Form SSA-3820-BK Disability Report - Child

DISABILITY REPORT - CHILD - Form SSA-3820-BK
READ ALL OF THIS INFORMATION BEFORE YOU BEGIN COMPLETING THIS FORM
THIS IS NOT AN APPLICATION

IF YOU NEED HELP
If you need help with this form, complete as much of it as you can, and your interviewer will
help you finish it.
HOW TO COMPLETE THIS FORM
The information that you give us on this form will be used by the office that makes the disability
decision on your disability claim. You can help them by completing as much of the form as you
can.

ABOUT THE CHILD'S MEDICAL AND OTHER RECORDS
If you have any of the following records for the child at home, send them to our office with your
completed forms or bring them with you to the interview. If you need the records back, tell us and
we will photocopy them and return them to you.
•
•
•
•

The child's medical records
Copies of the child's prescriptions or medicine containers
The child's Individualized Education Program
The child's Individualized Family Service Plan

YOU DO NOT NEED TO ASK DOCTORS OR HOSPITALS FOR ANY MEDICAL
RECORDS THAT YOU DO NOT ALREADY HAVE. With your permission, we will do that for
you. The information we ask for on this form tells us from whom to request medical and other
records. If you cannot remember the names and addresses of any of the doctors or hospitals, or the
dates of treatment, perhaps you can get this information from the telephone book, or from medical
bills, prescriptions and medicine containers.

Disability Report - Child - Form SSA-3820-BK

• Fill out as much of this form as you can before your interview appointment.
• Print or write clearly.
• DO NOT LEAVE ANSWERS BLANK. If you do not know the answers, or the answer is
"none" or "does not apply," write: "don't know," or " none," or "does not apply."
• IN SECTION 4, PUT INFORMATION ON ONLY ONE DOCTOR/HMO/THERAPIST/
OTHER/HOSPITAL/CLINIC IN EACH SPACE.
• Each address should include a ZIP code. Each telephone number should include an area code.
• DO NOT ASK A DOCTOR OR HOSPITAL TO COMPLETE THE FORM. However,
you can get help from other people, like a friend or family member.
• If your appointment is for an interview by telephone, have the form ready to discuss with us
when we call you.
• If your appointment is for an interview in our office, bring the completed form with you or
mail ahead of time, if you were told to do so.
• Be sure to explain an answer if the question asks for an explanation, or if you want to give
additional information.
• If you need more space to answer any questions or want to tell us more about an answer,
please use Section 10, "DATE AND REMARKS," on Pages 11 and 12, and show the number
of the question being answered.

The Privacy and Paperwork Reduction Acts

See Revised Privacy Act
Statement
Sections 205(a), 223(d), and 1631 of the Social Security Act, as amended, authorizes
us to collect
this information. The information you provide will allow the Social Security Administration
(SSA) to determine the child's potential eligibility benefit payments and to help us to decide if
additional information is needed. Your response is voluntary. However, failure to provide this
requested information may prevent an accurate and timely decision on any claim filed, or could
result in loss of benefits.
We rarely use the information provided on this form for any purpose other than for the reasons
stated above. However, we may use it for 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 an agency to assist Social Security in establishing right to
Medicare benefits 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 Department of Veterans
Affairs);
3) To make determination 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 Medicare programs.
We may also use the information you provide in computer matching programs. Matching
programs compare our records 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.
Explanations about these and other reasons why information you provide us may be used or given
out are available in Systems of Record Notice 60-0089 (Claims Folders Systems, SSA, Office of
General Counsel, Office of Privacy and Disclosure). The Notice, information about this form,
and any other information regarding our systems and programs, are available on-line at
www.socialsecurity.gov or at your local Social Security office.

See Revised Paperwork
Reduction Act
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 60 minutes to read the instructions, gather the
facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR
LOCAL SOCIAL SECURITY OFFICE. The office is listed under U. S. Government
agencies in your telephone directory or 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.

REMOVE THIS SHEET BEFORE RETURNING THE COMPLETED FORM.

Form Approved
OMB No. 0960-0577

SOCIAL SECURITY ADMINISTRATION

DISABILITY REPORT - CHILD
SECTION 1 -- INFORMATION ABOUT THE CHILD
A. CHILD'S NAME (First, Middle Initial, Last)
B. CHILD'S SOCIAL SECURITY NUMBER
C. YOUR NAME (If agency, provide name of agency and contact person)
YOUR MAILING ADDRESS (Number and Street, Apt. No. (if any), P.O. Box, or Rural Route)
CITY

STATE

ZIP CODE

YOUR EMAIL ADDRESS (Optional)

Area Code

(If you do not have a phone number where we can reach
you, give us a daytime number where we can leave a
message for you.)

