Fillable Ssa 3378 Bk SSA 3378 BK (Social Security Administration)

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Ssa 3378 Bk SSA 3378 BK (Social Security Administration)

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Function Report - Child Age 6 to 12th 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.
• 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.
PLEASE REMOVE THIS SHEET BEFORE
RETURNING THE COMPLETED FORM.
Continued on the Reverse
• Print or type.
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.
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.
Form SSA-3378-BK (10-2017) UF
Discontinue Prior Editions
Social Security Administration
Page 1 of 12
OMB No. 0960-0542
Privacy Act Statement
Collection and Use of Personal Information
- 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. 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, 1338 Annex Building, Baltimore, MD 21235-6401. Send only
comments relating to our time estimate to this address, not the completed form.
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.
Paperwork Reduction Act Statement
Form SSA-3378-BK (10-2017) UF Page 2 of 12
DATE FORM COMPLETED:
RELATIONSHIP TO CHILD:
FUNCTION REPORT - CHILD
AGE 6 TO 12th BIRTHDAY
SECTION 1 - IDENTIFYING INFORMATION
1.
A. Print NAME OF CHILD:
B. Child's SOCIAL SECURITY NUMBER:
C. Child's DATE OF BIRTH:
Month/Day/Year
D. PERSON COMPLETING FORM
NAME:
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
Form SSA-3378-BK (10-2017) UF
Discontinue Prior Editions
Social Security Administration
Page 3 of 12
OMB No. 0960-0542
LASTMIDDLEFIRST
Month/Day/Year
SECTION 2 - FUNCTION DETAILS
2. A. Does the child have
problems seeing?
YES (Continue)
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)
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).
Child has other hearing problems. If so, please describe:
Child uses American Sign Language.
Child reads lips.
Form SSA-3378-BK (10-2017) UF Page 4 of 12
Form SSA-3378-BK (10-2017) UF
2. C. Is the child totally
unable to talk?
YES (Go to 2.D.)
NO (Continue)
Does the child have problems talking clearly?
Yes (answer questions below)
No (continue to question 2.D.)
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:
Speech can be understood by people who know the child well:
Most of the time, or
Some of the time, or
Hardly ever.
Speech can be understood by people who don't know the
child well:
Most of the time, or
Some of the time, or
Hardly ever.
If the child has other problems talking, please explain:
Page 5 of 12
2. D. Is the child 's ability to
communicate limited?
YES (Continue)
NO (Go to 2.E.)
If "yes," or "not sure," please tell us what the child does or can
do by marking "yes" or "no" for each of the following:
NOT SURE
(Continue)
Deliver telephone messagesYes No
Repeat stories he or she has heardYes No
Tell jokes or riddles accuratelyYes No
Explain why he or she did somethingYes No
Uses sentences with "because," "what if,"
or "should have been"
Yes No
Talks with familyYes No
Talks with friendsYes No
If necessary, please explain. In addition, please tell us
anything else you think we should know about the child's ability
to communicate:
Form SSA-3378-BK (10-2017) UF Page 6 of 12
2. E. Is the child's ability
to progress in
learning limited?
YES (Continue)
NO (Go to 2.F.)
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:
NOT SURE
(Continue)
Read capital letters of alphabetYes No
Read capital letters and small lettersYes No
Read simple wordsYes No
Read and understands simple sentencesYes No
Read and understands stories in books
or magazines
Yes No
Print some lettersYes No
Print nameYes No
If necessary, please explain. In addition, please tell us anything
else you think we should know about the child's ability to progress
in learning:
Write in longhand (script)Yes No
Spell most 3-4 letter wordsYes No
Write a simple story with 6-7 sentencesYes No
Add and subtract numbers over 10Yes No
Knows days of the week and months of
the year
Yes No
Understands money - can make correct
change
Yes No
Tells timeYes No
Form SSA-3378-BK (10-2017) UF Page 7 of 12
Form SSA-3378-BK (10-2017) UF
2. F. Are the child's physical
abilities limited?
YES (Continue)
NO (Go to 2.G.)
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:
NOT SURE
(Continue)
WalkYes No
RunYes No
Throw a ballYes No
Ride a bikeYes No
Jump ropeYes No
Use roller skates or roller bladesYes No
SwimYes No
If necessary, please explain. In addition, please tell us anything
else you think we should know about the child's physical abilities:
Use scissorsYes No
Work video game controls Yes No
Dress/undress dolls or action figuresYes No
Page 8 of 12
2. G. Does the child's
impairment(s) affect his
or her behavior with
other people?
YES (Continue)
NO (Go to 2.H.)
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:
NOT SURE
(Continue)
Has friends his or her own ageYes No
Can make new friendsYes No
Generally gets along with you or other
adults
Yes No
Generally gets along with school teachersYes No
Plays team sports (for example, baseball,
basketball, soccer)
Yes No
If necessary, please explain. In addition, please tell us anything
else you think we should know about the child's behavior with
other people:
Form SSA-3378-BK (10-2017) UF Page 9 of 12
2. H. Does the child's
impairment(s) affect his
or her ability to help
himself or herself and
cooperate with others
in taking care of
personal needs?
YES (Continue)
NO (Go to 2.I.)
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:
NOT SURE
(Continue)
Uses zipper by selfYes No
Buttons clothes by selfYes No
Ties shoelacesYes No
Takes a bath or shower without helpYes No
Brushes teethYes No
Combs or brushes hairYes No
Washes hair by selfYes No
If necessary, please explain. In addition, please tell us anything
else you think we should know about the child's ability to help him
or herself and cooperate with others in caring for personal needs:
Chooses clothes by selfYes No
Eats by self using a knife, fork, and spoonYes No
Picks up and puts away toysYes No
Hangs up clothesYes No
Helps around the house (for example,
washes or dries dishes, makes bed(s),
sweeps/vacuums floor, rakes or mows
yard, helps with laundry)
Yes No
Does what he or she is told most of the timeYes No
Obeys safety rules; for instance, looks for
cars before crossing street
Yes No
Gets to school on timeYes No
Accepts criticism or correctionYes No
Form SSA-3378-BK (10-2017) UF Page 10 of 12
2. I. Is the child's ability to
pay attention and stick
with a task limited?
YES (Continue)
NO (Go to 2.J.)
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:
NOT SURE
(Continue)
Keeps busy on his/her ownYes No
Finishes things he or she startsYes No
Works on arts and crafts projects (draws,
paints, knits, does woodwork)
Yes No
Completes homeworkYes No
Completes chores most of the timeYes No
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:
J. Please tell us anything else about the child that you think we should know.
Form SSA-3378-BK (10-2017) UF Page 11 of 12
Form SSA-3378-BK (10-2017) UF
SECTION 3 - REMARKS
Page 12 of 12
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Completed 24 July 2020

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