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Fill in Your SSA SSA-3373-BK Template

The SSA SSA-3373-BK form is a document used by the Social Security Administration to gather information about an individual's daily activities and how their medical conditions affect their ability to work. This form plays a crucial role in the evaluation process for disability benefits. Completing it accurately is essential for a fair assessment of your situation.

Table of Contents

The SSA SSA-3373-BK form is an essential document for individuals seeking Social Security Disability benefits. This form plays a critical role in the evaluation process, as it gathers detailed information about a claimant's daily functioning and limitations due to their medical condition. Applicants must provide comprehensive insights into how their disability affects their ability to perform basic tasks, engage in social activities, and maintain employment. The SSA-3373-BK form requires specific information regarding physical and mental health challenges, as well as how these challenges impact overall quality of life. Completing this form accurately is crucial, as it directly influences the determination of eligibility for benefits. Understanding the importance of each section and responding thoughtfully can significantly affect the outcome of a claim. Whether you are filling it out for yourself or assisting someone else, attention to detail and honesty are paramount in this process.

Sample - SSA SSA-3373-BK Form

Form SSA-3373 (02-2024) UF
Discontinue Prior Editions	Page 1 of 10
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

Form SSA-3373 (02-2024) UF

Page 2 of 10

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.

Form SSA-3373 (02-2024) UF
Discontinue Prior Editions	Page 3 of 10
Social Security Administration	OMB No. 0960-0681

FUNCTION REPORT - ADULT

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?

____________________________________________________________________________________________________

Form SSA-3373 (02-2024) UF

Page 4 of 10

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?	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?			Yes	No
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?			Yes	No

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?		Yes	No
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

Form SSA-3373 (02-2024) UF		Page 5 of 10

b. Do you need any special reminders to take care of personal	Yes	No
needs and grooming?	Yes	No
If "YES," what type of help or reminders are needed?

__________________________________________________________________________________________________

c. Do you need help or reminders taking medicine?

Yes

If "YES," what kind of help do you need?

__________________________________________________________________________________________________

13. MEALS
a. Do you prepare your own meals?	Yes	No

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?	Yes	No
If "YES," what help is needed?

d. If you don't do house or yard work, explain why not.

__________________________________________________________________________________________________

Form SSA-3373 (02-2024) UF

Page 6 of 10

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?				Yes	No

If "NO," explain why you can't go out alone.

__________________________________________________________________________________________________

d. Do you drive?

Yes

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	Yes	No	Handle a savings account	Yes	No
	Count change	Yes	No	Use a checkbook/money orders	Yes	No
	Explain all "NO" answers.

b. Has your ability to handle money changed since the illnesses,					Yes	No
injuries, or conditions began?

If "YES," explain how the ability to handle money has changed.

__________________________________________________________________________________________________

Form SSA-3373 (02-2024) UF

Page 7 of 10

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)			Other (Explain)

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?	Yes	No
How often do you go and how much do you take part?

Do you need someone to accompany you?	Yes	No

If "YES", explain.

__________________________________________________________________________________________________

d. Do you have any problems getting along with family, friends, neighbors, or others?	Yes	No
If "YES," explain.

__________________________________________________________________________________________________

e. Describe any changes in social activities since the illnesses, injuries, or conditions began.

__________________________________________________________________________________________________

Form SSA-3373 (02-2024) UF

Page 8 of 10

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,	Yes	No
reading, watching a movie.)	Yes	No
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	Yes	No
along with other people?

If "YES," please explain.

__________________________________________________________________________________________________

If "YES," please give name of employer.

Form SSA-3373 (02-2024) UF

Page 9 of 10

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?

Yes

If "YES," please explain.

__________________________________________________________________________________________________

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
Other (Explain)

Which of these were prescribed by a doctor?

__________________________________________________________________________________________________

When was it prescribed?

__________________________________________________________________________________________________

When do you need to use these aids?

__________________________________________________________________________________________________

Form SSA-3373 (02-2024) UF		Page 10 of 10

22. Do you currently take any medicines for your illnesses, injuries, or conditions?	Yes	No
If "YES, "do any of your medicines cause side effects?	Yes	No

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

↓ SSA SSA-3373-BK PDF

File Specs

Fact Name	Description
Purpose	The SSA-3373-BK form is used to collect information about an individual's daily activities and how their condition affects their ability to work.
Target Audience	This form is primarily intended for individuals applying for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI).
Completion Requirement	Applicants must complete the form thoroughly, providing detailed information to support their disability claim.
Submission Process	The completed SSA-3373-BK form can be submitted online or mailed to the local Social Security office.
State-Specific Forms	While the SSA-3373-BK is a federal form, states may have additional requirements under their governing laws, such as the Social Security Act.

SSA SSA-3373-BK - Usage Guidelines

Filling out the SSA-3373-BK form is an important step in your application process. It is essential to provide accurate and complete information to ensure that your needs are properly understood. Follow the steps below to fill out the form correctly.