Your Number

Number

E. What is your relationship to the child?
F. Can you speak and understand English?
If "NO", what is your preferred language?

Message Number

YES

None

NO

NOTE: If you cannot speak and understand English, we will provide you an interpreter,
free of charge.
If you cannot speak and understand English, is there someone we may contact who
speaks and understands English and will give you messages?
YES

NO

(Enter name, address, phone number, relationship)

NAME

RELATIONSHIP TO CHILD

ADDRESS
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)

City

State

DAYTIME
PHONE

ZIP

Can you read and understand English?
G. Does the child live with you?

YES

YES

NO

NO

Area Code

Number

If "NO", with whom does the child live?

NAME

RELATIONSHIP TO CHILD

ADDRESS
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)

City

State

ZIP

Can this person speak and understand English?

DAYTIME
PHONE
Area Code
YES

NO

If "NO", what is this person's preferred language?
Can this person read and understand English?
YES

NO

Form SSA-3820-BK (08-2010) EF(08-2010)
Prior editions may be used

PAGE 1

Number

Disability Report - Child - Form SSA-3820-BK

D. YOUR DAYTIME PHONE NUMBER

SECTION 1 - INFORMATION ABOUT THE CHILD
YES

H. Can the child speak and understand English?

NO

If "NO," what languages can the child speak?

If the child understands any other languages, list them here:
I. What is the child's height (without shoes)?
What is the child's weight (without shoes)?
J. Does the child have a medical assistance card? (for example Medicaid, Medi-Cal)
YES

NO

If "YES", show the number here:

SECTION 2 - CONTACT INFORMATION
A. Does the child have a legal guardian or custodian other than you?
YES (Enter name, address, phone number, relationship)

NO

NAME
ADDRESS
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)
City

State

ZIP

DAYTIME PHONE NUMBER
Area Code

Number

RELATIONSHIP TO CHILD

Can this person speak and understand English?

YES

NO

YES

NO

If "NO", what is this person's preferred language?
Can this person read and understand English?

B. Is there another adult who helps care for the child and can help us get information
about the child if necessary?
YES (Enter name, address, phone number, relationship)

NO

NAME OF CONTACT
ADDRESS
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)
City

State

ZIP

DAYTIME PHONE NUMBER
Area Code

Number

RELATIONSHIP TO CHILD

Can this person speak and understand English?

YES

NO

YES

NO

If "NO", what is this person's preferred language?
Can this person read and understand English?
Form SSA-3820-BK (08-2010) EF (08-2010)

PAGE 2

SECTION 3 - THE CHILD'S ILLNESSES, INJURIES OR
CONDITIONS AND HOW THEY AFFECT HIM/HER
A. What are the child's disabling illnesses, injuries, or conditions?

Month

B. When did the child become disabled?

C. Do the child's illnesses, injuries or conditions cause pain
or other symptoms?

Day

Year

YES

NO

SECTION 4 - INFORMATION ABOUT THE CHILD'S MEDICAL RECORDS
A. Has the child been seen by a doctor/hospital/clinic or anyone else for the
illnesses, injuries or conditions?
YES

NO

B. Has the child been seen by a doctor/hospital/clinic or anyone else for emotional or
mental problems?
YES

Form SSA-3820-BK (08-2010) EF (08-2010)

NO

PAGE 3

SECTION 4 - INFORMATION ABOUT THE CHILD'S MEDICAL RECORDS

Tell us who may have medical records or other
information about the child's illnesses, injuries or conditions.
C. List each DOCTOR/HMO/THERAPIST/OTHER. Include the child's next appointment.
1. NAME

DATES

STREET ADDRESS

FIRST VISIT

CITY

STATE

ZIP

LAST VISIT

Patient ID # (If known)

PHONE
Area Code

NEXT APPOINTMENT

Number

REASONS FOR VISITS

WHAT TREATMENT WAS RECEIVED?

2. NAME

DATES
FIRST VISIT

STREET ADDRESS
STATE

CITY

ZIP

LAST SEEN

Patient ID # (If known)

PHONE
Area Code

Number

REASONS FOR VISITS

WHAT TREATMENT WAS RECEIVED?

Form SSA-3820-BK (08-2010) EF (08-2010)

PAGE 4

NEXT APPOINTMENT

SECTION 4 - INFORMATION ABOUT THE CHILD'S MEDICAL RECORDS
DOCTOR/HMO/THERAPIST/OTHER
3. NAME

DATES

STREET ADDRESS

FIRST VISIT

CITY

STATE

ZIP

Patient ID # (If known)

PHONE
Area Code

LAST VISIT
NEXT APPOINTMENT

Number

REASONS FOR VISITS

WHAT TREATMENT WAS RECEIVED?

