SSA-3378 Function Report - Child Age 6 to 12th Birthday

Function Report - Child Age 6 to 12th 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
RETURIG THE COMPLETED FORM.

Form SSA-3378-BK (5-2006) ef (01-2007)
Continued
Prior edition may be used until stock is exhausted

on the Reverse

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 REDUCTIO 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 20 minutes
to read the instructions, gather the facts, and answer the questions.
SED 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, 1338 Annex Building,
Baltimore, MD 21235-6401. Send only comments relating to our
time estimate to this address, not the completed form.

Form

SSA-3378-BK (5-2006) ef (01-2007)

Form Approved
OMB No. 0960-0542

SOCIAL SECURITY ADMINISTRATION

FUNCTION REPORT - CHILD
AGE 6 TO 12th 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
-

SSA-3378-BK (5-2006) ef (01-2007)
Prior edition may be used until stock is exhausted
Form

Page 1

SECTION 2 - FUNCTION DETAILS

2. A. Does the child have
problems seeing?

If "yes," please mark every statement below that is generally
true about the child:
Child uses glasses or contact lenses. If the child has problems
seeing even with glasses or contact lenses, please explain:

YES (Continue)

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?

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

YES (Continue)

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:

NO (Go to 2.C.)

Child cannot be fitted for hearing aid(s).
Child has other hearing problems. If so, please describe:

Child uses American Sign Language.
Child reads lips.
Form

SSA-3378-BK (5-2006) ef (01-2007)

Page 2

2. C. Is the child totally

Does the child have problems talking clearly?

unable to talk?
Yes (answer questions below)

YES (Go to 2.D.)

No (continue to question 2.D.)

NO (Continue)

If "yes," please mark the block that best describes the child in each of
the two statements below, and then describe any other speech
problems:
Speech can be understood by people who know the child well:

Most of the time, or
Some of the time, or
Hardly ever.
Speech can be understood by people who don't know the child well:

Most of the time, or
Some of the time, or
Hardly ever.

If the child has other problems talking, please explain:

Form

SSA-3378-BK (5-2006) ef (01-2007)

Page 3

2. D. Is the child 's ability
to communicate limited?

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

Yes

No

Deliver telephone messages

Yes

No

Repeat stories he or she has heard

Yes

No

Tell jokes or riddles accurately

Yes

No

Explain why he or she did something

Yes

No

Uses sentences with "because," "what if,"
or "should have been"

Yes

No Talks with family

Yes

No Talks with friends

YES (Continue)
NO (Go to 2.E.)
NOT SURE

(Continue)

If necessary, please explain. In addition, please tell us anything else
you think we should know about the child's ability to communicate:

Form

SSA-3378-BK (5-2006) ef (01-2007)

Page 4

2. E. Is the child's
ability to progress in
learning limited?

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

YES (Continue)

Yes

No

Read capital letters of alphabet

Yes

No

Read capital letters and small letters

Yes

No

Read simple words

Yes

No

Read and understands simple sentences

Yes

No

Read and understands stories in books or
magazines

Yes

No

Print some letters

Yes

No

Print name

Yes

No

Write in longhand (script)

Yes

No

Spell most 3-4 letter words

Yes

No

Write a simple story with 6-7 sentences

Yes

No

Add and subtract numbers over 10

Yes

No

Knows days of the week and months of the
year

Yes

No

Understands money - can make correct
change

Yes

No

Tells time

NO (Go to 2.F.)
NOT SURE
(Continue)

If necessary, please explain. In addition, please tell us anything else
you think we should know about the child's ability to progess in
learning:

Form

SSA-3378-BK (5-2006) ef (01-2007)

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2. F. Are the child's
physical abilities
limited?

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

YES (Continue)

Yes

No

Walk

Yes

No

Run

Yes

No

Throw a ball

Yes

No

Ride a bike

Yes

No

Jump rope

Yes

No

Use roller skates or roller blades

Yes

No

Swim

Yes

No

Use scissors

Yes

No

Work video game controls

Yes

No

Dress/undress dolls or action figures

NO (Go to 2.G.)
NOT SURE
(Continue)

If necessary, please explain. In addition, please tell us anything else
you think we should know about the child's physical abilities:

Form

SSA-3378-BK (5-2006) ef (01-2007)

Page 6

2. G. Does the child's
impairment(s) affect his
or her behavior with
other people?

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

Yes

No Has friends his or her own age

Yes

No Can make new friends

YES (Continue)

Yes

No Generally gets along with you or other adults

NO (Go to 2.H.)

Yes

No Generally gets along with school teachers

Yes

No Plays team sports (for example, baseball,
basketball, soccer)

NOT SURE
(Continue)

If necessary, please explain. In addition, please tell us anything else
you think we should know about the child's behavior with other
people:

Form

SSA-3378-BK (5-2006) ef (01-2007)

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2. H. Does the child's
impairment(s) affect his
or her ability to help
himself or herself and
cooperate with others
in taking care of
personal needs?

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

Yes

No

Uses zipper by self

Yes

No

Buttons clothes by self

Yes

No

Ties shoelaces

Yes

No

Takes a bath or shower without help

NO (Go to 2.I.)

Yes

No

Brushes teeth

NOT SURE
(Continue)

Yes

No

Combs or brushes hair

Yes

No

Washes hair by self

Yes

No

Chooses clothes by self

Yes

No

Eats by self using a knife, fork, and spoon

Yes

No

Picks up and puts away toys

Yes

No

Hangs up clothes

Yes

No

Helps around the house (for example,
washes or dries dishes, makes bed(s),
sweeps/vacuums floor, rakes or mows
yard, helps with laundry)

Yes

No

Does what he or she is told most of the time

Yes

No

Obeys safety rules; for instance, looks for
cars before crossing street

Yes

No

Gets to school on time

Yes

No

Accepts criticism or correction

YES (Continue)

If necessary, please explain. In addition, please tell us anything else
you think we should know about the child's ability to help him or
herself and cooperate with others in caring for personal needs:

Form

SSA-3378-BK (5-2006) ef (01-2007)

Page 8

2. I. Is the child's ability to
pay attention and stick
with a task limited?

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

Yes

No

Keeps busy on his/her own

Yes

No

Finishes things he or she starts

Yes

No

Works on arts and crafts projects (draws,
paints, knits, does woodwork)

Yes

No

Completes homework

Yes

No

Completes chores most of the time

YES (Continue)
NO (Go to 2.J.)
NOT SURE
(Continue)

If necessary, please explain. In addition, please tell us anything else
you think we should know about the child's ability to pay attention and
stick with a task:

J. Please tell us anything else about the child that you think we should know.

Form

SSA-3378-BK (5-2006) ef (01-2007)

Page 9

SECTION 3 - REMARKS

Form

SSA-3378-BK (5-2006) ef (01-2007)

Page 10

Privacy Act Statement
Collection and Use of Personal Information

Sections 205(a), 223(d), and 1631(e)(1), of the Social Security Act, as amended, authorize us to
collect this information. We will use the information you provide on behalf of the minor child to
determine his or her benefit eligibility.
Furnishing us the information is voluntary. However, failing to provide us with all or part of the
requested information may prevent us from making an accurate and timely decision on the claim.
We rarely use the information for any purpose other than for making a decision regarding
entitlements to benefits. 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 assure 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
payment’s or delinquent debts under these programs.
A complete list of routine uses of this information is available in our Privacy Act System of
Records Notices entitled, Claims Folders Systems, 60-0089. Additional information about this
and other system of records notices and our programs are available on-line
at www.socialsecurity.gov or at your local Social Security office.