The SSA-3373-BK form, also known as the Adult Function Report, is a crucial document used by the Social Security Administration to assess an individual's ability to perform daily activities. This form collects information about how a person's condition affects their daily life, providing essential insights for disability claims. If you need to fill out this form, click the button below to get started.
The SSA SSA-3373-BK form plays a crucial role in the Social Security Administration's (SSA) process for determining eligibility for Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI). This form, also known as the "Function Report – Adult," is designed to gather detailed information about an individual's daily activities, limitations, and the impact of their medical conditions on their ability to function. By assessing various aspects of a person's life, such as their capacity to perform basic tasks, engage in social interactions, and maintain employment, the SSA aims to paint a comprehensive picture of how disabilities affect their everyday existence. Completing this form accurately is vital, as it can significantly influence the outcome of a disability claim. Understanding the purpose and requirements of the SSA-3373-BK form can empower individuals to provide the necessary information that reflects their true circumstances, ultimately aiding in the pursuit of the benefits they may need for financial stability and support.
Form SSA-3373 (02-2024) UF
Discontinue Prior Editions
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Social Security Administration
OMB No. 0960-0681
FUNCTION REPORT - ADULT
READ ALL OF THIS INFORMATION BEFORE
YOU BEGIN COMPLETING THIS FORM
IF YOU NEED HELP
If you need help with this form, complete as much of it as you can and call the phone number provided on the letter sent with the form, or contact the person who asked you to complete the form. If you need the address or phone number for the office that provided the form, you can get it by calling Social Security at 1-800-772-1213.
HOW TO COMPLETE THIS FORM
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.
It is important that you tell us about your activities and abilities.
•Print or type.
•DO NOT LEAVE ANSWERS BLANK. If you do not know the answer or the answer is "none" or "does not apply," please write "don't know" or "none" or "does not apply."
•Do not ask a doctor or hospital to complete this form.
•Be sure to explain an answer if the question asks for an explanation, or if you think you need to explain an answer.
•If more space is needed to answer any questions, use the "REMARKS" section on Page 10, and show the number of the question being answered.
•If a specific activity is performed with the help of others, please indicate that.
Function Report - Adult - Form SSA-3373-BK
REMEMBER TO GIVE US THE NAME AND ADDRESS OF THE PERSON
COMPLETING THIS FORM ON PAGE 10
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Privacy Act Statements
Collection and Use of Personal Information
Sections 205(a), 223(d), and 1631 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 prevent an accurate and timely decision on any claim filed.
We will use the information you provide to determine benefits eligibility. We may also share the information for the following purposes, called routine uses:
•To third party contacts (e.g., employers and private pension plans) in situations where the party to be contacted has, or is expected to have, information relating to the individual's capability to manage his or her benefits or payments, or his or her eligibility for entitlement to benefits or eligibility for payments, under the Social Security program; and
•To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social Security Administration (SSA) in the efficient administration of its programs. We will disclose information under this routine use only in situations in which we may enter into a contractual or similar agreement to obtain assistance in accomplishing an SSA function relating to this system record.
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 Notices (SORN) 60-0089, entitled Claims Folders System, as published in the Federal Register (FR) on October 31, 2019, at 84 FR 58422, and 60-0320, entitled Electronic Disability Claim File, as published in the FR on June 6, 2020 at 85 FR 34477. Additional information, and a full listing of all of our SORNs, is available on our website at www.ssa.gov/privacy.
Paperwork Reduction Act Statement - 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 61 minutes to read the instructions, gather the facts, and answer the questions. SEND OR BRING 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 regarding this burden
estimate or any other aspect of this collection, including suggestions for reducing this burden to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to
our time estimate or other aspects of this collection to this address, not the completed form.
PLEASE REMOVE THIS SHEET BEFORE RETURNING
THE COMPLETED FORM.
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How your illnesses, injuries, or conditions limit your activities
For SSA Use Only
Do not write in this box.
Anyone who makes or causes to be made a false statement or representation of material fact for use in determining a payment under the Social Security Act, or knowingly conceals or fails to disclose an event with an intent to affect an initial or continued right to payment, commits a crime punishable under Federal law by fine, imprisonment, or both, and may be subject to administrative sanctions.
