Fillable Ssa-3820 Disability Report - Child

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Ssa-3820 Disability Report - Child

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Disability Report - Child - Form SSA-3820-BK
READ ALL OF THIS INFORMATION BEFORE YOU BEGIN
COMPLETING THIS FORM THIS IS NOT AN APPLICATION
If you need help with this form, complete as much of it as you can, and your interviewer will help
you finish it.
The information that you give us on this form will be used by the office that makes the disability
decision on your disability claim. You can help them by completing as much of the form as
you can.
Fill out as much of this form as you can before your interview appointment. Print or write
clearly.
DO NOT LEAVE ANSWERS BLANK. If you do not know the answers, or the answer is
"none" or "does not apply," write: "don't know," or " none," or "does not apply."
IN SECTION 4, PUT INFORMATION ON ONLY ONE DOCTOR/HMO/THERAPIST/ OTHER/
HOSPITAL/CLINIC IN EACH SPACE.
Each address should include a ZIP code. Each telephone number should include an
area code.
DO NOT ASK A DOCTOR OR HOSPITAL TO COMPLETE THE FORM. However, you can
get help from other people, like a friend or family member.
If your appointment is for an interview by telephone, have the form ready to discuss with us
when we call you.
If your appointment is for an interview in our office, bring the completed form with you or mail
ahead of time, if you were told to do so.
Be sure to explain an answer if the question asks for an explanation, or if you want to give
additional information.
If you need more space to answer any questions or want to tell us more about an answer,
please use Section 10, "DATE AND REMARKS," on Pages 11 and 12, and show the number
of the question being answered.
If you have any of the following records for the child at home, send them to our office with your
completed forms or bring them with you to the interview. If you need the records back, tell us and
we will photocopy them and return them to you.
The child's medical records
The child's Individualized Education Program
YOU DO NOT NEED TO ASK DOCTORS OR HOSPITALS FOR ANY MEDICAL RECORDS
THAT YOU DO NOT ALREADY HAVE. With your permission, we will do that for you. The
information we ask for on this form tells us from whom to request medical and other records. If
you cannot remember the names and addresses of any of the doctors or hospitals, or the dates of
treatment, perhaps you can get this information from the telephone book, or from medical bills,
prescriptions and medicine containers.
•
•
•
•
•
•
•
•
•
Copies of the child's prescriptions or medicine containers
The child's Individualized Family Service Plan
ABOUT THE CHILD'S MEDICAL AND OTHER RECORDS
HOW TO COMPLETE THIS FORM
IF YOU NEED HELP
•
•
•
•
DISABILITY REPORT - CHILD - Form SSA-3820-BK
REMOVE THIS SHEET BEFORE RETURNING THE COMPLETED FORM.
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 (OMB) control
number. We estimate that it will take about 90 minutes to read the instructions, gather the facts, and
answer the questions. Send only comments relating to our time estimate above to: SSA, 6401
Security Blvd, Baltimore, MD 21235-6401.
Paperwork Reduction Act Statement
Sections 205(a), 1631(e)(1), and 223(d)(5)(A) of the Social Security Act, as amended, allow us to
collect this information. Furnishing us this information is voluntary. However, failing to provide all or
part of the information may affect the decision on the claim.
We will use the information to make a decision regarding if a child is eligible for benefit
payments. We may also share your information for the following purposes, called routine uses:
1. To Federal, State, or local agencies that conduct business with the Social Security
Administration (SSA) and the release of records is determined to be relevant and
necessary; and disclosure is compatible to the reason why the records were collected;
2. To third party contacts when additional information about the child is needed or
verification of eligibility for benefits; and
3. To workers who are performing work for SSA as authorized by law and who technically
do not have the status of Federal employees; and other Federal agencies for assisting SSA
in the efficient administration of its programs.
In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice
(SORN) 60-0089, entitled Claims Folders Systems. Additional information and a full listing of
all our SORNs are available on our website at www.socialsecurity.gov/foia/bluebook.
G. Does the child live with you?
D. YOUR DAYTIME PHONE NUMBER
SOCIAL SECURITY ADMINISTRATION
DISABILITY REPORT - CHILD
Form Approved
OMB No. 0960-0577
SECTION 1 - INFORMATION ABOUT THE CHILD
C. YOUR NAME (If agency, provide name of agency and contact person)
YOUR EMAIL ADDRESS (Optional)
(If you do not have a phone number where we can reach you, give us
a daytime number where we can leave a message for you.)
