Fillable Ssa-3377-bk Function Report - Child Age 3 to 6th Birthday

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Ssa-3377-bk Function Report - Child Age 3 to 6th Birthday

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Continued on the Reverse
PLEASE REMOVE THIS SHEET BEFORE
RETURNING THE COMPLETED FORM.
Function Report Child Age 3 to 6th Birthday
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.
Filling out the Function Report
Form SSA-3377-BK (10-2017) UF
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Social Security Administration
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Page 1 of 10
OMB No. 0960-0542
- 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 OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL
SECURITY OFFICE. The office is 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 Boulevard, Baltimore, MD
21235-6401. Send only comments relating to our time estimate to this address, not the
completed form.
Privacy Act Statement
Collection and Use of Personal Information
Paperwork Reduction Act Statement
Form SSA-3377-BK (10-2017) UF
Sections 205(a), 223(d), and 1631(e)(1), of the Social Security Act, as amended, authorize us to
collect this information. We will use the information you provide on behalf of the minor child to
determine his or her benefit eligibility.
Furnishing us the information is voluntary. However, failing to provide us with all or part of the
requested information may prevent us from making an accurate and timely decision on the claim.
We rarely use the information for any purpose other than for making a decision regarding
entitlements to benefits. 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 assure 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 payment’s or delinquent
debts under these programs.
A complete list of routine uses of this information is available in our Privacy Act System of Records
Notices entitled, Claims Folders Systems, 60-0089. Additional information about this and other
system of records notices and our programs are available on-line at www.socialsecurity.gov or at
your local Social Security office.
Page 2 of 10
A. Print NAME OF CHILD:
B. Child's SOCIAL SECURITY NUMBER:
MAILING ADDRESS (Number and Street, Apt. No. (if any), P.O. Box, or Rural Route):
DAYTIME TELEPHONE NUMBER (including Area Code) :
DATE FORM COMPLETED:
FIRST MIDDLE LAST
C. Child's DATE OF BIRTH:
D. PERSON COMPLETING FORM
SECTION 1 - IDENTIFYING INFORMATION
FUNCTION REPORT -
CHILD AGE 3 TO 6th BIRTHDAY
1.
CITY STATE
NAME:
ZIP CODE
RELATIONSHIP TO CHILD:
Month/Day/Year
Month/Day/Year
Form SSA-3377-BK (10-2017) UF
Discontinue Prior Editions
Social Security Administration
Page 3 of 10
OMB No. 0960-0542
B. Does the child have
problems hearing?
If " yes," please mark every statement below that is generally true
about the child:
If "yes," please mark every statement below that is generally true
about the child:
A. Does the child have
problems seeing?
2.
SECTION 2 - FUNCTION DETAILS
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:
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:
YES (Continue)
NO (Go to 2.C.)
NO (Go to 2.B.)
YES (Continue)
Child cannot be fitted for hearing aid(s).
Child has other hearing problems. If so, please describe:
Child uses American Sign Language.
Child reads lips.
Form SSA-3377-BK (10-2017) UF Page 4 of 10
Does the child have problems talking clearly?
Form SSA-3377-BK (10-2017) UF
C. Is the child totally unable
to talk?
If the child has other problems talking, please explain:
If "yes," please mark the block that best describes the child in
each of the two statements below, and then describe any other
speech problems:
2.
Speech can be understood by people who know the child well:
Speech can be understood by people who don't know the child
well:
NO (Continue)
YES (Go to 2.D.)
Yes (answer questions below)
No (continue to question 2.D.)
Most of the time, or
Some of the time, or
Hardly ever.
Most of the time, or
Some of the time, or
Hardly ever.
Page 5 of 10
D. Is the child's ability to
communicate limited?
If "yes," or "not sure," please tell us what the child does or can
do by checking "yes" or "no" for each of the following:
Form SSA-3377-BK (10-2017) UF
Can deliver simple messages such
as telephone messages
Can answer questions about a short
read-aloud children's story or TV story
like "Little Red Ridinghood"
Can tell a made up or familiar short
story
Tells about things and activities that
happened in the past
