Table of Contents
The SSA-3380-BK form plays a crucial role in the Social Security Administration's (SSA) process for evaluating an individual's mental functioning and capacity to work. This form is specifically designed for adults who are applying for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) benefits based on mental health conditions. By providing detailed information about daily activities, social interactions, and cognitive abilities, the SSA-3380-BK helps the SSA assess how these factors impact an individual's ability to maintain employment. Applicants will find that the form includes sections that prompt them to describe their mental health history, treatment received, and the limitations they experience in various aspects of life. Completing the SSA-3380-BK accurately and thoroughly is essential, as it can significantly influence the outcome of a disability claim. Understanding the importance of this form and how to fill it out effectively can empower applicants in their pursuit of the benefits they may need to support their well-being.
Sample - SSA SSA-3380-BK Form
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Social Security Administration |
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FUNCTION REPORT - ADULT - THIRD PARTY Form
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
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
REMEMBER TO GIVE US THE NAME AND ADDRESS OF THE PERSON
COMPLETING THIS FORM ON PAGE 10
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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)
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
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.)
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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
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? |
Yes |
No |
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If "YES," how? |
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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?
Yes No
Yes No
16. MEALS |
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a. Does the disabled person prepare his/her own meals? |
Yes |
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.
No
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?
Yes
No
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d. If the disabled person doesn't do house or yard work, explain why not. |
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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.) |
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Walk |
Drive a car |
Ride in a car |
Ride a bicycle |
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Use public transportation |
Other (Explain) |
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c. When going out, can he/she go out alone? |
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Yes |
No |
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If "NO," explain why he/she can't go out alone. |
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d. Does the disabled person drive?
If he/she doesn't drive, explain why not.
Yes
No
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: |
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Pay bills |
Yes |
Count change |
Yes |
Explain all "NO" answers. |
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No |
Handle a savings account |
No |
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 |
Yes |
No |
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the illnesses, injuries, or conditions began? |
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If "YES," explain how the ability to handle money has changed. |
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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.) |
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In person |
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Texting |
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Video Chat (for example Skype or Facetime) |
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Other (Explain) |
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b. Describe the kinds of things he/she does with others. |
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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?
Yes
No
Does he/she need someone to accompany him/her?
Yes
No
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d. Does this person have any problems getting along with family, friends, neighbors, or others?
If "YES," explain.
Yes
No
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, |
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chores, reading, watching a movie.) |
Yes |
No |
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? |
Yes |
No |
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 |
Other (Explain) |
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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?
Yes
Yes
No
No
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
File Specs
| Fact Name | Description |
|---|---|
| Purpose | The SSA-3380-BK form is used to collect information about a person'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). |
| Filing Process | Applicants must complete the form and submit it to the Social Security Administration, either online or by mail. |
| Information Required | The form asks for detailed information about the applicant's medical conditions, treatment, and daily living activities. |
| State-Specific Forms | Some states may have additional requirements or specific forms related to disability claims, governed by their own laws. |
| Importance of Accuracy | Providing accurate and thorough information on the SSA-3380-BK is crucial, as it can significantly impact the outcome of the disability claim. |
SSA SSA-3380-BK - Usage Guidelines
Completing the SSA-3380-BK form is an important step in the process of applying for Social Security benefits. This form requires specific information about your condition and how it affects your daily life. Follow these steps carefully to ensure that your application is filled out correctly.
- Obtain the SSA-3380-BK form. You can download it from the Social Security Administration's website or request a paper copy from your local office.
- Begin with the personal information section. Fill in your name, Social Security number, and contact information accurately.
- Provide details about your medical condition. Clearly describe your diagnosis and any treatments you are receiving.
- Explain how your condition affects your daily activities. Use specific examples to illustrate the challenges you face.
- List any medications you are taking. Include the name of each medication, the dosage, and how often you take it.
- Complete the section on your work history. Include details about your past jobs, including job titles and the dates you worked.
- Review your answers for accuracy. Make sure all information is complete and clear.
- Sign and date the form. Your signature confirms that the information provided is true to the best of your knowledge.
- Submit the form. You can send it by mail or deliver it in person to your local Social Security office.
Your Questions, Answered
What is the SSA SSA-3380-BK form?
The SSA SSA-3380-BK form is used by the Social Security Administration (SSA) to gather information about an individual's daily functioning. It helps assess how a person's impairments affect their ability to perform basic activities and interact with others. This information is crucial for determining eligibility for Social Security Disability benefits.
Who needs to fill out the SSA SSA-3380-BK form?
Individuals applying for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) may be required to complete this form. It is typically filled out by applicants who have a medical condition that significantly limits their daily activities.
How is the SSA SSA-3380-BK form used in the application process?
The SSA uses the information provided on the SSA-3380-BK form to evaluate an applicant's functional limitations. This assessment helps determine whether the applicant meets the SSA's criteria for disability. It is one component of a larger review process that includes medical records and other documentation.