Begin by downloading the SSA-3373-BK form from the official Social Security Administration website or obtain a physical copy from your local Social Security office.
Read the instructions carefully before starting to fill out the form. This will help you understand what information is required.
Fill in your personal information in the designated sections. This includes your name, address, phone number, and Social Security number.
Provide detailed information about your medical condition. Describe how it affects your daily life and ability to work. Be specific and honest.
List all medications you are currently taking, including dosages and how long you have been on them.
Include information about any doctors or medical professionals you have seen for your condition. Provide their names, addresses, and phone numbers.
Answer all questions regarding your daily activities. This may include how you manage personal care, household tasks, and social interactions.
Review your answers for accuracy. Make sure all information is clear and complete.
Sign and date the form at the end. Your signature indicates that the information provided is true to the best of your knowledge.
Make a copy of the completed form for your records before submitting it.
Submit the form as instructed, either online, by mail, or in person at your local Social Security office.

After submitting the form, you may need to wait for a response from the Social Security Administration. Be prepared to provide any additional information they may request. It is important to keep track of your submission and follow up if necessary.

Your Questions, Answered

What is the SSA SSA-3373-BK form?

The SSA SSA-3373-BK form, also known as the Adult Function Report, is a document used by the Social Security Administration (SSA) to gather information about how a person's disability affects their daily life. This form helps the SSA assess an individual's ability to perform basic activities and work-related tasks.

Who needs to fill out the SSA SSA-3373-BK form?

This form is typically required for individuals applying for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI). If you have a medical condition that significantly limits your ability to work, you may be asked to complete this form as part of your application process.

What kind of information is requested on the SSA SSA-3373-BK form?

The form asks for detailed information about your daily activities, including how you handle personal care, household chores, social interactions, and any hobbies or interests. It also inquires about your medical conditions and how they affect your ability to function in various aspects of life.

How do I submit the SSA SSA-3373-BK form?

You can submit the completed SSA-3373-BK form in several ways. You can mail it directly to the SSA office handling your case, or you may be able to submit it online through your My Social Security account, depending on the SSA's current processes. Always check the SSA website for the most accurate submission methods.

Can someone help me fill out the SSA SSA-3373-BK form?

Yes, you can seek assistance from family members, friends, or professionals, such as legal representatives or advocates. They can help you accurately describe your limitations and how your condition impacts your daily life. However, it’s essential that the information provided reflects your own experiences and circumstances.

What happens after I submit the SSA SSA-3373-BK form?

Once you submit the form, the SSA will review the information as part of your disability claim. They may contact you for additional information or clarification. The review process can take time, so it's important to be patient and keep track of your application status.

Is there a deadline for submitting the SSA SSA-3373-BK form?

Yes, there is typically a deadline for submitting this form, which is often linked to your application for disability benefits. It’s crucial to submit the form promptly to avoid delays in processing your claim. If you’re unsure about the deadline, check with the SSA or refer to any correspondence you’ve received regarding your application.

What should I do if I make a mistake on the SSA SSA-3373-BK form?

If you realize you've made a mistake after submitting the form, don’t panic. You can contact the SSA to inform them of the error and provide the correct information. It’s important to ensure that all details are accurate to avoid complications with your claim.

Common mistakes

Failing to provide complete information about daily activities can lead to misunderstandings about the applicant's condition. It’s essential to detail how impairments affect routine tasks.
Not listing all medical conditions can result in an incomplete picture of the applicant's health. Every condition, even those that seem minor, should be included.
Omitting medications taken can hinder the evaluation process. A comprehensive list of all prescribed and over-the-counter medications is crucial.
Neglecting to mention the impact of symptoms on work abilities can lead to a denial of benefits. Clearly articulating how symptoms affect job performance is vital.
Providing vague descriptions of limitations can create confusion. Specific examples of how impairments hinder activities should be given.
Forgetting to include information about previous work history can weaken the application. A detailed account of past jobs and responsibilities is necessary.
Not signing and dating the form can result in delays or rejections. Ensure that all required signatures are present before submission.
Submitting the form without reviewing for accuracy can lead to mistakes. A thorough review can catch errors that might otherwise go unnoticed.
Ignoring the importance of supporting documentation can undermine the application. Including relevant medical records and statements can strengthen the case.
Failing to follow the instructions provided can result in incomplete submissions. Carefully reading and adhering to all guidelines is essential for success.

Documents used along the form

The SSA SSA-3373-BK form, also known as the Function Report, is a critical document used in the Social Security Administration's disability determination process. Alongside this form, several other documents can help provide a comprehensive view of an individual's situation. Below is a list of commonly used forms and documents that often accompany the SSA SSA-3373-BK.