Talks about what he or she is
doing
Uses complete sentences of more
than 4 words most of the time
If necessary, please explain. In addition, please tell us anything
else you think we should know about the child's ability to
communicate:
2.
Asks a lot of what, why, and where
questions
Takes part in conversations with other
children
Asks for what he or she wants
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
YES (Continue)
NO (Go to 2.E.)
NOT SURE
(Continue)
Page 6 of 10
If "yes," or "not sure," please tell us what the child does or can do
by checking "yes" or "no" for each of the following:
E. Does the child's
impairment(s) limit his or
her progress in
understanding and using
what he or she has
learned?
Understands a joke
Can read capital letters of the alphabet
Knows his or her birthday
Asks what words mean
Knows his or her age
Recite numbers to 3
2.
If necessary, please explain. In addition, please tell us anything
else you think we should know about the child's progress in
understanding and using what he or she has learned:
Count three objects (like blocks, cars
or dolls)
Recite numbers to 10
Identify most colors, such as purple, and
shapes, such as a star
Knows his or her telephone number
Can define common words
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
YES (Continue)
NO (Go to 2.F.)
NOT SURE
(Continue)
Form SSA-3377-BK (10-2017) UF Page 7 of 10
If " yes," or "not sure," please tell us what the child does or can
do by checking "yes" or "no" for each of the following:
If "yes," or "not sure," please tell us what the child does or can do
by checking "yes" or "no" for each of the following:
F. Are the child's physical
abilities limited?
G. Does the child's
impairment(s) affect his or
her behavior with other
people?
If necessary, please explain. In addition, please tell us anything
else you think we should know about the child's physical
abilities:
2.
Print at least some letters
Wind up a toy
Catch a large ball, like a beach ball
Ride a big wheel, tricycle, or bike with
training wheels
Shares toys
Enjoys being with other children the same age
Shows affection towards other children
If necessary, please explain. In addition, please tell us anything
else you think we should know about the child's behavior around
other people:
Takes turns
Copy first name
Use scissors fairly well
Plays "pretend" with other children
Plays games like tag, hide-and-seek
Plays board games (like checkers or
Candyland)
Is affectionate towards parents
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
YES (Continue)
NO (Go to 2.G.)
NOT SURE
(Continue)
YES (Continue)
NO (Go to 2.H.)
NOT SURE
(Continue)
Form SSA-3377-BK (10-2017) UF Page 8 of 10
If " yes," or " not sure," how long can the child pay attention to
TV, music, reading aloud or games?
If " yes ," or " not sure ," please tell us what the child does or
can do by checking "yes" or "no" for each of the following. Check
"yes" if it is something the child used to do but doesn't do any
more just because he or she is older. For example, if the child
used to dress with help but now dresses without help, check
"yes" for both.
H. Does the child's
impairment(s) affect his or
her habits and ability to take
care of personal needs?
2.
Washes or bathes without help
Dresses self without help (except tying
shoes)
Eats using a fork and spoon by self
Dresses self with help
If necessary, please explain. In addition, please tell us
anything else you think we should know about the child's
habits and ability to take care of personal needs:
I. Is the child's ability to
pay attention and stick with
a task limited?
If necessary, please explain. In addition, please tell us
anything else you think we should know about the child's
ability to pay attention and stick with a task:
Brushes teeth with help
Brushes teeth without help
Usually controls bowels and bladder
during the day
Puts toys away
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
15 minutes 30 minutes
YES (Continue)
NO (Go to 2.I.)
NOT SURE
(Continue)
YES (Continue)
NO (Go to 2.J.)
NOT SURE
(Continue)
Form SSA-3377-BK (10-2017) UF Page 9 of 10
2.
J. Please tell us anything else about the child that you think we should know.
SECTION 3 - REMARKS
Form SSA-3377-BK (10-2017) UF Page 10 of 10
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Ssa-3377-bk Function Report - Child Age 3 to 6th Birthday

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Completed 2 January 2020

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