Your Number
Message Number None
E. What is your relationship to the child?
F. Can you speak and understand English?
YES NO
If "NO", what is your preferred language?
NOTE: If you cannot speak and understand English, we will provide you an interpreter, free of charge. If you
cannot speak and understand English, is there someone we may contact who speaks and understands
English and will give you messages?
YES (Enter name, address, phone number, relationship) NO
NAME RELATIONSHIP TO CHILD
ADDRESS
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)
City
DAYTIME
PHONE
Area Code
Can you read and understand English?
If "NO", with whom does the child live?
Can this person speak and understand English?
If "NO", what is this person's preferred language?
Can this person read and understand English?
Disability Report - Child - Form SSA-3820-BK
A. CHILD'S NAME (First, Middle Initial, Last)
Number
B. CHILD'S SOCIAL SECURITY NUMBER
ZIP CODE
Number
YOUR MAILING ADDRESS (Number and Street, Apt. No. (if any), P.O. Box, or Rural Route)
CITY
STATE
Area Code
State ZIP
NOYES
NOYES
NumberArea Code
DAYTIME
PHONE
ZIP
StateCity
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)
RELATIONSHIP TO CHILD NAME
ADDRESS
NOYES
NOYES
Form SSA-3820-BK (03-2017) UF
Page 1 of 12
SECTION 1 - INFORMATION ABOUT THE CHILD
H. Can the child speak and understand English?
If "NO," what languages can the child speak?
If the child understands any other languages, list them here:
I. What is the child's height (without shoes)?
What is the child's weight (without shoes)?
J. Does the child have a medical assistance card? (for example Medicaid, Medi-Cal)
If "YES", show the number here:
SECTION 2 - CONTACT INFORMATION
A. Does the child have a legal guardian or custodian other than you?
NAME
ADDRESS
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)
DAYTIME PHONE NUMBER
RELATIONSHIP TO CHILD
If "NO", what is this person's preferred language?
Can this person read and understand English?
B. Is there another adult who helps care for the child and can help us get information about the child if necessary?
NAME OF CONTACT
ADDRESS
DAYTIME PHONE NUMBER
RELATIONSHIP TO CHILD
Can this person speak and understand English?
If "NO", what is this person's preferred language?
Can this person read and understand English?
Can this person speak and understand English?
NOYES
NOYES
NO
YES (Enter name, address, phone number, relationship)
ZIPState
City
NumberArea Code
NOYES
NOYES
NO
YES (Enter name, address, phone number, relationship)
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)
ZIPStateCity
NumberArea Code
NOYES
NOYES
Page 2 of 12
Form SSA-3820-BK (03-2017) UF
SECTION 3 - THE CHILD'S ILLNESSES, INJURIES OR
CONDITIONS AND HOW THEY AFFECT HIM/HER
A. What are the child's disabling illnesses, injuries, or conditions?
B. When did the child become disabled?
Month Day Year
C. Do the child's illnesses, injuries or conditions cause pain or other symptoms?
SECTION 4 - INFORMATION ABOUT THE CHILD'S MEDICAL RECORDS
A. Has the child been seen by a doctor/hospital/clinic or anyone else for the illnesses, injuries or conditions?
B. Has the child been seen by a doctor/hospital/clinic or anyone else for emotional or mental problems?
NOYES
NOYES
NOYES
Page 3 of 12
Form SSA-3820-BK (03-2017) UF
SECTION 4 - INFORMATION ABOUT THE CHILD'S MEDICAL RECORDS
Tell us who may have medical records or other
information about the child's illnesses, injuries or conditions.
C. List each DOCTOR/HMO/THERAPIST/OTHER. Include the child's next appointment.
1. NAME
CITY
PHONE
Number
DATES
FIRST VISIT
NEXT APPOINTMENT
STREET ADDRESS
STATE ZIP
LAST VISIT
Area Code
Patient ID # (If known)
REASONS FOR VISITS
WHAT TREATMENT WAS RECEIVED?
