The SSA-3380-BK form is a critical document used by the Social Security Administration to assess an individual's ability to work due to mental impairments. This form gathers essential information about daily activities, social functioning, and any psychological limitations. Completing this form accurately is vital for a successful disability claim; click the button below to start filling it out.
The SSA SSA-3380-BK form plays a crucial role in the Social Security Administration's process for evaluating claims related to disability benefits. This form, often referred to as the "Function Report - Adult," is designed to gather detailed information about how an individual's disability affects their daily activities and overall functioning. It prompts claimants to describe their abilities and limitations in various areas such as personal care, household tasks, social interactions, and community involvement. By providing insights into the day-to-day challenges faced by individuals with disabilities, the SSA-3380-BK form assists the Social Security Administration in making informed decisions regarding eligibility for benefits. Completing this form accurately and thoroughly is vital, as it can significantly impact the outcome of a disability claim. Understanding its components and the information required can empower individuals to present their cases effectively, ensuring that their unique circumstances are clearly communicated to the decision-makers at the SSA.
Form SSA-3380 (06-2020)
Discontinue Prior Editions
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Social Security Administration
OMB No. 0960-0635
FUNCTION REPORT - ADULT - THIRD PARTY Form SSA-3380-BK
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 (TTY 1-800-325-0778).
HOW TO COMPLETE THIS FORM
The information that you give on this form will be used to make a decision on the disabled person's claim. You can help by completing as much of the form as you can. When a question refers to the "disabled person," it refers to the person who is applying for or receiving disability benefits.
It is important that you tell us what you know about the disabled person's activities and abilities.
DO NOT ASK THE DISABLED PERSON TO GIVE YOU ANSWERS
•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 you need more space to answer any questions, use the "REMARKS" section on Page 10, and show the number of the question being answered.
Function Report - Adult - Third Party Form SSA-3380-BK
REMEMBER TO GIVE US THE NAME AND ADDRESS OF THE PERSON
COMPLETING THIS FORM ON PAGE 10
Form SSA-3380-BK (06-2020)
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Privacy Act and Paperwork Reduction Act Statements
Sections 205(a), 223(d), and 1631 of the Social Security Act (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 make a determination of eligibility for benefits. We may also share your information for the following purposes, called routine uses:
•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; and
•To applicants, claimants, prospective applicants or claimants, other than the data subject, their authorized representatives or representative payees to the extent necessary to pursue Social Security claims and to representative payees when the information pertains to individuals for whom they serve as representative payees, for the purpose of assisting SSA in administering its representative payment responsibilities under the Act and assisting the representative payees in performing their duties as payees, including receiving and accounting for benefits for individuals for whom they serve as payees.
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 Systems, as published in the Federal Register (FR) on April 1, 2003, at 68 FR 15784, and 60-0320, entitled Electronic Disability Claim File, as published in the FR December 22, 2003, at 68 FR 71210. Additional information, and a full listing of all of our SORNs, is available on our website at https://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 on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.
PLEASE REMOVE THIS SHEET BEFORE RETURNING
THE COMPLETED FORM.
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FUNCTION REPORT- ADULT - THIRD PARTY
How the disabled person's illnesses, injuries, or conditions limit his/her 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, Last)
2.YOUR NAME (Person completing the form)
3.RELATIONSHIP (To disabled person)
4.DATE (MM/DD/YYYY)
5.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.)
-
Area Code
Phone Number
Your Number
Message Number
None
6.a. How long have you known the disabled person?
b. How much time do you spend with the disabled person and what do you do together?
7. a. Where does the disabled person live? (Check one.)
House
Apartment
Boarding House
Shelter
Group Home
Other (What?)
Nursing Home
b. With whom does he/she live? (Check one.)
Alone
With Family
Other (describe relationship)
With Friends
SECTION B - INFORMATION ABOUT ILLNESSES, INJURIES, OR CONDITIONS
8. How does this person's illnesses, injuries, or conditions limit his/her ability to work?
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SECTION C - INFORMATION ABOUT DAILY ACTIVITIES
9. Describe what the disabled person does from the time he/she wakes up until going to bed.
10.Does this person take care of anyone else such as a wife/husband, children, grandchildren, parents, friend, other?
If "YES," for whom does he/she care, and what does he/she do for them?
Yes
No
11.Does he/she take care of pets or other animals? If "YES," what does he/she do for them?
12.Does anyone help this person care for other people or animals? If "YES," who helps, and what do they do to help?
Yes No
13. What was the disabled person able to do before his/her illnesses, injuries, or conditions that he/she can't do now?
14. Do the illnesses, injuries, or conditions affect his/her sleep?
If "YES," how?
15. PERSONAL CARE (Check here if NO PROBLEM with personal care.)
a.Explain how the illnesses, injuries, or conditions affect this person's ability to: Dress
Bathe
Care for hair
Shave
Feed self
Use the toilet
Other
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b. Does he/she need any special reminders to take care of personal needs and grooming?
If "YES," what type of help or reminders are needed?
c. Does he/she need help or reminders taking medicine? If "YES," what kind of help does he/she need?
16. MEALS
a. Does the disabled person prepare his/her own meals?
