Fillable Ssa-3379-bk Function Report - Child Age 12 to 18th Birthday

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Ssa-3379-bk Function Report - Child Age 12 to 18th Birthday

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Function Report Child Age 12 to 18th 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
Form SSA-3379-BK (10-2017) UF
Discontinue Prior Editions
Social Security Administration
Page 1 of 11
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-3379-BK (10-2017) UF Page 2 of 11
Form SSA-3379-BK (10-2017) UF
Discontinue Prior Editions
Social Security Administration
FUNCTION REPORT - CHILD
AGE 12 TO 18th BIRTHDAY
Page 3 of 11
OMB No. 0960-0542
SECTION 1 - IDENTIFYING INFORMATION
DATE FORM COMPLETED:
RELATIONSHIP TO CHILD:
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
LASTMIDDLEFIRST
Month/Day/Year
Form SSA-3379-BK (10-2017) UF
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.
Page 4 of 11
Form SSA-3379-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 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 11
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-3379-BK (10-2017) UF
E. Is the child's ability to
communicate limited?
2. D. Are the child's daily
activities limited?
YES (Continue)
NO (Go to 2.E.)
NOT SURE
(Continue)
If "yes," or "not sure," please mark every statement below that
is true about the child:
Goes to school full-time
Goes to school part-time
Other. Describe:
Works part-time
Works full-time
If necessary, please explain. In addition, please tell us anything
else you think we should know about the child's daily activities:
YES (Continue)
NO (Go to 2.F.)
NOT SURE
(Continue)
Answer the telephone and make
telephone calls
Yes No
Deliver phone messages
Yes No
Repeat stories he or she has heard
Yes No
Tell jokes or riddles accurately
Yes No
Explain why he or she did something
Yes No
Uses sentences with "because," "what if,"
or "should have been"
Yes No
Ask for what he or she needs
Yes No
Talks with family
Yes No
Talks with friends
Yes No
If necessary, please explain. In addition, please tell us anything
else you think we should know about the child's ability to
communicate:
Page 6 of 11
G. Are the child's physical
abilities limited?
2. F. Is there any limitation in
the child's progress in
understanding and using
what he or she has
learned?
YES (Continue)
NO (Go to 2.G.)
NOT SURE
(Continue)
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 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:
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:
YES (Continue)
NO (Go to 2.H.)
NOT SURE
(Continue)
Walk
Yes No
Run
Yes No
Dance
Yes No
Swim
Yes No
If necessary, please explain. In addition, please tell us anything
else you think we should know about the child's physical
abilities:
Ride a bike
Yes No
Drive a
car
Yes No
Throw a ball
Yes No
Jump rope
Yes No
Play sports
Yes No
Work video
games controls
Yes No
Multiply and divide numbers over 10
Read and understand sentences in comics
and cartoons
Yes No
Read and understand stories in books,
magazines, or newspapers
Yes No
Yes No
Add and subtract numbers over 10
Yes No
Yes No
Tell time
Understand, carry out, and remember
simple instructions
Understands money - can make correct
change
Yes No
Yes No
Yes No
Spell words of more than 4 letters
Form SSA-3379-BK (10-2017) UF
Page 7 of 11
Form SSA-3379-BK (10-2017) UF
2. H. Does the child's
impairment(s) affect his
or her social activities or
behavior with other
people?
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:
If necessary, please explain, In addition, please tell us anything
else you think we should know about the child's behavior around
other people:
NOT SURE
(Continue)
Generally gets along with school
teachers
Has friends his or her own age
Yes No
Can make new friends
Yes No
Yes No
Generally gets along all right with
brothers and sisters
Yes No
Yes No
Generally gets along with you or other
adults
Plays team sports (for example, baseball,
basketball, soccer)
Yes No
Page 8 of 11
2. I. Is the child's ability to take
care of his or her personal
needs and safety 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:
If necessary, please explain. In addition, please tell us anything
else you think we should know about the child's ability to take
care of his or her personal needs and safety:
NOT SURE
(Continue)
Gets to school on time
Takes care of personal hygiene (keep
clean, brush teeth, comb hair, etc.)
Yes No
Washes and puts away his or her clothes
Yes No
Yes No
Can cook a meal for self
Yes No
Yes No
Helps around the house (for example,
washes or dries dishes, makes bed(s),
sweeps/vacuums floor, rakes or mows yard,
helps with laundry)
Studies and does homework
Yes No
Accepts criticism or correction
Can use public transportation by himself/
herself
Takes needed medication
Yes No
Yes No
Yes No
Avoids accidents
Obeys rules
Keeps out of trouble
Yes No
Yes No
Yes No
Asks for help when needed
Yes No
Form SSA-3379-BK (10-2017) UF
Page 9 of 11
Form SSA-3379-BK (10-2017) UF
2. J. Is the child's ability to pay
attention and stick with a
task limited?
YES (Continue)
NO (Go to 2.K.)
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 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:
NOT SURE
(Continue)
Completes homework on time
Works on arts and crafts projects (draws,
paints, knits, does woodwork)
Yes No
Keeps busy on his or her own
Yes No
Yes No
Completes homework
Yes No
Yes No
Finishes things he or she starts
Completes chores most of the time
Yes No
K. Please tell us anything else about the child that you think we should know.
Page 10 of 11
SECTION 3 - REMARKS
Form SSA-3379-BK (10-2017) UF
Page 11 of 11
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Ssa-3379-bk Function Report - Child Age 12 to 18th Birthday

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Completed 16 November 2019

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