Form SSA-3881 BK SSA-3881 BK Questionnaire for Children Claiming SSI Benefits

Form Approved
OMB No. 0960-0499

Social Security Administration

QUESTIONNAIRE FOR CHILDREN CLAIMING SSI BENEFITS

Please print, type, or write clearly and answer all items to the best of your ability. If you
need help completing any part of this form, we will help you. If you are filing on behalf of
someone else, enter his or her name and social security number in the space provided
and answer all questions. If you do not know the answer, enter "unknown." If the
question does not apply, enter "N/A." If you need more space to answer any of the
questions, please use "REMARKS" and enter the number of the question next to your
answer.

Child's Full Name

Informant's Name

1.

2.

Social Security Number Date (month, day, year)

-

Relationship to Child

-

Daytime Telephone Number
(including Area Code)

Is (was) the child cared for by a baby sitter? Does (did) the child attend any type of preschool, daycare
and/or after school program? If so, please specify. If more than one of the above, use the "REMARKS"
section.
Name

Address (Number, Street, City, State, Zip Code)

Telephone Number (including Area Code)

Dates Attended

a. Is (was) the child in school?

}

Yes

No

If "yes," and the school was not listed in Item 12A of the SSA-3820-F6, please show it here.
(If more than one, use the "REMARKS" section.)
Name

Address (Number, Street, City, State, Zip Code)

Telephone Number (including Area Code)

Dates Attended

Grade Level Completed

Last Teacher's Name

Form SSA-3881-BK (6-2003) ef (07-2008) Destroy Prior Editions

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2.

b. Is the child in a special education program?

}

Yes

No

Don't Know

c. Does the school make any special accommodations for the
child; e.g., adaptive furniture, wheelchair ramps, extra
assistance or attention?
}

Yes

No

Don't Know

If "yes" in 2.b. or 2.c., indicate type of program and/or
accommodations:

d. Do you have a copy of the child's individual education plan
(IEP), the report in which the teacher outlines the child's
problems and lists the plans for correcting them?

Specify number of hours per week the
child is in special education program:

}

Yes

No

a. In school

}

Yes

No

b. Outside school

}

Yes

No

If "yes," please provide a copy.
3.

Does the child receive any special counseling or tutoring?

If "yes," in 3.a. or 3.b., please indicate: (If more than one, use the "REMARKS" section.)
Type of Counseling, Tutoring

Date Began and Ended (If completed)

Frequency of Visits

Counselor's or Tutor's Name

Telephone Number (including Area Code)

Address (Number and Street, City, State and Zip Code)

4.

Does the child or family have a child welfare, social services or
early intervention caseworker?
}

Yes

No

If "yes," please provide the following information: (If more than one,use the"REMARKS"section.)
Caseworker's Name

Organization

Address (Number and Street, City, State and Zip Code)

Telephone Number (including Area Code)

File or Record Number

Date First Saw/Last Saw Caseworker

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5.

Has the child ever been tested or evaluated by any of the following agencies or organizations?
If "yes," indicate in the space provided below the agency name, address, telephone number, record
number, and the type and date of test or evaluation performed (e.g., vision, hearing, speech, physical).
a. Public/Community Health Department

}

Yes

No

b. Child Welfare/Social Services Agency

}

Yes

No

c. Developmental Evaluation Center

}

Yes

No

d. Mental Health/Mental Retardation Center

}

Yes

No

e. Special Needs/Crippled Children Agency

}

Yes

No

f. Speech and Hearing Center

}

Yes

No

g. Women, Infants and Children (WIC) Program

}

Yes

No

Use the letter designation (5a, 5b, etc.) to identify the agency.

If additional space is needed, use "REMARKS" section.
Form SSA-3881-BK (6-2003) ef (07-2008)

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6.

Does (did) the child receive any special therapy (physical, speech and
language, occupational), exercises, or any other services for his/her
impairments?
}

Yes

No

Include information about any therapy or exercises the parent,
guardian or caregiver provides the child.
If "yes," indicate below the therapist's name, the name of the person who PRESCRIBED AND/OR
DESIGNED the therapy program, the type(s) and frequency of treatment, when treatment began and
ended (if completed), and where treatment was received (e.g., home, hospital, therapist's office, clinic.)
Telephone No. (including Area Code)

Therapist's Name
Address (Number and Street, City, State and Zip Code)

Person Who Prescribed/Designed Therapy

Information about Therapy:

Therapist's Name

Telephone No. (including Area Code)

Address (Number and Street, City, State and Zip Code)

Person Who Prescribed/Designed Therapy

Information about Therapy:

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7.

Does (did) the child receive vocational rehabilitation services?

}

Yes

No

If "yes," describe services received below the rehabilitation
counselor's information. Include dates and record number.
Rehabilitation Counselor's Name

Telephone No. (including Area Code)

Address (Number and Street, City, State and Zip Code)

Services received:

(If additional space is needed, use "REMARKS" section.)
8.

NOTE: PROVIDING INFORMATION ABOUT THE CHILD'S INVOLVEMENT
WITH THE COURT SYSTEM IS OPTIONAL
Has the child ever been involved with the court system other than in
custody proceedings?
}

Yes

No

If "yes," please explain involvement, including testing and evaluation.
Youth Development Center's Name

Address (Number and Street, City, State and Zip Code)

Probation or Parole Officer's Name

Telephone No. (including Area Code)

Address (Number and Street, City, State and Zip Code)

Involvement including any testing and evaluation:

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9.

Does (did) the child participate in any community or school activities,
such as choir, Special Olympics, Boy's/Girl's Club, Scouts, or sports?
}

Yes

No

If "yes," describe involvement, amount of time spent in activity, and level of participation. Provide name,
address, and telephone number of individual who supervises the activity. Include dates of involvement. If
involvement ended, explain why.

10.

If the child takes any medication on an ongoing basis, please indicate the following:
MEDICATION
DOSAGE/FREQUENCY

PRESCRIBED
BY (NAME)

REASON FOR
MEDICATION

How well does the medication(s) work? Please explain:

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DESCRIBE ANY
SIDE EFFECTS

11.

a. If you are unable to give us information we need about the child, is there someone else who
helps care for the child and, knows of the child's impairment who can help us get the
information we need, and, if necessary, bring the child to a consultative examination?

Yes

No

b. If "yes," please provide the following information about this person
Name
Address (Number and Street, City, State and ZIP Code)

Daytime telephone number (including Area Code)
Relationship (e.g., relative, neighbor, family friend) to the child?
REMARKS:

Form SSA-3881-BK (6-2003) ef (07-2008)

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REMARKS (continued):

PRIVACY ACT: The information requested on this form is authorized by Section 223 and Section 1632 of the Social Security Act.
The information provided will be used in making a decision on your claim. While completion of this form is voluntary, failure to
provide all or part of the requested information could prevent an accurate and timely decision on your claim and could result in the
loss of benefits. Information you furnish on this form may be disclosed by the Social Security Administration to another person or
governmental agency only with respect to Social Security programs and to comply with Federal law requiring the exchange of
information between Social Security and another agency.
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. If you want to learn more about this, contact any Social Security office.
PAPERWORK REDUCTION ACT: 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 OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. To find the nearest office, call 1-800-772-1213 TTY (1-800-325-0778) .Send only comments on our time estimate
above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401.
Form SSA-3881-BK (6-2003) ef (07-2008)

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