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pdfFunction 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
RETURNING THE COMPLETED FORM.
Form SSA-3378-BK (6-2003) ef (02-2005)
Destroy Prior Editions
Continued on the Reverse
The Privacy
And Paperwork
Reduction Acts
See Revised
Privacy Act
Statement Attached
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.
See Revised PRA
Attached
Form
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 20 minutes
to read the instructions, gather the facts, and answer the questions.
SEND 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. 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.
SSA-3378-BK (6-2003) ef (02-2005)
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 (6-2003) ef (02-2005)
Destroy Prior Editions
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 (6-2003) ef (02-2005)
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 (6-2003) ef (02-2005)
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 (6-2003) ef (02-2005)
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 (6-2003) ef (02-2005)
Page 5
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 (6-2003) ef (02-2005)
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 (6-2003) ef (02-2005)
Page 7
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 (6-2003) ef (02-2005)
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 (6-2003) ef (02-2005)
Page 9
SECTION 3 - REMARKS
Form
SSA-3378-BK (6-2003) ef (02-2005)
Page 10
SSA will insert the following revised Privacy Act and PRA Statements into the form
at its next scheduled reprinting:
Function - Child Age 6 to 12th Birthday, Form SSA-3378-BK
Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 223(d), and 1631(e)(1) [42 U.S.C. 405(a), 423(d), and 1383 (e)(1)]
of the Social Security Act authorize us to collect this information. We will use the
information you provide on this report to assist us in making a decision on the named
claimant’s claim. The information you provide on this form is voluntary. However,
failure to provide all or part of the requested information could prevent us from
making an accurate and timely decision on the named claimant’s claim.
We rarely use the information you provide on this form for any purpose other than for
the reasons explained above. 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 an 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, General
Services Administration, National Archives Records Administration, 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 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.
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 and
systems, are available on-line at www.socialsecurity.gov or at 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. You can find your local Social Security office
through SSA’s website at www.socialsecurity.gov. Offices are also 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.
| File Type | application/pdf |
| File Title | S3378-1.xft |
| Author | 054180 |
| File Modified | 2010-07-01 |
| File Created | 2005-02-08 |