SECTION A - GENERAL INFORMATION
1. NAME OF DISABLED PERSON (First, Middle Initial, Last)
2. SOCIAL SECURITY NUMBER
3.YOUR DAYTIME TELEPHONE NUMBER (If there is no telephone number where you can be reached, please give us a daytime number where we can leave a message for you.)
Your Number
Message Number
None
Area Code Phone Number
4. a. Where do you live? (Check one.)
House
Apartment
Boarding House
Nursing Home
Shelter
Group Home
Other (What?)
b. With whom do you live? (Check one.)
Alone
With Family
With Friends
Other (Describe relationship.)
SECTION B - INFORMATION ABOUT YOUR ILLNESSES, INJURIES, OR CONDITIONS
5.How do your illnesses, injuries, or conditions limit your ability to work?
____________________________________________________________________________________________________
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SECTION C - INFORMATION ABOUT DAILY ACTIVITIES
6.Describe what you do from the time you wake up until going to bed.
7. Do you take care of anyone else such as a wife/husband, children, grandchildren,
Yes
No
parents, friend, other?
If "YES," for whom do you care, and what do you do for them?
8. Do you take care of pets or other animals?
If "YES," what do you do for them?
9. Does anyone help you care for other people or animals?
If "YES," who helps, and what do they do to help?
10.
What were you able to do before your illnesses, injuries, or conditions that you can't do now?
11.
Do the illnesses, injuries, or conditions affect your sleep?
If "YES," how?
12.
PERSONAL CARE (Check here
if NO PROBLEM with personal care.)
a. Explain how your illnesses, injuries, or conditions affect your ability to:
Dress
Bathe
Care for hair
Shave
Feed self
Use the toilet
Other
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b. Do you need any special reminders to take care of personal
needs and grooming?
If "YES," what type of help or reminders are needed?
__________________________________________________________________________________________________
c. Do you need help or reminders taking medicine?
If "YES," what kind of help do you need?
13. MEALS
a. Do you prepare your own meals?
If "Yes," what kind of food do you prepare? (For example, sandwiches, frozen dinners, or complete meals with several courses.)
How often do you prepare food or meals? (For example, daily, weekly, monthly.)
How long does it take you?
Any changes in cooking habits since the illness, injuries, or conditions began?
b. If "No," explain why you cannot or do not prepare meals.
14.HOUSE AND YARD WORK
a.List household chores, both indoors and outdoors, that you are able to do. (For example, cleaning, laundry, household repairs, ironing, mowing, etc.)
b. How much time does it take you, and how often do you do each of these things?
c. Do you need help or encouragement doing these things?
If "YES," what help is needed?
d. If you don't do house or yard work, explain why not.
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15.GETTING AROUND
a. How often do you go outside?
If you don't go out at all, explain why not.
b.
When going out, how do you travel? (Check all that apply.)
Walk
Drive a car
Ride in a car
Ride a bicycle
Use public transportation
Other (Explain)
c. When going out, can you go out alone?
If "NO," explain why you can't go out alone.
d. Do you drive?
If you don't drive, explain why not.
16.SHOPPING
a. If you do any shopping, do you shop: (Check all that apply.)
In stores
By phone
By mail
By computer
b. Describe what you shop for.
c. How often do you shop and how long does it take?
17. MONEY
a. Are you able to:
Pay bills
Handle a savings account
Count change
Use a checkbook/money orders
Explain all "NO" answers.
b. Has your ability to handle money changed since the illnesses,
injuries, or conditions began?
If "YES," explain how the ability to handle money has changed.
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18.HOBBIES AND INTERESTS
a. What are your hobbies and interests? (For example, reading, watching TV, sewing, playing sports, etc.)
b. How often and how well do you do these things?
c. Describe any changes in these activities since the illnesses, injuries, or conditions began.
19.SOCIAL ACTIVITIES
a. How do you spend time with others? (Check all that apply.)
In person
On the phone
Email
Texting
Mail
Video Chat (for example Skype or Facetime)
b. Describe the kinds of things you do with others.
How often do you do these things?
c. List the places you go on a regular basis. (For example, church, community center, sports events, social groups, etc.)
Do you need to be reminded to go places?
How often do you go and how much do you take part?
Do you need someone to accompany you?
If "YES", explain.
d. Do you have any problems getting along with family, friends, neighbors, or others?
If "YES," explain.
e. Describe any changes in social activities since the illnesses, injuries, or conditions began.