If "Yes," what kind of food is prepared? (For example, sandwiches, frozen dinners, or complete meals with several courses.)
How often does he/she prepare food or meals? (For example, daily, weekly, monthly.)
How long does it take him/her?
Any changes in cooking habits since the illness, injuries, or conditions began?
b. If "No," explain why he/she cannot or does not prepare meals.
17.HOUSE AND YARD WORK
a . List household chores, both indoors and outdoors, that the disabled person is able to do . (For example, cleaning, laundry, household repairs, ironing, mowing, etc.)
b. How much time do chores take, and how often does he/she do each of these things?
c. Does he/she need help or encouragement doing these things? If "YES," what help is needed?
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d. If the disabled person doesn't do house or yard work, explain why not.
18.GETTING AROUND
a. How often does this person go outside?
If he/she doesn't go out at all, explain why not.
b. When going out, how does he/she 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 he/she go out alone?
If "NO," explain why he/she can't go out alone.
d. Does the disabled person drive?
If he/she doesn't drive, explain why not.
19.SHOPPING
a. If the disabled person does any shopping, does he/she shop: (Check all that apply.)
In stores By phone By mail By computer b. Describe what he/she shops for.
c. How often does he/she shop and how long does it take?
20. MONEY
a. Is he/she able to:
Pay bills
Count change
Explain all "NO" answers.
Handle a savings account
Use a checkbook/money orders
Yes Yes
No No
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b. Has the disabled person's ability to handle money changed since
the illnesses, injuries, or conditions began?
If "YES," explain how the ability to handle money has changed.
21.HOBBIES AND INTERESTS
a. What are his/her hobbies and interests? (For example, reading, watching TV, sewing, playing sports, etc.)
b. How often and how well does he/she do these things?
c. Describe any changes in these activities since the illnesses, injuries, or conditions began.
22.SOCIAL ACTIVITIES
a. How does the disabled person 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 he/she does with others.
How often does he/she do these things?
c. List the places he/she goes on a regular basis. (For example, church, community center, sports events, social groups, etc.)
Does he/she need to be reminded to go places?
How often does he/she go and how much does he/she take part?
Does he/she need someone to accompany him/her?
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d. Does this person 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.
SECTION D - INFORMATION ABOUT ABILITIES
23. a. Check any of the following items the disabled person's illnesses, injuries, or conditions affect:
Lifting
Squatting
Bending
Standing
Reaching
Walking
Sitting
Kneeling
Talking
Hearing
Stair Climbing
Seeing
Memory
Completing Tasks
Concentration
Understanding Following Instructions Using Hands
Getting Along with Others
Please explain how his/her illnesses, injuries, or conditions affect each of the items you checked. (For example, he/she can only lift [how many pounds], or he/she can only walk [how far])
b. Is the disabled person:
Right Handed?
Left Handed?
c. How far can he/she walk before needing to stop and rest?
If he/she has to rest, how long before he/she can resume walking?
d. For how long can the disabled person pay attention?
e. Does the disabled person finish what he/she starts? ( For example, a
conversation,
chores, reading, watching a movie.)
f. How well does the disabled person follow written instructions? (For example, a recipe.)
g. How well does the disabled person follow spoken instructions?
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h. How well does the disabled person get along with authority figures? (For example, police, bosses, landlords or teachers.)
i. Has he/she ever been fired or laid off from a job because of problems
getting along with other people? Yes No If "YES," please explain.
If "YES," please give name of employer.
j . How well does the disabled person handle stress?
k. How well does he/she handle changes in routine?
l. Have you noticed any unusual behavior or fears in the disabled person?
If "YES," please explain.
24. Does the disabled person 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 does this person need to use these aids?
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25.Does the disabled person currently take any medicines for his/her illnesses, injuries, or conditions?
If " YES," do any of the medicines cause side effects?
If "YES," please explain. (Do not list all of the medicines that the disabled person takes. List only the medicines that cause side effects for the disabled person.)
NAME OF MEDICINE
SIDE EFFECTS PERSON HAS
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)
Address (Number and Street)
Date (MM/DD/YYYY)
Email address (optional)
City
State
ZIP Code
After obtaining the SSA-3380-BK form, you will need to complete it accurately to ensure that your application is processed smoothly. Each section of the form must be filled out with the correct information. Follow these steps to fill out the form properly.
Once you have filled out the form, review it for accuracy. Ensure that all sections are complete and that your information is clear. After verifying everything, you can submit the form as instructed, either by mail or online, depending on the guidelines provided by the SSA.
The SSA SSA-3380-BK form is a questionnaire used by the Social Security Administration (SSA) to gather information about an individual's ability to work. This form is specifically designed for those who are applying for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI). It helps the SSA assess how a person's medical condition affects their daily activities and ability to perform work-related tasks.
This form is typically required from individuals who have applied for disability benefits. If you are claiming that a medical condition prevents you from working, you will likely need to complete this form. It is essential for providing detailed information about your limitations and how they impact your daily life. Family members or caregivers may also assist in completing the form if needed.
Completing the SSA SSA-3380-BK form involves several steps:
It is important to be as specific as possible. The more information you provide, the better the SSA can understand your situation.
