Form SSA-3380 Function Report -- Adult Third Party

FUNCTION REPORT - ADULT - THIRD PARTY Form SSA-3380-BK

READ ALL OF THIS INFORMATION BEFORE
YOU BEGIN COMPLETING THIS FORM

IF YOU NEED HELP

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 8, and show the number of the question being answered.

REMEMBER TO GIVE US THE NAME AND ADDRESS OF THE PERSON
COMPLETING THIS FORM ON PAGE 8

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

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.

Privacy Act and Paperwork Reduction Act Statements
The Social Security Administration is authorized to collect the information on this form under sections
205(a), 1631(d)(1) and 1631(e)(1) of the Social Security Act. The information on this form is needed by
Social Security to make a decision on the named claimant's claim. While giving us the information on this
form is voluntary, failure to provide all or part of the requested information could prevent an accurate or
timely decision on the named claimant's claim. Although the information you furnish is almost never used
for any purpose other than making a determination about the claimant's disability, such information may
be disclosed by the Social Security Administration as follows: (1) to enable a third party or agency to
assist Social Security in establishing rights to Social Security benefits and/or coverage; (2) to comply with
Federal Laws requiring the release of information from Social Security records (e.g., to the General
Accounting Office and the Department of Veterans Affairs); and (3) to facilitate statistical research and
such activities necessary 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 information you give us when we match records by computer. 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 to 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 are available in Social Security
offices.
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 30 minutes to read the instructions, gather the facts, and answer the questions.
SEND THE COMPLETED FORM TO THE OFFICE THAT REQUESTED IT. If you do not have
that address, you may call Social Security at 1-800-772-1213. You may send comments on our time
estimate above to: SSA, 1338 Annex Building, 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.

Form Approved
OMB No. 0960-0635

SOCIAL SECURITY ADMINISTRATION

FUNCTION REPORT - ADULT -THIRD PARTY
How the disabled person's illnesses, injuries, or conditions limit his/her activities

SECTION A - GENERAL INFORMATION
1. NAME OF DISABLED PERSON (First, Middle, Last)

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

4. DATE (Month, Day, Year)

(To disabled 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 can leave a message for you.)

(

)

Area Code

-

Your Number

Message Number

None

Phone Number

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

With Friends

Other (Describe relationship.)

SECTION B - INFORMATION ABOUT DAILY ACTIVITIES
8.

Describe what the disabled person does from the time he/she wakes up until going to bed.

Form SSA-3380-BK (7-2004) ef (12-2004)
Use 03-2003 edition until exhausted

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9. Does this person take care of anyone else such as a wife/husband, children,

Yes

No

Yes

No

Yes

No

grandchildren, parents, friend, other?
If "YES," for whom does he/she care, and what does he/she do for them?

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

11. Does anyone help this person care for other people or animals?
If "YES," who helps, and what do they do to help?

12. What was the disabled person able to do before his/her illnesses, injuries, or conditions that he/she can't
do now?

13. Do the illnesses, injuries, or conditions affect his/her sleep?

Yes

No

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 (12-2004)

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b. Does he/she need any special reminders to take care of
personal needs and grooming?

Yes

No

Yes

No

Yes

No

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?

15. 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.

16. 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?

Yes

No

If "YES," what help is needed?

Form SSA-3380-BK (7-2004) ef (12-2004)

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

17. 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

Use public transportation

Ride a bicycle

Other (Explain)

c. When going out, can he/she go out alone?

Yes

No

Yes

No

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.

18. 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?

19. MONEY
a. Is he/she 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.

Form SSA-3380-BK (7-2004) ef (12-2004)

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

Yes

No

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

20. 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.

21. SOCIAL ACTIVITIES
a. Does the disabled person spend time with others?(In person, on the phone,
on the computer, etc.)

Yes

No

If "YES," describe the kinds of things he/she does with others.

How often does he/she do these things?

b. 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?

Yes

No

Yes

No

How often does he/she go and how much does he/she take part?

Does he/she need someone to accompany him/her?

Form SSA-3380-BK (7-2004) ef (12-2004)

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Yes

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

No

If "YES," explain.

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

SECTION C - INFORMATION ABOUT ABILITIES
22. a. Check any of the following items the disabled person's 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 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?

Yes
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)

No

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

Form SSA-3380-BK (7-2004) ef (12-2004)

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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

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.

23. 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)
Which of these were prescribed by a doctor?

When was it prescribed?

When does this person need to use these aids?

Form SSA-3380-BK (7-2004) ef (12-2004)

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SECTION D - 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.

Date (month, day, year)

Name of person completing this form (Please print)
Address (Number and Street)

email address (optional)

City

State

Zip Code
-

Form SSA-3380-BK (7-2004) ef (12-2004)

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