK by detailing an applicant's past employment. It requires the applicant to provide information about their job duties, skills, and any relevant training. While the SSA-3380-BK emphasizes daily living activities, the SSA-3369-BK focuses on the specifics of work experience and how impairments have influenced work performance.
The SSA-3441-BK, or the Disability Report – Appeal, is used when an applicant is appealing a decision made by the SSA regarding their disability claim. This form, like the SSA-3380-BK, seeks updated information about the applicant's condition and daily functioning. Both forms aim to present a clear picture of the individual's current situation, although the SSA-3441-BK is specifically tailored for appeals processes.
The SSA-827-BK, which is the Authorization to Disclose Information to the SSA, also relates to the SSA-3380-BK. It allows the SSA to obtain necessary medical records and information from healthcare providers. While the SSA-3380-BK focuses on the applicant's personal experiences and daily activities, the SSA-827-BK ensures that the SSA has access to the medical documentation that supports those claims.
The SSA-3881-BK, or the Third Party Adult Function Report, is designed for use by individuals who can provide information on behalf of the applicant. This document is similar to the SSA-3380-BK in that it collects information about the applicant's daily activities and limitations. However, the SSA-3881-BK is filled out by someone who knows the applicant well, providing an external perspective on the individual’s functional abilities.
The SSA-3367-BK, known as the Request for Reconsideration, is another document that can be compared to the SSA-3380-BK. While the SSA-3380-BK focuses on an individual's daily functioning, the SSA-3367-BK is used when an individual seeks to contest a decision made by the SSA. Both forms require detailed information about the applicant's condition and how it affects their life, but the SSA-3367-BK is specifically for the reconsideration process.
The SSA-827-BK, or the Authorization to Disclose Information to the SSA, is a critical document that parallels the SSA-3380-BK. This form permits the SSA to request medical records from healthcare providers. While the SSA-3380-BK collects personal accounts of functioning and daily activities, the SSA-827-BK ensures that the SSA has access to the medical evidence necessary to substantiate the claims made by the applicant.
The SSA-3374-BK, or the Continuing Disability Review Report, is similar in purpose to the SSA-3380-BK, as it assesses an individual's ongoing eligibility for disability benefits. Both forms require information about how a person's condition affects their daily life. However, the SSA-3374-BK is specifically used for reviewing individuals who are already receiving benefits, focusing on any changes in their condition or functional capabilities since the last evaluation.
Dos and Don'ts
When filling out the SSA SSA-3380-BK form, it is essential to approach the task with care and attention to detail. Here are some important guidelines to consider:
- Do read the instructions carefully before starting the form.
- Do provide complete and accurate information to avoid delays in processing.
- Do use black or blue ink to fill out the form.
- Do keep a copy of the completed form for your records.
- Don’t leave any sections blank; if a question does not apply, write “N/A.”
- Don’t rush through the form; take your time to ensure clarity.
- Don’t use abbreviations or shorthand that may confuse the reviewer.
- Don’t forget to sign and date the form before submission.
- Don’t submit the form without double-checking for errors or omissions.
By following these guidelines, you can help ensure that your SSA SSA-3380-BK form is filled out correctly and efficiently, leading to a smoother process for your application.
Misconceptions
The SSA-3380-BK form, also known as the Function Report - Adult, is often misunderstood. Here are five common misconceptions about this form:
- Misconception 1: The SSA-3380-BK form is only for those applying for Social Security Disability Insurance (SSDI).
- Misconception 2: Completing the SSA-3380-BK form is optional.
- Misconception 3: You can fill out the SSA-3380-BK form quickly without much thought.
- Misconception 4: The SSA-3380-BK form only requires information about physical limitations.
- Misconception 5: Once submitted, the SSA-3380-BK form cannot be updated.
This form is used for various disability claims, including Supplemental Security Income (SSI). It helps the Social Security Administration assess how your condition affects daily activities.
In reality, this form is a crucial part of the disability evaluation process. Failing to submit it can delay your application or lead to a denial.
While it may seem straightforward, taking the time to provide detailed and accurate information is essential. The more comprehensive your responses, the better the SSA can understand your limitations.
This form also addresses mental and emotional challenges. It’s important to include how your condition affects your social interactions, concentration, and daily routines.
You can provide additional information or corrections if your situation changes. It’s advisable to keep the SSA informed about any new developments that may impact your claim.
Key takeaways
When filling out the SSA SSA-3380-BK form, consider the following key takeaways:
- Purpose of the Form: The SSA-3380-BK form is used to collect information about a person's ability to work and their functional limitations.
- Accuracy is Crucial: Providing accurate and detailed information will help the Social Security Administration (SSA) make informed decisions regarding disability claims.
- Be Thorough: Answer all questions completely. Incomplete forms may lead to delays or denials in processing your claim.
- Use Clear Language: Write in clear, concise language. Avoid jargon or overly complex terms to ensure your responses are easily understood.
- Review Before Submission: Always review the completed form for any errors or omissions before submitting it to the SSA.
- Keep Copies: Retain copies of the completed form and any supporting documents for your records. This may be useful for future reference.