The SSA SSA-3380-BK form is a document utilized by the Social Security Administration to gather information regarding an individual's mental functioning and how it affects their daily life. This form plays a crucial role in the assessment process for disability benefits, as it helps determine eligibility based on mental health conditions. For those needing to fill out this form, please click the button below.
The SSA-3380-BK form plays a crucial role in the Social Security Administration's process for determining eligibility for Social Security Disability benefits. This form is specifically designed for individuals who are applying for disability benefits due to mental impairments. It gathers detailed information about the applicant's daily activities, social interactions, and overall functioning. By completing this form, applicants provide the SSA with insights into how their mental condition affects their ability to work and perform everyday tasks. The form requires respondents to describe their limitations and any treatment they have received, as well as the impact of their condition on their daily lives. Accuracy and thoroughness are essential when filling out the SSA-3380-BK, as the information provided can significantly influence the outcome of the disability claim. Understanding the components of this form is vital for applicants seeking to navigate the complexities of the disability benefits process effectively.
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
Once you have the SSA-3380-BK form ready, you will need to provide accurate information to ensure the processing of your request. Follow the steps below carefully to complete the form correctly.
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 condition affects their ability to function. This form is typically required when applying for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI).
Who needs to fill out the SSA SSA-3380-BK form?
Individuals applying for SSDI or SSI may be asked to complete this form. It is particularly important for those whose medical conditions impact their daily living activities, work capabilities, and overall quality of life. Family members or caregivers may also provide input to help paint a complete picture of the applicant's situation.
What kind of information is required on the form?
The SSA SSA-3380-BK form requests detailed information about various aspects of daily life, including:
Providing thorough and accurate information is essential, as it helps the SSA assess the impact of the applicant's condition on their daily life.
How should the form be submitted?
Once completed, the SSA SSA-3380-BK form can be submitted in several ways. Applicants may choose to send it via mail to the designated SSA office or submit it online through the SSA's official website, if applicable. It is crucial to keep a copy of the completed form for personal records.
What happens after the form is submitted?
After submission, the SSA will review the information provided on the SSA SSA-3380-BK form as part of the disability determination process. The SSA may contact the applicant for further clarification or additional information. It is important to respond promptly to any requests to avoid delays in processing the application.
Filling out the SSA SSA-3380-BK form can be a daunting task for many individuals. One common mistake is leaving questions unanswered. Each section of the form is designed to gather specific information about your condition and its impact on your daily life. When questions are skipped, it can lead to delays in processing your application or even a denial. Always take the time to read each question carefully and provide thorough answers.
Another frequent error is providing vague or unclear responses. The SSA wants detailed information to understand how your condition affects you. Instead of saying, "I have trouble walking," explain how far you can walk without assistance and what pain or fatigue you experience. Specific examples can paint a clearer picture of your situation, which is crucial for your case.
People also often fail to include supporting documentation. The SSA requires medical records, treatment history, and any other relevant documents to support your claims. Without these, your application may lack the necessary evidence for approval. Make sure to gather all required documents and submit them along with your form.
Lastly, some individuals overlook the importance of consistency in their answers. Inconsistencies between different sections of the form or between the form and your medical records can raise red flags. It's vital to ensure that all information is accurate and aligns with your medical history. Double-checking your responses can help avoid potential issues.
The SSA-3380-BK form is a critical document used in the Social Security Administration (SSA) process, particularly for disability claims. Several other forms and documents often accompany this form to provide additional information or support. Below is a list of these documents, each with a brief description.
These forms and documents play a vital role in the evaluation of disability claims. They provide the SSA with comprehensive information necessary to make informed decisions regarding eligibility and benefits.
The SSA-3380-BK form is used by the Social Security Administration (SSA) to gather information about an individual's daily activities and limitations. This form helps assess eligibility for disability benefits. Several other documents serve similar purposes in the context of disability evaluations and benefits. Here are four documents that share similarities with the SSA-3380-BK form:
Each of these documents plays a crucial role in the disability evaluation process, contributing to a comprehensive understanding of an individual's situation.
When filling out the SSA SSA-3380-BK form, it is important to be thorough and accurate. Here are some guidelines to help you through the process.
Following these tips can help ensure that your form is filled out correctly and efficiently.
The SSA SSA-3380-BK form, also known as the "Function Report - Adult," is often misunderstood. Below are ten common misconceptions about this form, along with clarifications.
This form is a required part of the Social Security Administration's (SSA) disability evaluation process. It provides essential information about an applicant's daily functioning.
While medical professionals may provide supporting documentation, the SSA-3380-BK must be completed by the individual applying for benefits. Their personal insights are crucial.
The SSA-3380-BK addresses both physical and mental limitations. It captures how various impairments affect daily activities and overall functioning.
Completion of the SSA-3380-BK does not ensure approval. The information provided will be evaluated alongside medical records and other evidence.
Many applicants find the SSA-3380-BK challenging. It requires detailed descriptions of daily activities, which can be difficult for individuals with disabilities.
The SSA takes the information from the SSA-3380-BK seriously. It plays a significant role in assessing an applicant's eligibility for benefits.
While timely submission is encouraged, the SSA allows for some flexibility. Applicants should focus on providing accurate and thorough responses.
The SSA-3380-BK is relevant for all applicants, regardless of the severity of their condition. It helps illustrate how any impairment affects daily life.
Applicants can request to amend their responses if new information arises or if they realize that their initial answers were incomplete.
While important, the SSA-3380-BK is one of several forms required for a complete disability claim. Other forms and documentation will also be necessary.
When filling out the SSA SSA-3380-BK form, it is important to keep several key points in mind to ensure accuracy and effectiveness in your application process.