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SECTION D - INFORMATION ABOUT ABILITIES
20. a. Check any of the following items that your illnesses, injuries, or conditions affect:
Lifting
Walking
Stair Climbing
Understanding
Squatting
Sitting
Seeing
Following Instructions
Bending
Kneeling
Memory
Using Hands
Standing
Talking
Completing Tasks
Getting Along With Others
Reaching
Hearing
Concentration
Please explain how your illnesses, injuries, or conditions affect each of the items you checked. (For example, you can only lift [how many pounds], or you can only walk [how far])
b. Are you:
Right Handed?
Left Handed?
c. How far can you walk before needing to stop and rest?
If you have to rest, how long before you can resume walking?
d. For how long can you pay attention?
e. Do you finish what you start? (For example, a conversation, chores,
reading, watching a movie.)
f. How well do you follow written instructions? (For example, a recipe.)
g. How well do you follow spoken instructions?
h. How well do you get along with authority figures? (For example, police, bosses, landlords or teachers.)
i. Have you ever been fired or laid off from a job because of problems getting
along with other people?
If "YES," please explain.
If "YES," please give name of employer.
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j. How well do you handle stress?
k. How well do you handle changes in routine?
l. Have you noticed any unusual behavior or fears?
21. Do you use any of the following? (Check all that apply.)
Crutches
Cane
Hearing Aid
Walker
Brace/Splint
Glasses/Contact Lenses
Wheelchair
Artificial Limb
Artificial Voice Box
Which of these were prescribed by a doctor?
When was it prescribed?
When do you need to use these aids?
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22. Do you currently take any medicines for your illnesses, injuries, or conditions?
If "YES, "do any of your medicines cause side effects?
If "YES," please explain. (Do not list all of the medicines that you take. List only the medicines that cause side effects.)
NAME OF MEDICINE
SIDE EFFECTS YOU HAVE
SECTION E - REMARKS
Use this section for any added information you did not show in earlier parts of this form. When you are done with this section (or if you didn't have anything to add), be sure to complete the fields at the bottom of this page.
______________________________________________________________________________________________________
Name of person completing this form (Please print)
Date (MM/DD/YYYY)
Address (Number and Street)
Email address (optional)
City
State
ZIP Code
After obtaining the SSA SSA-3373-BK form, individuals will need to complete it accurately to provide information relevant to their case. This form is crucial for the Social Security Administration's assessment process. Follow the steps below to fill out the form correctly.
The SSA SSA-3373-BK form, also known as the "Function Report - Adult," is used by the Social Security Administration (SSA) to gather information about an individual's daily activities and functional capabilities. This information helps the SSA assess disability claims.
This form is typically required from individuals applying for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI). If you are claiming a disability, you will likely need to complete this form to provide a comprehensive overview of how your condition affects your daily life.
You can obtain the SSA-3373-BK form in several ways:
The form asks for detailed information about various aspects of your life, including:
The time it takes to complete the form can vary based on individual circumstances. On average, it may take anywhere from 30 minutes to a few hours. It is advisable to set aside enough time to provide thorough and accurate responses.
Yes, you can seek assistance from family members, friends, or professionals, such as social workers or advocates. They can help you understand the questions and provide guidance on how to describe your condition and its impact on your daily life.
If you realize you made a mistake after submitting the form, you can contact the SSA to correct it. Provide them with the correct information and explain the error. It is important to ensure that all information is accurate to avoid delays in processing your claim.
You should submit the completed form to the SSA office handling your disability claim. This can be done by mailing it to the address provided in your claim instructions or submitting it in person at your local SSA office.
After submission, the SSA will review your form along with other evidence related to your disability claim. This process may take several weeks. You will receive updates regarding your claim status and any additional information that may be needed.
Inadequate Detail in Descriptions: Many individuals provide vague or incomplete descriptions of their daily activities and limitations. This can lead to misunderstandings about the severity of their condition. It's crucial to be specific and detailed in explaining how disabilities impact daily life.
Failure to Include Supporting Documentation: Applicants often neglect to attach necessary medical records or evidence that supports their claims. Without this documentation, the Social Security Administration may not have enough information to make a fair assessment.
Not Reporting All Relevant Conditions: Some people only list their primary disability, overlooking other conditions that may also affect their ability to work. All relevant conditions should be reported to provide a complete picture of the applicant's health.