You can submit the completed SSA SSA-3380-BK form in several ways:
Make sure to keep a copy of the completed form for your records. This can be helpful for future reference or if you need to follow up on your application.
Not providing complete information: Many people forget to fill out all sections of the form. Each question is important for the Social Security Administration to understand your situation. Leaving sections blank can lead to delays or denials.
Inaccurate or inconsistent details: Providing incorrect information can cause confusion. For example, if your medical history or current symptoms are not accurately described, it may affect the outcome of your application. Always double-check your entries for consistency.
Failure to include supporting documentation: Supporting documents are crucial. Without them, your claims may lack the necessary evidence. Ensure you attach any relevant medical records, treatment histories, or other documents that support your case.
Not reviewing the form before submission: Rushing through the process can lead to mistakes. Take the time to review the entire form for errors or omissions. A final check can help catch mistakes that could delay your application.
The SSA SSA-3380-BK form, also known as the Adult Function Report, is an essential document for individuals applying for Social Security Disability benefits. It provides a comprehensive overview of how a disability affects daily living activities. Alongside this form, several other documents are frequently utilized in the application process to ensure a complete and accurate representation of an applicant's situation. Below is a list of five such forms and documents.
Each of these documents plays a vital role in the Social Security Disability application process. Together, they help create a thorough picture of an applicant's health and functioning, aiding the SSA in making informed decisions regarding eligibility for benefits.
The SSA-3380-BK form, known as the Adult Function Report, serves a vital role in assessing an individual's ability to perform daily activities. Similar to the SSA-3373-BK form, the Work History Report, both documents gather information about an individual's functional capacity. While the SSA-3380-BK focuses on daily living activities and social functioning, the SSA-3373-BK emphasizes past work experience and the ability to sustain employment. Together, they provide a comprehensive view of how an individual's conditions impact their life and work capabilities.
Another related document is the SSA-827, also known as the Authorization to Disclose Information to the Social Security Administration. This form allows the SSA to obtain medical records and other relevant information from healthcare providers. Like the SSA-3380-BK, it is crucial in determining eligibility for benefits. The SSA-827 ensures that the SSA has the necessary information to evaluate an individual's medical condition and its effects on daily living.
The SSA-3368-BK, or the Disability Report – Adult, is another form that shares similarities with the SSA-3380-BK. It collects detailed information about an individual's medical conditions, treatment history, and how these conditions limit their daily activities. While the SSA-3380-BK focuses on functional capabilities, the SSA-3368-BK provides a broader overview of the medical aspects that contribute to an individual's disability claim.
The SSA-3441-BK, known as the Disability Report – Appeal, is also comparable to the SSA-3380-BK. This form is used when an individual appeals a decision made by the SSA regarding their disability claim. It requires updated information about the claimant's condition and daily activities, similar to the SSA-3380-BK. Both forms aim to paint a clear picture of how an individual's disability affects their life.
In addition, the SSA-4513, or the Medical Release Form, is relevant in this context. This document allows the SSA to request medical records from healthcare providers, similar to the SSA-827. While the SSA-3380-BK focuses on functional limitations, the SSA-4513 facilitates the gathering of essential medical evidence to support the claims made in the SSA-3380-BK.
The SSA-3820, or the Work Incentives Planning and Assistance (WIPA) Referral Form, is another document that complements the SSA-3380-BK. This form helps individuals understand how work can affect their benefits. While the SSA-3380-BK assesses functional limitations, the SSA-3820 provides guidance on how to navigate work-related issues while receiving benefits, ensuring that individuals are aware of their options.
Furthermore, the SSA-827-BK, an updated version of the SSA-827, also aligns with the SSA-3380-BK. This form streamlines the process of authorizing the release of medical information. It serves the same purpose as the original SSA-827 but may include additional fields or updated language to enhance clarity. Both forms are essential in gathering information needed to evaluate a disability claim.
Lastly, the SSA-3367, or the Function Report – Child, while focused on children, is similar in purpose to the SSA-3380-BK. It collects information about a child's daily activities and how their condition affects their ability to function. Both forms aim to provide a thorough understanding of how disabilities impact daily life, whether for adults or children, ensuring that the SSA has the information needed to make informed decisions about benefits.
When filling out the SSA SSA-3380-BK form, it’s crucial to approach the process with care. Here’s a helpful list of what you should and shouldn’t do:
Following these guidelines can help streamline the process and ensure that your application is processed without unnecessary delays. Take your time, and make sure every detail is correct!
The SSA SSA-3380-BK form, also known as the "Function Report - Adult," plays a crucial role in the Social Security Administration's evaluation of disability claims. However, several misconceptions surround this important document. Here are nine common misunderstandings, along with clarifications to help you navigate the process more effectively.
Understanding these misconceptions can empower you to complete the SSA-3380-BK form more effectively, ensuring that your application for disability benefits is as strong as possible. Remember, your experiences matter, and accurately representing them can make a significant difference in the outcome of your claim.
The SSA SSA-3380-BK form is essential for individuals seeking Social Security benefits based on mental or emotional conditions. Here are key takeaways to consider when filling out and using this form: