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Ssa 3375 Bk SSA 3375 BK (Social Security Administration)

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Form SSA-3375-BK (02-2015) ef (02-2015)
Use (05-2006) ef (12-2006) edition until exhausted
Function Report - Child Birth to 1st Birthday
Filling Out The Function Report
IF YOU NEED HELP COMPLETING ANY PART OF THIS FORM, CONTACT YOUR SOCIAL
SECURITY OFFICE. WE WILL HELP YOU.
The information that you give us on this form will be used by the office that makes the disability
decision on the child's claim. You can help them by completing as much of the form as you can.
• Print or type.
• Do not ask a doctor or hospital to complete this form.
• Be sure to explain your answer if an explanation is requested or needed.
•
If more space is needed to answer any of the questions, please use the "REMARKS"
section and show the number of the question being answered.
The information we ask for on this form tells us how you think the child's illnesses or injuries affect
the way he or she does many of his or her usual activities.
PLEASE REMOVE THIS SHEET BEFORE
RETURNING THE COMPLETED FORM.
Continued on the Reverse
u
Privacy Act Statement
Sections 1614 and 1631(e)(1), of the Social Security Act, as amended, and 20 CFR 416.924(a),
authorize us to collect this information. We will use the information you provide on behalf of the
child to determine his or her eligibility for Supplemental Security Income (SSI) payments based
on disability.
Furnishing us the information is voluntary. However, failing to provide all or part of the
requested information may prevent our making an accurate and timely decision on the claim.
We rarely use the information you supply for any purpose other than to make a decision
regarding the child’s eligibility for SSI payments. However, we may use it for the administration
and integrity of our programs. We may also disclose the information to another person or to
another agency in accordance with approved routine uses, including but not limited to
the following:
1. To enable a third party or an agency to assist us in establishing rights to our benefits
and coverage;
2. 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);
3. To make determinations for eligibility in similar health and income maintenance programs
at the Federal, State, and local level; and,
4. To facilitate statistical research, audit, and investigatory 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).
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. We use the information from these programs to establish or verify a person's eligibility
for federally funded and administered benefit programs and for repayment of incorrect payments
or delinquent debts under these programs.
A complete list of routine uses of this information is available in our Privacy Act System of
Records Notice 60-0089, entitled, Claims Folders Systems. Additional information about this
and other system of records notices and our programs is available on-line at
www.socialsecurity.gov
or at your local Social Security office.
- 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 20 minutes to read the instructions, gather the facts, and
answer the questions. SEND 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.
Paperwork Reduction Act Statement
Form SSA-3375-BK (02-2015) ef (02-2015)
Form SSA-3375-BK (02-2015) ef (02-2015)
Use (05-2006) ef (12-2006) edition until exhausted
SOCIAL SECURITY ADMINISTRATION
FUNCTION REPORT - CHILD
BIRTH TO 1st BIRTHDAY
Form Approved
OMB No. 0960-0542
Page 1
SECTION 1 - IDENTIFYING INFORMATION
1.
A. Print NAME OF CHILD:
FIRST
MIDDLE
LAST
B. Child's SOCIAL SECURITY NUMBER:
C. Child's DATE OF BIRTH:
Month/Day/Year
D. PERSON COMPLETING FORM
NAME:
RELATIONSHIP TO CHILD:
DATE FORM COMPLETED:
Month/Day/Year
DAYTIME TELEPHONE NUMBER (including Area Code):
MAILING ADDRESS (Number and Street, Apt. No. (if any), P.O. Box, or Rural Route):
CITY STATE ZIP CODE
Page 2
SECTION 2 - FUNCTION DETAILS
2.
A. Does the child have
problems seeing?
YES (Continue)
u
NO (Go to 2.B.)
If "yes," please mark every statement below that is generally true
about the child:
Child uses glasses or contact lenses. If the child has
problems seeing even with glasses or contact lenses, please
explain:
Child cannot be fitted for glasses or contact lenses. Explain:
Child has other seeing problems. If so, please describe:
B. Does the child have
problems hearing?
YES (Continue)
u
NO (Go to 2.C.)
If "yes," please mark every statement below that is generally true
about the child:
Child uses hearing aid(s). If the child has problems hearing
even with a hearing aid(s) OR has trouble using a hearing
aid, please explain:
Child cannot be fitted for hearing aid(s). Explain:
Child has other hearing problems. If so, please describe:
Form SSA-3375-BK (02-2015) ef (02-2015)
Page 3
2. C. Are the child's activities
or abilities limited?
YES (Continue)
u
NO (Go to 2.D.)
NOT SURE
(Continue)
u
If "yes," or "not sure," please tell us what the child does by
marking "yes" or "no" for each of the following:
Yes No
Makes various cooing sounds, such as
"aaah" and "oooh"
Yes No
Makes various babbling sounds, such
as "babababa" or "mamamama"
Yes No
Says simple words other than "mama"
and "dada"
Child generally
Yes No
Stops crying when picked up and held
Yes No
Watches face of person talking to him or
her
Yes No
Pats, "talks to" or otherwise responds to
himself or herself in mirror
Yes No
Plays games, such as "peek-a-boo"
Yes No
Understands simple statements like "come
here" or "sit down"
Yes No
Points to something he or she wants that
is out of reach, such as a toy or food
NoYes
Understands names of favorite toys or
other things, such as a bottle
Yes No
Turns head in direction of familiar noises
or voices
Yes No
Turns head when his or her name is called
Yes No
Smiles at faces he or she knows
Yes No
Quiets or stops crying when sees parent
or other person he or she knows
Yes No
Cuddles in arms when held by parent or
caregiver
Yes No
Reaches out to be picked up
Form SSA-3375-BK (02-2015) ef (02-2015)
Page 4
2. C. (Continued)
Child can
Roll from stomach to back
Yes No
Roll from back to stomach
Yes No
Get to a sitting position without help
Yes No
Rock back and forth on hands and knees
Yes No
Crawl or creep
Yes No
Pull self up to a standing position
Yes No
Reach for toys, or other objects
Yes No
Stand up without holding on to someone
or something
Yes No
Walk holding on to someone or something
Yes No
Eat foods, such as cereal, cookie, by self
Yes No
Move toy or other object from hand-to-
hand
Yes No
Hold small objects between fingers
Yes No
Throw ball or other object
Yes No
D. If necessary, please explain any of the items in Question 2.C. In addition, please tell us
anything else about the child that you think we should know:
Form SSA-3375-BK (02-2015) ef (02-2015)
Page 5
SECTION 3 - REMARKS
Form SSA-3375-BK (02-2015) ef (02-2015)
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Completed 25 July 2020

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