If you need more space, use Section 10.
D. List each HOSPITAL/CLINIC. Include the child's next appointment.
1.

HOSPITAL/CLINIC
NAME

TYPE OF VISIT

DATES
DATE IN

INPATIENT STAYS

DATE OUT

(Stayed at least overnight)

STREET ADDRESS

OUTPATIENT VISITS

CITY
STATE

(Sent home same day)

ZIP

PHONE
Area Code

DATE FIRST VISIT DATE LAST VISIT

EMERGENCY ROOM
VISITS

Number

Next appointment

The child's hospital/clinic number

Reasons for visits

What treatment did the child receive?

What doctors does the child see at this hospital/clinic on a regular basis?

Form SSA-3820-BK (08-2010) EF (08-2010)

PAGE 5

DATES OF VISITS

SECTION 4 - INFORMATION ABOUT THE CHILD'S MEDICAL RECORDS
HOSPITAL/CLINIC
2.

HOSPITAL/CLINIC

TYPE OF VISIT

NAME

DATES
DATE IN

INPATIENT STAYS

DATE OUT

(Stayed at least overnight)

STREET ADDRESS

OUTPATIENT VISITS

CITY

DATE FIRST VISIT DATE LAST VISIT

(Sent home same day)

STATE

ZIP

Area Code

DATES OF VISITS

EMERGENCY ROOM
VISITS

PHONE
Number

The child's hospital/clinic number

Next appointment
Reasons for visits

What treatment did the child receive?

What doctors does the child see at this hospital/clinic on a regular basis?

If you need more space, use Section 10.
E. Does anyone else have medical records or information about the child's illnesses,
injuries or conditions (foster parents, social workers, counselors, tutors, school nurses,
detention centers, attorneys, insurance companies, and/or Worker's Compensation), or
is the child scheduled to see anyone else?
YES (If "YES," complete information below.)

NO

NAME

DATES

ADDRESS

FIRST VISIT

CITY

STATE

ZIP

PHONE

LAST SEEN
NEXT APPOINTMENT

Area Code

Number

CLAIM NUMBER (If any)
REASONS FOR VISITS

If you need more space, use Section 10.
Form SSA-3820-BK (08-2010) EF (08-2010)

PAGE 6

SECTION 5 - MEDICATIONS
Does the child currently take any medications for illnesses, injuries or conditions?
If "YES", tell us the following: (Look at the child's medicine containers, if necessary.)
NAME OF MEDICINE

IF PRESCRIBED,
GIVE NAME OF DOCTOR

REASON FOR
MEDICINE

YES
NO

SIDE EFFECTS
THE CHILD HAS

If you need more space, use Section 10.
SECTION 6 - TESTS
Has the child had, or will he/she have, any medical tests for illnesses, injuries or
conditions?
If "YES", tell us the following (give approximate dates, if necessary).
YES
NO

KIND OF TEST

WHEN WAS/WILL
TESTS BE DONE?
(Month, day, year)

WHERE DONE
(Name of Facility)

EKG (HEART TEST)
TREADMILL (EXERCISE TEST)
CARDIAC CATHETERIZATION
BIOPSY--Name of body part
SPEECH/LANGUAGE
HEARING TEST
VISION TEST
IQ TESTING
EEG (BRAIN WAVE TEST)
HIV TEST
BLOOD TEST (NOT HIV)
BREATHING TEST
X-RAY--Name of body part
MRI/CAT SCAN - Name of body
part

If the child has had other tests, list them in Section 10.
Form SSA-3820-BK (08-2010) EF (08-2010)

PAGE 7

WHO SENT THE
CHILD FOR
THIS TEST

SECTION 7 - ADDITIONAL INFORMATION
A. Has the child been tested or examined by any of the following?
Headstart (Title V)

YES

NO

Public or Community Health Department

YES

NO

Child Welfare or Social Service Agency or WIC

YES

NO

Early Intervention Services

YES

NO

Program for Children with Special Health
Care Needs

YES

NO

Mental Health/Mental Retardation Center

YES

NO

B. Has the child received Vocational Rehabilitation or other employment support services
to help him or her go to work?
YES

NO

If you answered "YES" to any of the above in A. or B., please complete C. below:

C. 1. NAME OF AGENCY
ADDRESS
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)

City

State

ZIP

PHONE NUMBER
Area Code

Number

TYPE OF TEST

WHEN DONE

TYPE OF TEST

WHEN DONE

FILE OR RECORD NUMBER
2. NAME OF AGENCY
ADDRESS
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)

City

State

ZIP

PHONE NUMBER
Area Code

Number

TYPE OF TEST

WHEN DONE

TYPE OF TEST

WHEN DONE

FILE OR RECORD NUMBER

If there are any other agencies, show them in Section 10.
Form SSA-3820-BK (08-2010) EF (08-2010)

PAGE 8

SECTION 8 - EDUCATION
A. Is the child currently enrolled in any school?

