Content Overview
The SSA SSA-3380-BK form plays a crucial role in the Social Security Administration's process for evaluating disability claims. Designed to gather comprehensive information about an individual's daily activities and limitations, this form helps assess the impact of a person's condition on their ability to function. Claimants are asked to provide detailed descriptions of their physical and mental capabilities, including how their disability affects their routine tasks, social interactions, and overall quality of life. By collecting this information, the SSA can make informed decisions about eligibility for Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI). Completing the SSA-3380-BK form accurately is essential, as it directly influences the outcome of a claim. Understanding the importance of this form can empower individuals to present their situations effectively and advocate for their needs.
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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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Texting |
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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
Form Specifications
| Fact Name | Details |
|---|---|
| Purpose | The SSA-3380-BK form is used to collect information about a person's disability and how it affects their daily life. |
| Eligibility | This form is typically completed by individuals applying for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI). |
| Sections | The form includes sections that ask about medical conditions, treatments, and the impact of disabilities on work and daily activities. |
| Submission | The completed form should be submitted to the Social Security Administration (SSA) as part of the disability application process. |
| State-Specific Laws | While the SSA-3380-BK is a federal form, it operates under the Social Security Act, which governs disability benefits across all states. |
SSA SSA-3380-BK: Usage Guidelines
Once you have the SSA-3380-BK form in front of you, it's important to take your time and fill it out carefully. Each section requires specific information, and accuracy is crucial for the processing of your request. Follow these steps to ensure that you complete the form correctly.
- Start with the personal information section at the top of the form. Fill in your full name, Social Security number, and date of birth.
- Provide your contact information. This includes your current address, phone number, and email address if applicable.
- In the next section, describe your medical conditions. Be specific about each condition and how it affects your daily life.
- List any medications you are currently taking. Include the name of the medication, dosage, and how often you take it.
- Provide information about any medical treatments you have received. This includes hospital visits, surgeries, or therapy sessions.
- Complete the section regarding your daily activities. Explain how your conditions limit your ability to perform routine tasks.
- Review your answers carefully. Make sure all information is accurate and complete.
- Sign and date the form at the designated area. Your signature confirms that the information provided is true to the best of your knowledge.
- Make a copy of the completed form for your records before submitting it.
After filling out the form, you will need to submit it to the appropriate Social Security Administration office. Ensure that you follow any additional instructions provided with the form to avoid delays in processing your request.
Your Questions, Answered
What is the SSA SSA-3380-BK form?
The SSA SSA-3380-BK form is a document used by the Social Security Administration (SSA) to gather information regarding an individual's ability to work. It is typically utilized in the evaluation process for disability claims. The form collects details about the claimant's daily activities, work history, and the impact of their medical condition on their ability to perform work-related tasks.
Who needs to fill out the SSA SSA-3380-BK form?
This form is generally required for individuals applying for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI). It is specifically designed for those who are claiming disability due to physical or mental impairments. Claimants may be asked to complete this form as part of their application process.
How do 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. It is also available at local SSA offices. Additionally, individuals can request the form by calling the SSA's toll-free number. It is important to ensure that the most current version of the form is used to avoid any processing delays.
What information is required on the SSA SSA-3380-BK form?
The form requires detailed information about the claimant's medical conditions, daily activities, work history, and any limitations caused by their impairments. It includes sections for describing how these conditions affect the individual's ability to perform work tasks. Claimants should provide as much detail as possible to support their case.
How should I complete the SSA SSA-3380-BK form?
Where do I submit the completed SSA SSA-3380-BK form?
The completed SSA SSA-3380-BK form should be submitted to the Social Security Administration. Claimants can mail the form to their local SSA office or submit it online if they are applying through the SSA's online portal. It is advisable to keep a copy of the completed form for personal records.
What happens after I submit the SSA SSA-3380-BK form?
After submission, the SSA will review the information provided on the form as part of the disability evaluation process. The SSA may contact the claimant for additional information or clarification. A decision regarding the disability claim will be made based on the information submitted, along with medical evidence and other relevant documentation.
Can I appeal if my claim is denied after submitting the SSA SSA-3380-BK form?
If a disability claim is denied, individuals have the right to appeal the decision. The SSA provides a process for appeals, which typically involves submitting a Request for Reconsideration. It is important to act promptly, as there are deadlines for filing an appeal. Claimants may benefit from seeking assistance from legal professionals during this process.
Is there a deadline for submitting the SSA SSA-3380-BK form?
While there is no specific deadline for submitting the SSA SSA-3380-BK form itself, it is essential to submit it in a timely manner as part of the overall disability application process. Delays in submitting the form may result in a delay in the processing of the disability claim. It is advisable to check with the SSA for any specific timelines related to individual cases.
Common mistakes
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Not reading the instructions carefully. Many individuals overlook the detailed guidelines provided at the beginning of the form.
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Failing to provide complete information. Incomplete answers can lead to delays in processing.
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Using unclear handwriting. Illegible writing can cause confusion and may result in errors during data entry.
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Neglecting to sign and date the form. An unsigned form is considered invalid and will not be processed.
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Not including necessary documentation. Supporting documents are often required to substantiate claims.
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Overlooking the deadline for submission. Late submissions can jeopardize the application process.
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Providing inconsistent information. Discrepancies between different sections of the form can raise red flags.
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Not keeping a copy of the submitted form. Retaining a copy is essential for future reference and follow-up.
