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
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 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

Privacy Act and Paperwork Reduction Act Statements
Sections 205(a), 1631(d)(1) and 1631(e)(1) of the Social Security Act, as amended, authorize us to
collect this information. 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. We generally use the information you supply for the
purpose of making decisions regarding claims. However, we may use it for the administration and
integrity of Social Security programs. We may also disclose information to another person or to
another agency in accordance with approved routine uses, which include but are not limited to the
following: (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 Government Accountability Office and the
Department of Veterans Affairs); (3) to make determinations for eligibility in similar health and
income maintenance programs at the Federal, State, and local level; and, (4) to facilitate statistical
research, audit, or investigative activities necessary to assure the integrity of Social Security
programs.
We may also use the information you provide in computer matching programs. Matching
programs compare our records with those kept by other Federal, State, or local government
agencies. Information from these matching programs can be used to establish or verify a person’s
eligibility for Federally-funded or administered benefit programs and for repayment of payments or
delinquent debts under these programs.
Additional information regarding this form, routine uses of information, and our programs and
systems, is available on-line at www.socialsecurity.gov or any local Social Security office.
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 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 (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.

Form Approved

SOCIAL SECURITY ADMINISTRATION

OMB No. 0960-0635

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
□ Shelter

□ Apartment
□ Boarding House
□ Nursing Home
□ Group Home □ Other (What?) ________________________________________

b. With whom does he/she live? (Check one.)

□Alone
□ With Family □ With Friends
□ Other (Describe relationship.) __________________________________________________________
SECTION B – INFORMATION ABOUT ILLNESSES, INJURIES, OR CONDITIONS
8. How do this person's illnesses, injuries, or other conditions limit his/her ability to work? ______________
_

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

FORM SSA-3380-BK (7-2004) ef(07-2008)

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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?

□ Yes □ No

If "YES," for whom does he/she care, and what does he/she do for them? ________________________
___________________________________________________________________________________
11. Does he/she take care of pets or other animals?

□ Yes □ No

If "YES," what does he/she do for them? __________________________________________________
___________________________________________________________________________________
12. Does anyone help this person care for other people or animals?

□ Yes □ No

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

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___________________________________________________________________________
FORM SSA-3380-BK (7-2004) ef(07-2008)

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

□ Yes □ No

If "YES," what type of help or reminders are needed? ________________________________________
___________________________________________________________________________________

c. Does he/she need help or reminders taking medicine?

□ Yes □ No

If "YES," what kind of help does he/she need? ______________________________________________
___________________________________________________________________________________
16. MEALS
a. Does the disabled person prepare his/her own meals?

□ Yes □ No

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 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? ________________________________________________________
d. If the disabled person doesn't do not do house or yard work, explain why not. ___________________
________________________________________________________________________________
FORM SSA-3380-BK (7-2004) ef(07-2008)

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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.)

□ Walk
□ Drive a car
□ Use public transportation

□ Ride in a car
□ Ride a bicycle
□ Other (Explain)___________________________________
c. When going out, can he/she go out alone?
□ Yes □ No
If "NO," explain why he/she can't go out alone. ____________________________________________
__________________________________________________________________________________

□ Yes □ No

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

□ Yes □ No
□ Yes □ No

Handle a savings account
Use a checkbook/money orders

□ Yes □ No
□ Yes □ No

Explain all "NO" answers.____________________________________________________________
________________________________________________________________________________

FORM SSA-3380-BK (7-2004) ef(07-2008)

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□

□

b. Has the disabled person's ability to handle money changed since
Yes
No
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. 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

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(07-2008)

□ Yes □ No
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c. Does this person have any problems getting along with family, friends,
neighbors, or others?

□ Yes □ No

If "YES," explain. _________________________________________________________________
________________________________________________________________________________
d. 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 that 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)

□ 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? _____________________________
________________________________________________________________________________

FORM SSA-3380-BK (7-2004) ef(07-2008)

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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 the name of the 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) _______________________________________________________________
Which of these were prescribed by a doctor? ______________________________________________
__________________________________________________________________________________
When was it prescribed? _____________________________________________________________
__________________________________________________________________________________
When does this person need to use these aids? ___________________________________________
__________________________________________________________________________________
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 □ No
□ Yes □ 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

FORM SSA-3380-BK (7-2004) ef(07-2008)

Side Effects Person Has

Page 7

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 (month, day, year)

Address (Number and Street)

Email address (optional)

City

State

Zip Code
-

FORM SSA-3380-BK (7-2004) ef(07-2008)

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