What types of questions are included on the SSA SSA-3380-BK form?
The form includes questions about various aspects of daily living, such as personal care, social interactions, and the ability to manage tasks and responsibilities. Applicants may be asked to describe how their condition affects their ability to work, socialize, and perform routine activities.
Can someone help me fill out the SSA SSA-3380-BK form?
Is there a deadline for submitting the SSA SSA-3380-BK form?
While there is no specific deadline for the SSA-3380-BK form itself, it should be submitted as part of the overall disability application process. It is advisable to complete and submit the form promptly to avoid delays in the evaluation of the application.
What happens after I submit the SSA SSA-3380-BK form?
Once submitted, the SSA will review the information provided on the form along with other application materials. They may contact the applicant for additional information or clarification. The review process can take several months, and applicants will be notified of the decision once it is made.
Can I appeal if my application is denied after submitting the SSA SSA-3380-BK form?
Yes, if an application for disability benefits is denied, individuals have the right to appeal the decision. The appeals process allows applicants to present additional evidence or clarify information that may have influenced the initial decision.
Where can I obtain the SSA SSA-3380-BK form?
The SSA SSA-3380-BK form can be obtained directly from the Social Security Administration's website or at local SSA offices. It is also available through various disability advocacy organizations that assist applicants in the process.
Common mistakes
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Inaccurate Personal Information: Many individuals fail to provide correct personal details, such as their name, address, or Social Security number. This can lead to delays or complications in processing the application.
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Incomplete Responses: Some people skip questions or provide vague answers. Each section of the form is important, and omitting information can hinder the assessment of their case.
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Neglecting to Sign the Form: A common oversight is forgetting to sign and date the form. Without a signature, the application is not considered valid.
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Failure to Provide Medical Evidence: Applicants often do not include necessary medical documentation. This evidence is crucial for supporting claims about their condition.
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Misunderstanding the Questions: Some individuals misinterpret what is being asked. This can lead to providing irrelevant or incorrect information, which can affect the outcome.
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Not Keeping Copies: It is important to retain a copy of the completed form. Many forget to do this, making it difficult to track what was submitted or to follow up.
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Ignoring Deadlines: Some applicants miss important deadlines for submission. Being aware of timelines is essential for ensuring that the application is processed in a timely manner.
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Submitting the Wrong Version: Occasionally, individuals submit an outdated version of the form. Always check to ensure you have the most current version before submitting.
Documents used along the form
The SSA-3380-BK form is an important document used in the Social Security Administration's process for determining eligibility for disability benefits. When filling out this form, it is often helpful to have other related documents on hand. Below is a list of forms and documents that may accompany the SSA-3380-BK, each serving a unique purpose in the application process.
- SSA-3368-BK: This form, known as the "Disability Report - Adult," collects detailed information about the applicant's medical history, work history, and daily activities. It provides essential context for the SSA-3380-BK, which focuses on the applicant's functional limitations.
- SSA-827: The "Authorization to Disclose Information to the Social Security Administration" form allows the SSA to obtain medical records and other information from healthcare providers. This is crucial for verifying the information provided in the SSA-3380-BK.
- SSA-3441: This form, titled "Disability Report - Appeal," is used when an applicant wishes to appeal a decision made by the SSA regarding their disability claim. It helps to provide updated information and context that may not have been included in the original SSA-3380-BK.
- Medical Records: While not a form, medical records are vital to the disability application process. They provide evidence of the applicant's medical conditions and treatment history, supporting the claims made in the SSA-3380-BK.
Gathering these documents can streamline the application process and improve the chances of a successful claim. Each piece of information contributes to a clearer picture of the applicant's situation, helping the SSA make informed decisions about disability benefits.
Similar forms
The SSA-3380-BK form, known as the Adult Function Report, is similar to the SSA-3368-BK form, which is the Disability Report – Adult. Both forms aim to gather detailed information about an individual's daily activities and limitations. While the SSA-3380-BK focuses on how a person's condition affects their ability to perform everyday tasks, the SSA-3368-BK collects broader information regarding the individual's medical history and the specific impairments that may qualify them for disability benefits.
Another document that parallels the SSA-3380-BK is the SSA-827 form, the Authorization to Disclose Information to the Social Security Administration. This form allows the SSA to obtain necessary medical records and other relevant information from healthcare providers. While the SSA-3380-BK gathers information directly from the claimant about their functioning, the SSA-827 facilitates the collection of third-party medical documentation to support the claims made in the Adult Function Report.
The SSA-3373-BK form, also known as the Function Report – Adult, is another document that serves a similar purpose. Like the SSA-3380-BK, it seeks to understand how a claimant’s disability impacts their daily life. However, the SSA-3373-BK emphasizes the claimant's ability to perform specific tasks and activities, whereas the SSA-3380-BK provides a more narrative account of the individual's functional limitations and the impact of their condition over time.