Documents used along the form
The SSA-3380-BK form is used by the Social Security Administration to collect information about a person's daily activities and how their condition affects their ability to function. Along with this form, several other documents may be required to support a claim or application. Here are some commonly used forms and documents that often accompany the SSA-3380-BK.
- SSA-3368-BK: This form, also known as the Disability Report - Adult, gathers detailed information about a claimant's medical history, treatment, and work history. It helps the Social Security Administration assess the severity of the disability.
- 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. Claimants must complete this form to ensure their medical information is shared appropriately.
- Form SSA-5002: This form is used for documenting the claimant's allegations and other relevant information during an interview. It provides a detailed account of the claimant's situation and can help clarify any issues in the application process.
- Medical Records: These documents include all relevant medical evaluations, treatment notes, and test results that support the claimant's disability claim. They are crucial for establishing the extent of the disability and its impact on daily living.
Each of these documents plays a vital role in the disability claims process. They provide the necessary information for the Social Security Administration to make informed decisions regarding eligibility and benefits. Properly completing and submitting these forms can significantly impact the outcome of a claim.
Similar forms
The SSA-3380-BK form is a crucial document used by the Social Security Administration (SSA) to gather information about an individual's mental functioning. Several other forms serve similar purposes, collecting information about an individual's capabilities and limitations. Below are six documents that share similarities with the SSA-3380-BK form:
- SSA-3368-BK: This form, known as the "Function Report," collects information about an individual's daily activities and how their condition affects their ability to perform routine tasks. Like the SSA-3380-BK, it focuses on the individual's functional limitations.
- SSA-827: The "Authorization to Disclose Information to the Social Security Administration" form allows the SSA to obtain medical records and other relevant information. While it does not assess functioning directly, it supports the evaluation process by providing necessary background information.
- SSA-3373-BK: This is the "Function Report - Adult," which gathers information about how an individual's disability impacts their daily life. Similar to the SSA-3380-BK, it emphasizes the individual's functional abilities and limitations.
- SSA-4006: Known as the "Disability Report - Adult," this form collects comprehensive information about an individual's medical condition and its impact on their daily functioning. It aligns with the SSA-3380-BK in assessing how disabilities affect everyday activities.
- SSA-451: The "Request for Reconsideration" form allows individuals to appeal a decision made by the SSA regarding their disability claim. While not a direct assessment tool, it often references information gathered in forms like the SSA-3380-BK.
- SSA-3820: This is the "Mental Residual Functional Capacity Assessment" form, which evaluates an individual's mental capabilities. It shares the goal of assessing mental functioning with the SSA-3380-BK, although it is typically completed by medical professionals.
Each of these documents plays a role in the broader evaluation of an individual's disability claim, ensuring that the SSA has a comprehensive understanding of the person's functional limitations and needs.
Dos and Don'ts
When filling out the SSA SSA-3380-BK form, attention to detail is crucial. Here are some important dos and don'ts to keep in mind:
- Do read the instructions carefully before starting the form.
- Do provide accurate and complete information to avoid delays.
- Do review your answers for clarity and correctness.
- Do keep a copy of the completed form for your records.
- Don't leave any sections blank unless instructed to do so.
- Don't use abbreviations or shorthand that may confuse reviewers.
- Don't submit the form without checking for any required signatures.
- Don't ignore deadlines; submit the form as soon as possible.
Misconceptions
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Misconception 1: The SSA-3380-BK form is only for individuals with severe disabilities.
This form is actually used to assess the functional limitations of individuals with various types of disabilities, not just severe ones. It helps the Social Security Administration (SSA) understand how a person's condition affects their daily activities, regardless of the severity.
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Misconception 2: Completing the SSA-3380-BK form guarantees approval for disability benefits.
While the form is an important part of the application process, it does not guarantee that benefits will be awarded. The SSA considers multiple factors, including medical records and work history, when making a determination.
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Misconception 3: The SSA-3380-BK form is too complicated for most people to complete.
Although the form may seem daunting at first, it is designed to be user-friendly. Clear instructions accompany the form, and many individuals find they can complete it with relative ease. Assistance is also available through various organizations and resources.
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Misconception 4: You can only submit the SSA-3380-BK form once.
Applicants can submit the form multiple times if they need to update information or if their condition changes. It is important to keep the SSA informed about any new developments that may affect the assessment of the disability.
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Misconception 5: The SSA-3380-BK form is only relevant during the initial application process.
This form may also be relevant during appeals or reviews of existing claims. Changes in a person's condition or circumstances can prompt a reevaluation, and the SSA-3380-BK can provide necessary updates to the SSA.
Key takeaways
When filling out the SSA SSA-3380-BK form, keep these key takeaways in mind:
- Understand the purpose: The SSA-3380-BK form is used to assess your ability to work and function in daily life due to mental impairments.
- Provide detailed information: Be specific about your limitations and how they affect your daily activities. Vague responses may lead to delays.
- Use clear language: Avoid jargon and write in plain language to ensure your responses are easily understood.
- Review before submission: Double-check your answers for accuracy and completeness. An incomplete form can result in processing delays.
- Keep a copy: Retain a copy of the completed form for your records. This can be helpful for future reference or follow-up inquiries.
- Follow up: After submitting the form, monitor your application status. Contact the SSA if you have not received a response within the expected timeframe.