The SSA-3373-BK form is a crucial document used by the Social Security Administration to evaluate an individual's ability to work due to a disability. Completing this form accurately is essential for those seeking disability benefits. Take action now by filling out the form; click the button below to get started.
The SSA SSA-3373-BK form is an essential document used by the Social Security Administration (SSA) to evaluate an individual's ability to work due to medical conditions. This form plays a crucial role in the disability determination process. It requires detailed information about the applicant’s daily activities, physical and mental limitations, and how these limitations affect their ability to perform work-related tasks. Applicants must provide comprehensive descriptions of their symptoms, treatments, and the impact of their condition on their everyday life. Completing this form accurately is vital, as it helps the SSA assess the severity of the applicant's disability and make informed decisions regarding benefits. Understanding the form's structure and requirements can significantly enhance the chances of a successful application for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI). Properly filling out the SSA-3373-BK can streamline the evaluation process and ensure that all relevant information is considered.
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
Filling out the SSA-3373-BK form is an important step in the process of applying for Social Security benefits. This form allows individuals to provide detailed information about their daily activities and how their condition affects their ability to function. Completing the form accurately and thoroughly can help ensure that the application is processed smoothly.
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 an individual's daily activities and functional capabilities. This form is typically required when someone applies for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI). It helps the SSA assess how a disability affects a person's ability to perform everyday tasks.
Individuals applying for SSDI or SSI due to a disability must complete this form. It is essential for those whose disabilities impact their ability to work or manage daily living activities. Family members or caregivers may also assist in completing the form if necessary.
The SSA-3373-BK form asks for detailed information regarding:
Providing thorough and accurate information is crucial, as it directly impacts the evaluation of your disability claim.
You can submit the SSA-3373-BK form in several ways. The most common methods include:
Make sure to keep a copy for your records after submission.
Yes, assistance is available for those who need it. You can ask a family member, friend, or caregiver to help you complete the form. Additionally, local advocacy groups and legal aid organizations often provide support for individuals navigating the disability application process.
Once the SSA receives your completed form, they will review the information provided alongside your medical records and other documentation. This process may take time, and you might be contacted for further information or clarification. After the review, you will receive a decision regarding your disability claim.
Filling out the SSA-3373-BK form can be a daunting task, and many people make common mistakes that can delay their Social Security Disability benefits. One frequent error is not providing enough detail about their medical conditions. It's essential to explain how your conditions affect your daily life. Vague descriptions can lead to misunderstandings and may result in a denial of benefits.
Another common mistake is failing to list all relevant medical treatments and providers. If you see multiple doctors or have undergone various treatments, make sure to include them all. Missing this information can create gaps in your medical history, which can be detrimental to your case.
Many individuals overlook the importance of consistency in their responses. Inconsistencies between your SSA-3373-BK form and other documents can raise red flags. Ensure that your answers align with what you’ve stated in other forms, such as your initial application or medical records.
People often forget to mention the impact of their conditions on their daily activities. It’s not enough to simply list diagnoses; you should also describe how these conditions hinder your ability to work or perform everyday tasks. This information is crucial for the evaluation process.
Another mistake is neglecting to review the form before submission. Simple typographical errors or omissions can lead to unnecessary delays. Taking a moment to double-check your answers can save you time and frustration later on.
Some applicants fail to provide supporting documentation. It’s vital to attach any relevant medical records, test results, or treatment notes that can substantiate your claims. Without this evidence, your application may lack the necessary support to be approved.
Additionally, people sometimes misinterpret the questions on the form. If a question seems unclear, it’s better to seek clarification than to guess. Misunderstanding a question can lead to incorrect information being provided, which may harm your application.
Another common issue is not signing the form. It may seem trivial, but an unsigned form is incomplete and cannot be processed. Always ensure that you sign and date your application before sending it in.
Finally, some applicants underestimate the importance of timelines. Submitting the form late or not adhering to deadlines can result in a denial. Make sure to keep track of dates and submit your application promptly to avoid complications.
The SSA SSA-3373-BK form is an important document for individuals applying for Social Security Disability benefits. However, there are several other forms and documents that may be necessary to support your application. Below is a list of these documents, each serving a specific purpose in the process.
Gathering these documents can streamline your application process and enhance your chances of approval. Make sure to review each form carefully and provide accurate information to support your case.
The SSA-3373-BK form, also known as the Function Report – Adult, is used by the Social Security Administration to gather information about an individual's daily activities and how their condition affects their ability to work. There are several other documents that serve similar purposes in assessing an individual's functional capabilities and limitations. Here are five such documents:
Each of these forms plays a critical role in the evaluation process for disability claims. They help the SSA gain a comprehensive understanding of an individual's situation, ensuring that decisions are made based on accurate and thorough information.
When filling out the SSA SSA-3373-BK form, there are several important practices to follow to ensure accuracy and clarity.
The SSA-3373-BK form is an important document for those applying for Social Security Disability benefits. However, there are several misconceptions surrounding it. Here’s a list to clarify some common misunderstandings:
Understanding these misconceptions can help you navigate the process more effectively. Taking the time to complete the SSA-3373-BK form accurately can make a significant difference in your application experience.
When filling out the SSA SSA-3373-BK form, it is essential to keep several key points in mind to ensure that your application is complete and accurately reflects your situation.