SSA-3375 Function Report-Child Birth to 1st Birthday

Function Report - Child Birth to 1st Birthday
Filling Out The Function Report
IF YOU NEED HELP COMPLETING ANY PART OF THIS FORM, CONTACT YOUR
SOCIAL SECURITY OFFICE. WE WILL HELP YOU.
The information that you give us on this form will be used by the office that makes the disability
decision on the child's claim. You can help them by completing as much of the form as you
can.
Print or type.
Do not ask a doctor or hospital to complete this
form.
Be sure to explain your answer if an explanation is requested or
needed.
If more space is needed to answer any of the questions, please use the
"REMARKS" section and show the number of the question being answered.

The information we ask for on this form tells us how you think the child's illnesses or injuries
affect the way he or she does many of his or her usual activities.

PLEASE REMOVE THIS SHEET BEFORE
RETURNING THE COMPLETED FORM.

Form SSA-3375-BK (5-2006) ef (12-2006)
Prior edition may be used until stock is exhausted

Continued on the Reverse

X

The Privacy
And Paperwork
Reduction Acts
See revised
Privacy Act
Statement below.

The Social Security Administration is authorized to collect the
information on this form under sections 205(a), 223(d) 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 Government Accountability 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. If
you want to learn more about this, contact any 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 20 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 Boulevard,
Baltimore, MD 21235-6401. Send only comments relating to our
time estimate to this address, not the completed form.

Form SSA-3375-BK (5-2006) ef (12-2006)

Form Approved
OMB No. 0960-0542

SOCIAL SECURITY ADMINISTRATION

FUNCTION REPORT - CHILD
BIRTH TO 1st BIRTHDAY

SECTION 1 - IDENTIFYING INFORMATION
1. A. Print NAME OF CHILD:
FIRST

MIDDLE

LAST

B. Child's SOCIAL SECURITY NUMBER:

- C. Child's DATE OF BIRTH:
Month/Day/Year

D. PERSON COMPLETING FORM
NAME:
RELATIONSHIP TO CHILD:
DATE FORM COMPLETED:
Month/Day/Year

DAYTIME TELEPHONE NUMBER (including Area Code) :

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

CITY

STATE

ZIP CODE
-

Form SSA-3375-BK (5-2006) ef (12-2006)
Prior edition may be used until stock is exhausted

Page 1

SECTION 2 - FUNCTION DETAILS
2.

If "yes ," please mark every statement below that is generally
true about the child:

A. Does the child have
problems seeing?
YES (Continue)

X

Child uses glasses or contact lenses. If the child has problems
seeing even with glasses or contact lenses, please explain:

NO (Go to 2.B.)

Child cannot be fitted for glasses or contact lenses.
Explain:

Child has other seeing problems. If so, please
describe:

B. Does the child have
problems hearing?
YES (Continue)

If "yes," please mark every statement below that is generally true
about the child:

X

NO (Go to 2.C.)

Child uses hearing aid(s). If the child has problems hearing
even with a hearing aid(s) OR has trouble using a hearing
aid, please explain:

Child cannot be fitted for hearing aid(s).
Explain:

Child has other hearing problems. If so, please
describe:

Form SSA-3375-BK (5-2006) ef (12-2006)

Page 2

2. C. Are the child's activities
or abilities limited?

If "yes," or "not sure," please tell us what the child does by
marking "yes" or "no" for each of the following:

X

YES (Continue)

Yes

No

Makes various cooing sounds, such as "aaah"
and "oooh"

NO (Go to 2.D.)

Yes

No

Makes various babbling sounds, such as
"babababa" or "mamamama"

NOT SURE
(Continue)

Yes

No

Says simple words other than "mama" and
"dada"

Yes

No

Stops crying when picked up and held

Yes

No

Watches face of person talking to him or her

Yes

No

Pats, "talks to" or otherwise responds to
himself or herself in mirror

Yes

No

Plays games, such as "peek-a-boo"

Yes

No

Understands simple statements like
"come here" or "sit down"

Yes

No

Points to something he or she wants that is
out of reach, such as a toy or food

Yes

No

Understands names of favorite toys or other
things, such as a bottle

Yes

No

Turns head in direction of familiar noises or
voices

Yes

No

Turns head when his or her name is called

Yes

No

Smiles at faces he or she knows

Yes

No

Quiets or stops crying when sees parent or
other person he or she knows

Yes

No

Cuddles in arms when held by parent or
caregiver

Yes

No

Reaches out to be picked up

X
Child generally

Form SSA-3375-BK (5-2006) ef (12-2006)

Page 3

2. C. (Continued)

Child can

Yes

No Roll from stomach to back

Yes

No Roll from back to stomach

Yes

No Get to a sitting position without help

Yes

No

Yes

No Crawl or creep

Yes

No Pull self up to a standing position

Yes

No Reach for toys, or other objects

Yes

No Stand up without holding on to someone or
something

Yes

No Walk holding on to someone or something

Yes

No Eat foods, such as cereal, cookie, by self

Yes

No Move toy or other object from hand-to-hand

Yes

No Hold small objects between fingers

Yes

No Throw ball or other object

Rock back and forth on hands and knees

D. If necessary, please explain any of the items in Question 2.C. In addition, please tell us
anything else about the child that you think we should know:

Form SSA-3375-BK (5-2006) ef (12-2006)

Page 4

SECTION 3 - REMARKS

Form SSA-3375-BK (5-2006) ef (12-2006)

Page 5

Revised Privacy Act Statement
Sections 1614 and 1631(e)(1), of the Social Security Act, as amended, and 20 CFR 416.924(a),
authorize us to collect this information. We will use the information you provide on behalf of the
child to determine his or her eligibility for Supplemental Security Income (SSI) payments based
on disability.
Furnishing us the information is voluntary. However, failing to provide all or part of the
requested information may prevent our making an accurate and timely decision on the claim.
We rarely use the information you supply for any purpose other than to make a decision
regarding the child’s eligibility for SSI payments. However, we may use it for the administration
and integrity of our programs. We may also disclose the information to another person or to
another agency in accordance with approved routine uses, including but not limited to the
following:
1. To enable a third party or an agency to assist us in establishing rights to our benefits and
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, and investigatory activities necessary to ensure the
integrity and improvement of our programs (e.g., to the Bureau of the Census and to
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 programs to establish or verify a person's eligibility
for federally funded and administered benefit programs and for repayment of incorrect payments
or delinquent debts under these programs.
A complete list of routine uses of this information is available in our Privacy Act System of
Records Notice 60-0089, entitled, Claims Folders Systems. Additional information about this
and other system of records notices and our programs is available on-line at
www.socialsecurity.gov or at your local Social Security office.