Form SSA-3380-BK Function Report--Adult--Third Party

FUNCTION REPORT - ADULT - THIRD PARTY Form SSA-3380-BK
READ ALL OF THIS INFORMATION BEFORE
YOU BEGIN COMPLETlNG 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. I f you need the address or phone number for the office that provided the fom, you can get it
by calling Social Security at 1-800-772-1213.

HOW TO COMPLETE TElS 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 mu& ofthe farm as you can. When a question d e r s to the
"disabled ~ n , it"refers to the pason who is applying fbr or receiving disdility benefits.
It is important that you tell us what you h o w about the disabled person's activities and abilities.

DO NOT ASK THE DISABLED PERSON TO GIVE YOU ANSWERS
Printortype.

DO NOT LEAVE ANSWERS BLANK I f you do not know the answer or the answer
is "none" or "doesnot apply,' please write ndonttknow" 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 a0 answer.
If you need mare space to answer any questions, use the "REMARKS" section on
Page 8, and show the number of the question being answered.

REMEMBER TO GIVE US TBE M A M E AND ADDRESS OF TKE PERSON
COMPLETlNG TEE3 FORM O N PAGE 8

Mvorcy Act and Paperwork Reduction Act Statements
The Social Security Administdon is authorized to collect the information on this form under sections
205(a), 163 1(d)(l ) and 163 1(e)( 1) of the Social Security Act. The infomtion on this form is needed by
Social Security to make a decision on the m
e
d claimant's daim. While giving us the information on this
form is voluntary, failwe to provide dl or part of the requested infoxmation wuld prevent an accurate or
timeIy decision on the named claimant's claim. Although the informaton you furnish is almost never used
for my purpose other than msrking a detemimtim about the claimant's diaility, such information may
be disclosed by the Social S d t y Administration as fbllows: (1) to enable a third party or agency to
assist Social Security in establishing rights to Social Security benefits andlor coverage; (2) to cumply with
Fed& Laws e
g the release of infomation from Social Security records (e.g., to the Government
Accountability m c e and the Department of Veteraos AfWm);and (3) to facilitate statistical research and
such activities neassary to assure the integrity and improvement of the Social Security programs (e.g., to
the Bureau of the Census and private concerns under contract to Social Security).
We may also use the i n f o d o n you give us when we match records by computa. Matching programs
compare our records with those of other Federal, State, or local government agencies. Many agencies
may use matching programs to find or prove that a person qualifies for benefits paid by the Federal
government, The law allows us b do this even if you do not agree to it. Explanations about these and
other reasons why information you provide us may be used or given out m available inSocial Security

offices.
Paperwork Reduction Act Statement - Paperwork Reductfon Act Statement - This information
collection meets the requirements of 44 U.S.C. 5 3 507, as amended by section 2 of the
R
Act of 1995. You do not need to answer thae questions unless we display a valid Office of
Management and Budget control numk. We estimate that it will take about 30 minutes to read the
instructions, gather the facts, and answer the questions. SEND THE COMPLETED FORM TO TBE
OFPICE THAT REQUESTED IT. If you do not have that address, you may call S d a l Security at
1-800-772-12 13, Send only cumments on our time estimate above to: SSA, 6401 Security Blvd.,
Baltimore, MD 2 1235-6401.

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PLEASE REMOVE THIS SEiEET BEFORE RETURNING
THE COMPLETED FORM,

Form Approved

SOCIAL SECURlfY ADMINISTRATION

OM8 NO.0980-0835

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FUNCTION REPORT ADULT -THIRD PARTY
How the djsabled person rS ilinesses, injuries, or conditions limit his/her activities

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SECTION A GENERAL INFORMATION
1. NAME OF DISABLED PERSON (First, Middle, &ad)

2.YOUR NAME (Person completing the form) 3. RELATIONSHIP

4. DATE (Month, Day, Year)

(To dimbled person)

5. YOUR DAYTIME TELEPHONE NUMBER (If there is no telephone number where you can be reached,
please give us a daytime number where we oan leav8 a message for you.)

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)

[jYour Number

.

Message Number

None

PhatmNumhr

~re7-

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 togethefl

7. a, Where does the disabled person live? (Check one.)
Shelter

Apartment
G m p Home

Boarding House
other m a t ? )

Nursing b

e

b, With whom does hdshe live? (Check one.)

Alone

With Family

WU
I I Friends

other (Demibe relationship..)

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SECTION B INFORMATION ABOUT DAILY ACTIVITIES

8. Describe what the disabled person does from the t i m e hdshe wakes up until going to bed.

Form 58AS380-M (7-2004) ef (07-2005)
Us8 0%2003 8cMm until supply is exhausted

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9. Does this person take care of anyone else such as a wifelhusband, children,
grandchildren, parents, friend, other?
If "YES,"for whom does helshe care, and what does helshe do for them?

Yes

No

10.Does helshe take care of pets or other animals?
If "YES,"what does helshe do for them?

11. Does anyone help this person care for other people or animals?

ayes

NO

If "YES,"who helps, and what do they do to help?

12.What was the disabled person able to do before hisfher illnesses, injuries, or conditions that hefshe can't

do now?

13. Do the illnesses, injuries, or conditions affect hislher sleep?
If "YES," how?

14. 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?