YES, grade:

NO, too young

NO, other reason (complete B)

B. Other reason the child is not enrolled in school:

C. List the name of the school the child is currently attending and give dates attended.
If the child is no longer in school, list the name of the last school attended and give
dates attended.
NAME OF SCHOOL
ADDRESS
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)

City

County

State

PHONE NUMBER
Area Code

Number

DATES ATTENDED
TEACHER'S NAME
Has the child been tested for behavioral or learning problems?
If "YES", complete the following:
TYPE OF TEST

WHEN DONE

TYPE OF TEST
Is the child in special education?

WHEN DONE
YES

NO

If "YES", and different from above, give:
NAME OF SPECIAL EDUCATION TEACHER
Is the child in speech/language therapy?

YES

If "YES", and different from above, give:
NAME OF SPEECH/LANGUAGE THERAPIST

Form SSA-3820-BK (08-2010) EF (08-2010)

YES

PAGE 9

NO

NO

ZIP

SECTION 8 - EDUCATION
D. List the names of all other schools attended in the last 12 months and give dates
attended.
NAME OF SCHOOL
ADDRESS
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)

City

County

State

ZIP

PHONE NUMBER
Area Code

Number

DATES ATTENDED
TEACHER'S NAME

Was the child tested for behavioral or learning problems?
If "YES", complete the following:

YES

TYPE OF TEST

WHEN DONE

TYPE OF TEST

WHEN DONE

Was the child in special education?
YES
If "YES", and different from above, give:

NO

NO

NAME OF SPECIAL EDUCATION TEACHER
Was the child in speech/language therapy?
If "YES", and different from above, give:

YES

NO

NAME OF SPEECH/LANGUAGE THERAPIST

If there are other schools, show them in Section 10.
E. Is the child attending Daycare/Preschool?

YES

NO

If "YES", complete the following:
NAME OF DAYCARE/
PRESCHOOL/CAREGIVER
ADDRESS
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)

City

County

PHONE NUMBER
Area Code

Number

DATES ATTENDED
TEACHER'S/CAREGIVER'S NAME
Form SSA-3820-BK (08-2010) EF (08-2010)

PAGE 10

State

ZIP

SECTION 9 - WORK HISTORY
A. Has the child ever worked (including sheltered work)?

YES

NO

If "YES", complete the following:
DATES WORKED
NAME OF EMPLOYER
ADDRESS
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)

City

State

ZIP

PHONE NUMBER
Area Code

Number

NAME OF SUPERVISOR

B. List job title, and briefly describe the work and any problems the child may have had
doing the job.

SECTION 10 - DATE AND REMARKS
Please give the date you filled out this disability report.
Date (MM/DD/YYYY)

Use this section for any additional information about your child.

Form SSA-3820-BK (08-2010) EF (08-2010)

PAGE 11

SECTION 10 - REMARKS

Form SSA-3820-BK (08-2010) EF (08-2010)

PAGE 12

SSA will insert the following revised Privacy Act Statement into the form at its
next scheduled reprinting:
Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 223(d), and 1631 of the Social Security Act, as amended, authorize us to collect
this information. We will use the information you provide to determine if a child is eligibility for
benefit payments.
Furnishing us this information is voluntary. However, failing to provide us with the requested
information could prevent us from making an accurate and timely decision on your claim.
We rarely use the information you supply for any purpose other than the reason stated above.
However, we may use the information for the efficient administration and integrity of our
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 an agency to assist us in establishing rights to Social
Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from our records
(e.g., to the Government Accountability Office and 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 and improvement of our programs (e.g., to the Bureau of the Census and
private entities under contract with us).
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, State, or local government
agencies. We use the information from these matching programs to establish or verify a person’s
eligibility for federally funded or administered benefit programs and for repayment of incorrect
payments or delinquent debts under these programs.
A complete list of routine uses for this information is available in our System of Records Notice
entitled Claims Folder System (60-0089). This notice, additional information regarding this
form, and information regarding our programs, are available on-line at www.socialsecurity.gov
or at your local Social Security office.

SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
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 (OMB) control number. We estimate that it will take about
90 minutes to read the instructions, gather the facts, and answer the questions. Send only
comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-0001.