Fillable FUNCTION REPORT - ADULT - THIRD PARTY Form

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FUNCTION REPORT - ADULT - THIRD PARTY Form

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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
•
•
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 8, and show the number of the question being answered.
REMEMBER TO GIVE US THE NAME AND ADDRESS OF THE PERSON
COMPLETING THIS FORM ON PAGE 8
Function Report - Adult - Third Party Form SSA-3380-BK
Print or type.
- 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 21235-0001. Send only comments relating to
our time estimate to this address, not the completed form.
Privacy Act and Paperwork Reduction Act Statements
Paperwork Reduction Act Statement
PLEASE REMOVE THIS SHEET BEFORE RETURNING
THE COMPLETED FORM.
Sections 205(a), 223(d)(5)(A), 1631(d)(1) and 1631(e)(1) of the Social Security Act, as
amended, authorize us to collect this information. We will use the information you provide to
make a determination of eligibility for Social Security benefits.
Furnishing us this information is voluntary. However, failing to provide us with all or part of
the information may prevent an accurate and timely decision on any claim filed.
We rarely use the information you supply us for any purpose other than to make a
determination regarding benefits eligibility. However, we may use the information for the
administration of our programs including sharing information:
1. To comply with Federal laws requiring the release of information from our records
(e.g., to the Government Accountability Office and Department of Veterans Affairs);
and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure
the integrity and improvement of our programs (e.g., to the Bureau of the Census and
to private entities under contract with us).
A list of when we may share your information with others, called routine uses, is available in
our Privacy Act System of Records Notices 60-0089, entitled Claims Folders Systems; and,
60-0320, entitled Electronic Disability (eDIB) Claim File. Additional information about these
and other system of records notices and our programs are available online at www.
socialsecurity.gov or at your local Social Security office.
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, State or local government
agencies. Information from these matching programs can be used to establish or verify a
person's eligibility for federally funded or administered benefit programs and for repayment of
incorrect payments or delinquent debts under these programs.
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.)
Form SSA-3380-BK (09-2017)
Use (12-2015) Edition Until Supply Exhausted
SOCIAL SECURITY ADMINISTRATION
Form Approved
OMB No. 0960-0635
Page 1
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 (Month, Day, Year)
Area Code
Your Number
Message Number None
7. a. Where does the disabled person live? (Check one.)
House
Apartment Boarding House Nursing Home
Shelter
Group Home Other (What?)
b. With whom does he/she live? (Check one.)
Alone
With Family
With Friends
Other (describe relationship)
SECTION B - INFORMATION ABOUT ILLNESSES, INJURIES, OR CONDITIONS
6. a. How long have you known the disabled person?
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.
Phone Number
-
b. How much time do you spend with the disabled person and what do you do together?
For SSA Use Only
Do not write in this box.
How the disabled person's illnesses, injuries, or conditions limit his/her activities
FUNCTION REPORT- ADULT - THIRD PARTY
8. How does this person's illnesses, injuries, or conditions limit his/her ability to work?
Form SSA-3380-BK (09-2017)
Page 2
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?
Yes No
If "YES," for whom does he/she care, and what does he/she do for them?
11. Does he/she take care of pets or other animals?
Yes No
If "YES," what does he/she do for them?
12. Does anyone help this person care for other people or animals?
Yes No
If "YES," who helps, and what do they do to help?
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
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
Form SSA-3380-BK (09-2017) Page 3
b. Does he/she need any special reminders to take care of
personal needs and grooming?
Yes No
If "YES," what type of help or reminders are needed?
c. Does he/she need help or reminders taking medicine?
Yes
No
If "YES," what kind of help does he/she need?
16. MEALS
a. Does the disabled person prepare his/her own meals?
Yes No
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?
Yes No
If "YES," what help is needed?
Form SSA-3380-BK (09-2017) Page 4
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?
Yes No
If "NO," explain why he/she can't go out alone.
d. Does the disabled person drive?
Yes No
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 Yes No Handle a savings account Yes No
Count change
Yes No Use a checkbook/money orders Yes No
Explain all "NO" answers.
Form SSA-3380-BK (09-2017) Page 5
b. Has the disabled person's ability to handle money changed since
the illnesses, injuries, or conditions began?
Yes No
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. Does the disabled person spend time with others? (In person, on the phone,
on the computer, etc.)
Yes No
If "YES," describe the kinds of things he/she does with others.
How often does he/she do these things?
b. 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?
Yes No
How often does he/she go and how much does he/she take part?
Does he/she need someone to accompany him/her?
Yes No
Form SSA-3380-BK (09-2017)
Page 6
c. Does this person have any problems getting along with family, friends,
neighbors, or others?
Yes No
If "YES," explain.
d. 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.)
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?
Form SSA-3380-BK (09-2017)
Page 7
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)
Which of these were prescribed by a doctor?
When was it prescribed?
When does this person need to use these aids?
Form SSA-3380-BK (09-2017)
Page 8
25. Does the disabled person currently take any medicines for his/her illnesses,
injuries, or conditions?
Yes No
If " YES," do any of the medicines cause side effects?
Yes 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
Name of person completing this form (Please print)
Date (month, day, year)
Address (Number and Street)
Email address (optional)
City State ZIP Code
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.
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FUNCTION REPORT - ADULT - THIRD PARTY Form

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Completed 23 March 2021

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