Form SSA-3380-BK (7-2004) ef (07-2005)

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b. Daes helshe need any special reminders to take care of
personal needs and grooming?
If "YES,"what type of help or reminders are needed?

c. Does helshe need help or mmlnders taking rnedicfna?
If "YES,"what kind of help does helshe need?

15. MEALS
a. Does the disabled parson prepare hislher own meals?
If "Yes,"what kind of food is prepared? (For example, sandwiches, frozen dinners, or complete meals
with several courses).

How often does hd&e prepare food or meals? (For exampie, dally, weekly, monthly.)

How long does it take himfheR
Any changes In cooking habits since the illness, injuries, or conditions began?

b. If "No,"explain why hdshe cannot or does not prepare meals.

16. HOUSE AND YARD WORK
a. List household chores, both indoors and outdoors, that the disabled person is able to do.
(For examph, cleaning, laundry, hwsehold repairs, ironing, mowing, etc.)
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b. How much time do chores take, and how often does helshe do each of these things?

c. Does helshe need help or encouragement doing these things?
If "YES,"what help is needed?

Form SSA5380-BK (7-2004) ef (07-2005)

yes

No

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d. If the disabled person doesn't do house or yard work, explain why not.

t 7.GETTING AROUND
a. How often does this person go outside?
If helshe doesnY go out at all, explaln why not.

b. When going out, how does hdshe travel? (Check all that apply)

Walk

Drive a car

Ride in a ear

Ride a b i m e

Use public transportation
c. When golng out, can helshe go out alone?
If "NO,"explain why helshe can't go out alone.

d. Does the disabled person drive?
If he/she doesn't drive, explain why not.

18. SHOPPING
a. If the disabled person does any shopping, does hdshe shop: (Check all that apply.)
In stores
BY phone
6 y mail
BY c m p ~ t ~
b. Describe what helshe shops for.

c. How often does helshe shop and how long does it take?

19. MONEY
a. Is helshe able to:

Pay bills

Handle a savings account

Count change

Use a checkbooklrnoney orders

Explain all "NOuanswers.

~

Y S
Yes

NO
No

b. Has the disabled person's ability to handle money changed since
the illnesses, injuries, or conditions m a n ?

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

20, HOBBiES AND INTERESTS
a. What are hidher hobbies and interests? (For example, reading, watching N ,sewing, playing
SpOm, 8tc.)

b. How often and how well does heishe do these things?

c. Describe any changes in these activities since the Illnesses,injuries, or conditions began.

21. SOCIAL ACTMTIES
a. Does the disabled person spend time with others?(Inperson, on the phone,
on the computer, etc.)
If "YES,"descrjbe the kinds of things helshe does with ohers.

my=

ab

How often does helshe do these things?

b. List the places helshe goes on a regular basis. (For example, church, community center, sports
events, d a l groups, etc.)

Does helshe need to be reminded to go places?
How often does helshe go and how much does helshe take parf?

Does helshe need someone to accompany himher?

Form SSA-33-K

(7-2004) ef (07-2005)

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c. Does this person have any problems getting along with family, friends,
neighbors, or others?

If "YES,"explain.

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

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SECTION C INFORMATION ABOUT ABIlITtES
22. a. Check any of the following bms the disabled person's illnesses, injuries, or conditions affect:

a Walking

El ~ i f f i ~
W

~

W

BWing

mi^

sitting
heeling
Talking

El

Stair Climblng

Undmtandlng

Seeing
Memory

Following instructions
Using Hands
Getting Along Wlth Others

Completing Tasks
Reaching
W ~ W
Concentration
Please explain how hislher illnesses, injuries, or conditions affect each of the items you checked. (For
example, helshe can only l imow many pounds], or helshe can only walk pow far])

b. Is the disabled person:

r]Right Handed?

Left Handd?
c. How far can helshe walk before needing to stop and rest?
If helshe has to rest, how long before hdshe can resume walking?

d. For how long can the disabled person pay attention?

e. Does the disabled person finish what helshe starts? (For example, a

Dye

conwrsafh, chores, reading watchlng a movie)
f. How well does the disabled person follow written instructions? (For example, a recipe)

nw

g. How well does the disabled person follow spoken instructions?

F m SSA-3380-BK (7-2W) ef (07-2005)

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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 helshe 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.
j.

How well does the disabled person handle stress?

k. How well does heishe handle changes in routine?

I. Have you noticed any unusual behavior or fears in the disabled person?

Yes

•

No

If "YES,"please explain.

23. Does the disabled person use any of the following? (Check all that apply.)
Crutches

a Walker
a Wheelchair

Cane

Hearing Aid

Bradsplint

GlasseslContact Lenses

Artificial Limb

Artificial Voice Box

Other (Explain)
Which of these were prescribed by a doctor?

I

When was it prescribed?

When does this person need to use these aids?

Form SSA-3380-BK (7-2004)ef (07-2005)

Page 7

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SECTION D REMARKS

Use thb sectlon for any added informath you did not show In earlier parts of this form. When you
are done with thk W o n (or if you didn't have anything to add), be sure to complete the *Ids at the
bottom of this page.

Date (month, day, year)

Name of person completing this form (Please print)
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Address (Numkr and Skeet)

mall address (optional)

ab

State
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Form SSA99804K (7-2004) ef (07-2005)

ZIP Code
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