Misunderstanding the Questions: Misinterpretation of the form's questions can lead to incorrect answers. It's important to read each question carefully and seek clarification if needed. This ensures that the information provided is accurate and relevant.
The SSA SSA-3373-BK form, also known as the "Function Report," is a crucial document used in the Social Security Administration's disability determination process. Alongside this form, there are several other documents that can help support your case for disability benefits. Here’s a list of commonly used forms and documents that may be needed.
Gathering these documents can make a significant difference in the outcome of your disability claim. Having everything organized and ready will help streamline the process and ensure that your case is as strong as possible.
The SSA-3373-BK form is used by the Social Security Administration (SSA) to assess an individual's ability to work due to mental impairments. This form gathers information about daily activities, social interactions, and cognitive functions. Similar to the SSA-3373-BK, the SSA-3368-BK form, also known as the Adult Function Report, focuses on how an individual's impairments affect their daily life. It asks questions about the claimant's ability to perform everyday tasks, interact with others, and maintain personal care, providing a comprehensive view of the individual's functional limitations.
Another document, the SSA-827, is a medical release form that allows the SSA to obtain medical records from healthcare providers. While it does not assess functionality directly, it complements the SSA-3373-BK by ensuring that the SSA has access to relevant medical information that may support the claims made in the SSA-3373-BK regarding mental impairments and their impact on daily living.
The SSA-2506, known as the Disability Report - Adult, is another relevant document. This form collects detailed information about an individual's medical history, work history, and education. It serves a similar purpose to the SSA-3373-BK by providing the SSA with insight into how various factors, including mental health, affect an individual's ability to work.
The SSA-827 also shares similarities with the SSA-3367, the Work History Report. While the SSA-3367 focuses on an individual's past employment, it can highlight how mental impairments may have influenced job performance and career choices. This information can be critical in understanding the overall impact of a disability on a person's work life.
The SSA-3881, the Authorization to Disclose Information to the Social Security Administration, is another form that may be relevant. It allows third parties to provide information about the claimant's condition. This can be particularly useful when corroborating the details provided in the SSA-3373-BK, ensuring a thorough review of the individual's situation.
The SSA-3369, the Work History Report, also complements the SSA-3373-BK. It details the claimant's past jobs, duties, and any changes in work due to impairments. This document helps the SSA understand how a mental impairment has impacted job performance over time.
Lastly, the SSA-827 is similar to the SSA-3368, as both forms address the impact of impairments on daily living. While the SSA-3368 focuses on functional limitations, the SSA-3373-BK dives deeper into mental health challenges, making both documents essential in the evaluation process for disability claims.
When filling out the SSA SSA-3373-BK form, it is important to follow specific guidelines to ensure accuracy and completeness. Below is a list of things you should and shouldn't do.
The SSA-3373-BK form is an important document for individuals applying for Social Security Disability benefits. However, there are several misconceptions surrounding this form that can lead to confusion. Here are six common misconceptions:
Many people believe the SSA-3373-BK form is solely for those with physical ailments. In reality, it is designed for both physical and mental health conditions. Any disability that significantly impairs daily functioning can be reported using this form.
Some applicants think that filling out the SSA-3373-BK form ensures their claim will be approved. Approval depends on a variety of factors, including medical evidence and how well the disability meets Social Security’s criteria.
While medical professionals play a crucial role in the application process, individuals can provide their own input on the form. It’s important for applicants to describe their experiences and limitations accurately.
Many believe that once the SSA-3373-BK form is submitted, it is the end of the process. However, applicants may need to update or resubmit information if their condition changes or if additional documentation is required.
Some applicants think that having extensive medical records makes the SSA-3373-BK form unnecessary. However, this form is specifically designed to gather personal insights about how the disability affects daily life, which medical records alone may not fully convey.
While the form may seem simple, many find it challenging to articulate their limitations and experiences. Taking time to carefully consider each question can make a significant difference in the outcome of the application.
Understanding these misconceptions can help individuals approach the SSA-3373-BK form with clarity and confidence. It’s essential to provide a complete and honest representation of one’s situation to improve the chances of a successful claim.
When filling out the SSA SSA-3373-BK form, there are several important points to keep in mind. This form is essential for individuals seeking Social Security Disability benefits. Here are some key takeaways:
Filling out the SSA-3373-BK form accurately and thoroughly can significantly impact your chances of receiving the benefits you need. Take the process seriously and ensure you provide all necessary information.