2. NAME
CITY
PHONE
Number
DATES
FIRST VISIT
NEXT APPOINTMENT
STREET ADDRESS
STATE ZIP
LAST VISIT
Area Code
Patient ID # (If known)
REASONS FOR VISITS
WHAT TREATMENT WAS RECEIVED?
Form SSA-3820-BK (03-2017) UF
Page 4 of 12
Reasons for visits
SECTION 4 - INFORMATION ABOUT THE CHILD'S MEDICAL RECORDS
DOCTOR/HMO/THERAPIST/OTHER
If you need more space, use Section 10.
D. List each HOSPITAL/CLINIC. Include the child's next appointment.
1. HOSPITAL/CLINIC
NAME
STREET ADDRESS
CITY
STATE ZIP
PHONE
Area Code
INPATIENT STAYS
(Stayed at least overnight)
OUTPATIENT VISITS
(Sent home same day)
EMERGENCY ROOM
VISITS
DATES
DATE OUT
DATE FIRST VISIT DATE LAST VISIT
DATES OF VISITS
What treatment did the child receive?
What doctors does the child see at this hospital/clinic on a regular basis?
TYPE OF VISIT
DATE IN
3. NAME
CITY
PHONE
Number
DATES
FIRST VISIT
NEXT APPOINTMENT
STREET ADDRESS
STATE ZIP
LAST VISIT
Area Code
Patient ID # (If known)
REASONS FOR VISITS
WHAT TREATMENT WAS RECEIVED?
Number
Next appointment
The child's hospital/clinic number
Form SSA-3820-BK (03-2017) UF
Page 5 of 12
SECTION 4 - INFORMATION ABOUT THE CHILD'S MEDICAL RECORDS
HOSPITAL/CLINIC
If you need more space, use Section 10.
E. Does anyone else have medical records or information about the child's illnesses, injuries or conditions (foster
parents, social workers, counselors, tutors, school nurses, detention centers, attorneys, insurance companies, and/or
Worker's Compensation), or is the child scheduled to see anyone else?
NAME
ADDRESS
PHONE
Number
DATES
FIRST VISIT
LAST SEEN
NEXT APPOINTMENT
REASONS FOR VISITS
If you need more space, use Section 10.
2. HOSPITAL/CLINIC DATESTYPE OF VISIT
CITY
Reasons for visits
NAME
STREET ADDRESS
CITY
STATE ZIP
PHONE
Area Code
INPATIENT STAYS
(Stayed at least overnight)
OUTPATIENT VISITS
(Sent home same day)
EMERGENCY ROOM
VISITS
DATE OUT
DATE FIRST VISIT DATE LAST VISIT
DATES OF VISITS
What treatment did the child receive?
What doctors does the child see at this hospital/clinic on a regular basis?
DATE IN
Number
Next appointment
The child's hospital/clinic number
NO
YES (If "YES," complete information below.)
STATE ZIP
Area Code
CLAIM NUMBER (If any)
Page 6 of 12
Form SSA-3820-BK (03-2017) UF
SECTION 5 - MEDICATIONS
Does the child currently take any medications for illnesses, injuries or conditions?
If "YES", tell us the following: (Look at the child's medicine containers, if necessary.)
NAME OF MEDICINE
IF PRESCRIBED,
GIVE NAME OF DOCTOR
REASON FOR MEDICINE
SIDE EFFECTS THE
CHILD HAS
If you need more space, use Section 10.
SECTION 6 - TESTS
Has the child had, or will he/she have, any medical tests for illnesses, injuries or conditions?
If "YES", tell us the following (give approximate dates, if necessary).
KIND OF TEST
WHEN WAS/WILL TESTS BE DONE?
(Month, day, year)
WHERE DONE
(Name of Facility)
WHO SENT THE CHILD
FOR THIS TEST
EKG (HEART TEST)
TREADMILL (EXERCISE TEST)
CARDIAC CATHETERIZATION
BIOPSY - Name of body part
SPEECH/LANGUAGE
HEARING TEST
VISION TEST
IQ TESTING
EEG (BRAIN WAVE TEST)
HIV TEST
BLOOD TEST (NOT HIV)
BREATHING TEST
X-RAY - Name of body part
MRI/CAT SCAN - Name of
body part
If the child has had other tests, list them in Section 10.