SSA-16: This is the Application for Disability Insurance Benefits. It initiates the process for individuals seeking Social Security disability benefits.
SSA-827: This form is the Authorization to Disclose Information to the Social Security Administration. It allows the SSA to obtain medical records and other relevant information from healthcare providers.
SSA-3368: The Disability Report - Adult form collects information about the claimant's medical conditions, work history, and education. It provides detailed context for the SSA's review.
SSA-3820: This is the Work History Report. It outlines the claimant's work experience, including job duties and the physical and mental demands of each position held.
SSA-3441: The Appeal Disability Report is used when a claimant is appealing a decision made by the SSA regarding their disability claim. It updates the SSA on the current status of the claimant's condition.
SSA-827: This is the Authorization to Disclose Information to the Social Security Administration. It allows the SSA to obtain medical records and other relevant information from healthcare providers.
Medical Records: Documentation from healthcare providers detailing the claimant's medical history, diagnoses, treatments, and prognosis. This information is vital for substantiating a disability claim.
Personal Statements: Written accounts from the claimant or their family detailing how the disability affects daily life. These statements can provide personal insights that complement medical evidence.
Work Performance Evaluations: These documents assess how a claimant has performed in previous jobs and can illustrate the impact of their disability on work capabilities.

These forms and documents, when used in conjunction with the SSA SSA-3373-BK, can create a clearer picture of an individual's disability and support their claim for benefits. Providing thorough and accurate information is essential for a successful application process.

Similar forms

The SSA-3373-BK form is similar to the SSA-3368-BK, which is the Adult Function Report. Both documents are designed to gather information about an individual's daily activities and limitations. The SSA-3368-BK focuses on how a person's condition affects their ability to work and engage in everyday tasks. It asks for details about physical and mental limitations, making it a crucial tool for assessing disability claims.

Another related document is the SSA-827, 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-3373-BK, it plays a vital role in the disability determination process. It ensures that the SSA has access to the necessary information to evaluate a claimant's condition accurately.

The SSA-3820, the Work History Report, also shares similarities with the SSA-3373-BK. This document collects detailed information about a person's past employment, including job duties, skills, and the physical demands of each position. While the SSA-3373-BK focuses on current limitations, the SSA-3820 provides context about how past work experiences may impact an individual’s ability to perform in the present.

Lastly, the SSA-3380-BK, the Function Report-Child, is comparable in that it gathers information about a child’s daily functioning. This form, like the SSA-3373-BK, aims to understand how a disability affects an individual’s life. It emphasizes the child’s activities, social interactions, and the impact of their condition on their ability to learn and grow, making it essential for evaluating childhood disability claims.

Dos and Don'ts

When filling out the SSA SSA-3373-BK form, it's important to follow some guidelines to ensure your application is processed smoothly. Here are six things you should and shouldn't do:

Do read the instructions carefully before starting the form.
Don't leave any sections blank unless instructed to do so.
Do provide detailed information about your daily activities and limitations.
Don't exaggerate or understate your condition; be honest.
Do review your answers for clarity and accuracy before submission.
Don't forget to sign and date the form at the end.

Misconceptions

The SSA SSA-3373-BK form, also known as the "Function Report - Adult," is often misunderstood. Here are seven common misconceptions about this form:

It is only for people with physical disabilities. Many believe this form is limited to those with visible physical impairments. However, it is designed for all types of disabilities, including mental health conditions.
Completing the form is optional. Some individuals think that filling out the SSA-3373-BK is not mandatory. In reality, it is a crucial part of the application process for Social Security Disability benefits.
Only medical professionals should fill it out. There is a misconception that only doctors or therapists can provide the necessary information. In fact, the individual applying for benefits is the best source of information about their daily functioning and limitations.
It only needs to be filled out once. Many applicants believe that they only need to submit the form at the beginning of their application. However, updates may be required if circumstances change or if the SSA requests more information.
The form is straightforward and quick to complete. Some think that the SSA-3373-BK is simple and can be filled out in a short time. In reality, it requires careful thought and reflection on one’s daily activities and limitations, which can take longer than expected.
Submitting the form guarantees approval. There is a belief that completing the SSA-3373-BK will automatically result in receiving benefits. Approval depends on a variety of factors, including medical evidence and how well the form reflects the individual’s limitations.
It is not necessary to provide detailed information. Some applicants assume that brief answers will suffice. However, providing detailed and specific information about daily activities, limitations, and the impact of the disability is essential for a thorough evaluation.

Understanding these misconceptions can help individuals navigate the application process more effectively and improve their chances of a favorable outcome.

Key takeaways

Filling out the SSA-3373-BK form, which is used to assess an individual's ability to work due to disability, requires careful attention to detail. Here are some key takeaways to consider:

Accurate Information is Crucial: Ensure that all information provided on the form is complete and accurate. Inaccuracies can lead to delays or denials in benefits.
Detail Your Limitations: Clearly describe how your condition affects your daily activities and ability to work. Specific examples can strengthen your case.
Use Clear Language: Avoid technical jargon. Use straightforward language to convey your experiences and limitations effectively.
Review Before Submission: Take the time to review the completed form. A thorough check can help catch any mistakes or missing information before it is submitted.

By keeping these takeaways in mind, individuals can enhance their chances of a successful application for disability benefits.