The SSA-3441-BK form, which is the Disability Update Report, shares similarities with the SSA-3380-BK in that it requires claimants to report any changes in their condition or functional abilities. Both documents are essential for the SSA to assess ongoing eligibility for benefits. However, the SSA-3441-BK is typically used for individuals already receiving benefits, while the SSA-3380-BK is primarily for initial claims.
The SSA-3379 form, the Request for Administrative Law Judge Hearing, also relates to the SSA-3380-BK. While the SSA-3380-BK is used to gather information for initial claims, the SSA-3379 may be submitted when a claimant appeals a decision. The information in both documents can be crucial in establishing the extent of a claimant’s disability, although the context of their use differs significantly.
Another related document is the SSA-16-BK, which is the Application for Disability Insurance Benefits. This form is the initial application for disability benefits and requires claimants to provide personal information, work history, and details about their medical condition. The SSA-3380-BK complements this by focusing specifically on how the claimant's condition affects their daily functioning, providing a more in-depth look at the impact of their disability.
The SSA-451 form, also known as the Request for Reconsideration, is another document that can be seen as related to the SSA-3380-BK. When a claim is denied, the SSA-451 allows the claimant to contest that decision. The information provided in the SSA-3380-BK can be instrumental in supporting the claimant's case during this reconsideration process, as it details their functional limitations in a comprehensive manner.
The SSA-827-U4 form, which is the Authorization to Disclose Information to the Social Security Administration for Mental Health Treatment Records, is similar in that it also facilitates the gathering of information necessary for disability claims. While the SSA-3380-BK focuses on the individual's functional abilities, the SSA-827-U4 specifically addresses mental health records, which can be critical in substantiating claims related to mental health conditions.
Lastly, the SSA-3375-BK form, the Work History Report, complements the SSA-3380-BK by providing a detailed account of a claimant's past employment. While the SSA-3380-BK assesses how a disability affects daily functioning, the SSA-3375-BK focuses on the claimant's work history and any relevant skills or training. Together, these documents create a comprehensive picture of the claimant's situation and eligibility for benefits.
Dos and Don'ts
When filling out the SSA SSA-3380-BK form, attention to detail is crucial. Here are four key actions to consider:
- Do read the instructions carefully. Understanding the requirements will help ensure that all necessary information is provided.
- Do provide accurate and complete information. Double-check all entries to avoid delays in processing your application.
- Don't rush through the form. Taking your time can prevent mistakes that might require you to start over.
- Don't leave any sections blank. If a question does not apply, indicate that with "N/A" to clarify your response.
Misconceptions
The SSA-3380-BK form, also known as the "Function Report - Adult," is an important document used by the Social Security Administration (SSA) to assess an individual's functional abilities and limitations. However, there are several misconceptions surrounding this form that can lead to confusion. Here are five common misconceptions:
- The SSA-3380-BK form is optional. Many people believe that completing this form is not necessary. In reality, it is a crucial part of the disability evaluation process. Failing to provide this information can hinder the assessment of a claim.
- Only medical professionals should fill out the SSA-3380-BK form. Some individuals think that only doctors or therapists can provide the necessary information. However, this form is designed to be completed by the individual themselves or someone who knows them well, such as a family member or caregiver.
- The SSA-3380-BK form is only about physical limitations. There is a misconception that the form focuses solely on physical abilities. In truth, it also addresses mental and emotional limitations, as these factors play a significant role in determining an individual’s overall functionality.
- Providing too much detail is unnecessary. Some individuals worry that they might overwhelm the SSA with information. However, providing detailed and specific examples of daily activities and limitations can strengthen a claim and offer a clearer picture of the individual’s situation.
- Submitting the SSA-3380-BK form guarantees approval. While completing the form accurately is essential, it does not guarantee that a claim will be approved. The SSA considers many factors, and the form is just one part of the overall evaluation process.
Understanding these misconceptions can help individuals approach the SSA-3380-BK form with greater clarity and confidence. Accurate and thorough information can significantly impact the outcome of a disability claim.
Key takeaways
The SSA SSA-3380-BK form is an important document used for disability claims. Here are six key takeaways to consider when filling out and using this form:
- Purpose of the Form: The SSA-3380-BK is designed to gather detailed information about your daily activities and how your condition affects your ability to function.
- Completeness is Crucial: Ensure that all sections of the form are filled out completely. Incomplete forms can lead to delays in processing your claim.
- Be Honest and Detailed: Provide accurate descriptions of your limitations and daily challenges. Specific examples can help illustrate the impact of your condition.
- Review Before Submission: Double-check your answers for accuracy and clarity. Errors can complicate your application process.
- Submit on Time: Adhere to any deadlines for submission to avoid potential denial of your claim. Timeliness is key in the application process.
- Keep Copies: Always keep a copy of the completed form for your records. This can be useful for future reference or in case of follow-up questions.