NOYES
NOYES
Form SSA-3820-BK (03-2017) UF
Page 7 of 12
SECTION 7 - ADDITIONAL INFORMATION
A. Has the child been tested or examined by any of the following?
Headstart (Title V)
Public or Community Health Department
Child Welfare or Social Service Agency
or WIC
Early Intervention Services
Program for Children with Special Health
Care Needs
Mental Health/Mental Retardation Center
B. Has the child received Vocational Rehabilitation or other employment support services to help him or her go to work?
If you answered "YES" to any of the above in A. or B., please complete C. below:
C. 1. NAME OF AGENCY
ADDRESS
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)
City
PHONE NUMBER
TYPE OF TEST
WHEN DONE TYPE OF TEST
WHEN DONE
FILE OR RECORD NUMBER
2. NAME OF AGENCY
If there are any other agencies, show them in Section 10.
Number
NOYES
NOYES
NOYES
NOYES
NOYES
NOYES
NOYES
State ZIP
Area Code
ADDRESS
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)
City
PHONE NUMBER
TYPE OF TEST
WHEN DONE TYPE OF TEST
WHEN DONE
FILE OR RECORD NUMBER
Number
State ZIP
Area Code
Form SSA-3820-BK (03-2017) UF
Page 8 of 12
SECTION 8 - EDUCATION
A. Is the child currently enrolled in any school?
B. Other reason the child is not enrolled in school:
C. List the name of the school the child is currently attending and give dates attended. If the child is no longer in school,
list the name of the last school attended and give dates attended.
NAME OF SCHOOL
ADDRESS
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)
PHONE NUMBER
Area Code
DATES ATTENDED
TEACHER'S NAME
Has the child been tested for behavioral or learning problems?
TYPE OF TEST WHEN DONE
Is the child in special education?
If "YES", and different from above, give:
NAME OF SPECIAL EDUCATION TEACHER
Is the child in speech/language therapy?
If "YES", and different from above, give:
NAME OF SPEECH/LANGUAGE THERAPIST
Number
If "YES", complete the following:
NO, too young
YES, grade:
NO, other reason (complete B)
ZIPStateCity County
NOYES
TYPE OF TEST WHEN DONE
NOYES
NOYES
Form SSA-3820-BK (03-2017) UF
Page 9 of 12
Form SSA-3820-BK (03-2017) UF
SECTION 8 - EDUCATION
D. List the names of all other schools attended in the last 12 months and give dates attended.
Was the child tested for behavioral or learning problems?
If "YES", complete the following:
Was the child in special education?
If "YES", and different from above, give:
NAME OF SPECIAL EDUCATION TEACHER
Was the child in speech/language therapy?
If "YES", and different from above, give:
NAME OF SPEECH/LANGUAGE THERAPIST
If there are other schools, show them in Section 10.
E. Is the child attending Daycare/Preschool?
If "YES", complete the following:
NAME OF DAYCARE/
PRESCHOOL/CAREGIVER
ADDRESS
PHONE NUMBER
DATES ATTENDED
TEACHER'S/CAREGIVER'S NAME
NAME OF SCHOOL
ADDRESS
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)
PHONE NUMBER
Area Code
DATES ATTENDED
TEACHER'S NAME
Number
ZIPStateCity County
NOYES
TYPE OF TEST WHEN DONE
TYPE OF TEST WHEN DONE
NOYES
NOYES
NOYES
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)
ZIPStateCity County
NumberArea Code
Page 10 of 12
Form SSA-3820-BK (03-2017) UF
SECTION 9 - WORK HISTORY
A. Has the child ever worked (including sheltered work)?
DATES WORKED
NAME OF EMPLOYER
NAME OF SUPERVISOR
SECTION 10 - DATE AND REMARKS
Please give the date you filled out this disability report.
Date (MM/DD/YYYY)
If "YES", complete the following:
NOYES
NumberArea Code
ADDRESS
PHONE NUMBER
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)
ZIPStateCity County
B. List job title, and briefly describe the work and any problems the child may have had doing the job.
Use this section for any additional information about your child.
Page 11 of 12
Form SSA-3820-BK (03-2017) UF
SECTION 10 - REMARKS
Page 12 of 12
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Ssa-3820 Disability Report - Child

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Completed 15 November 2019

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