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pdfFunction Report - Child Age 12 to 18th 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.
SSA-3379-BK (6-2003) ef (03-2005)
Destroy Prior Editions
Form
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 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 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-3379-BK (6-2003) ef (03-2005)
Form Approved
OMB No. 0960-0542
SOCIAL SECURITY ADMINISTRATION
FUNCTION REPORT - CHILD
AGE 12 TO 18th 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-3379-BK (6-2003) ef (03-2005)
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-3379-BK (6-2003) ef (03-2005)
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 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-3379-BK (6-2003) ef (03-2005)
Page 3
2. D. Are the child's daily
activities limited?
If "yes," or "not sure," please mark every statement below that is true
about the child:
Goes to school full-time
Works part-time
Goes to school part-time
Works full-time
YES (Continue)
No (Go to 2.E.)
Other. Describe:
NOT SURE
(Continue)
If necessary, please explain. In addition, please tell us anything else
you think we should know about the child's daily activities:
E. Is the child's ability to
communicate 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
Answer the telephone and make telephone
calls
Yes
No
Deliver phone 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
Ask for what he or she needs
Yes
No
Talks with family
Yes
No
Talks with friends
YES (Continue)
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 communicate:
Form
SSA-3379-BK (6-2003) ef (03-2005)
Page 4
2. F. Is there any limitation in
the child's progress in
understanding and using
what he or she has
learned?
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)
NO (Go to 2.G.)
NOT SURE
(Continue)
Yes
No
Read and understand sentences in
comics and cartoons
Yes
No
Read and understand stories in books,
magazines, or newspapers
Yes
No
Spell words of more than 4 letters
Yes
No
Tell time
Yes
No
Add and subtract numbers over 10
Yes
No
Multiply and divide numbers over 10
Yes
No
Understands money - can make correct
change
Yes
No
Understand, carry out, and remember
simple instructions
If necessary, please explain. In addition, please tell us anything else
you think we should know about the child's progress in understanding
and using what he or she has learned:
G. 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
No
Walk
Yes
No
Ride a bike
Yes
No
Run
Yes
No
Throw a ball
Yes
No
Dance
Yes
No
Jump rope
Yes
No
Swim
Yes
No
Play sports
Yes
No
Drive
a car
Yes
No
Work video
games controls
YES (Continue)
NO (Go to 2.H.)
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-3379-BK (6-2003) ef (03-2005)
Page 5
2. H. Does the child's
impairment(s) affect his
or her social activities or
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.I.)
Yes
No
Generally gets along all right with brothers
and sisters
NOT SURE
(Continue)
Yes
No
Generally gets along with school teachers
Yes
No
Plays team sports (for example, baseball,
basketball, soccer)
If necessary, please explain. In addition, please tell us anything else
you think we should know about the child's behavior around other
people:
Form
SSA-3379-BK (6-2003) ef (03-2005)
Page 6
2. I. Is the child's ability to
take care of his or her
personal needs and
safety 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
Takes care of personal hygiene (keep clean,
brush teeth, comb hair, etc.)
Yes
No
Washes and puts away his or her 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
Can cook a meal for self
Yes
No
Gets to school on time
Yes
No
Studies and does homework
Yes
No
Takes needed medication
Yes
No
Can use public transportation by himself/
herself
Yes
No
Accepts criticism or correction
Yes
No
Keeps out of trouble
Yes
No
Obeys rules
Yes
No
Avoids accidents
Yes
No
Asks for help when needed
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 take care of his or
her personal needs and safety:
Form
SSA-3379-BK (6-2003) ef (03-2005)
Page 7
2. J. 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
Works on arts and crafts projects (draws,
paints, knits, does woodwork)
Yes
No
Keeps busy on his or her own
NO (Go To 2.K.)
Yes
No
Finishes things he or she starts
NOT SURE
(Continue)
Yes
No
Completes homework
Yes
No
Completes homework on time
Yes
No
Completes chores most of the time
YES (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:
K. Please tell us anything else about the child that you think we should know.
Form
SSA-3379-BK (6-2003) ef (03-2005)
Page 8
SECTION 3 - REMARKS
Form
SSA-3379-BK (6-2003) ef (03-2005)
Page 9
SSA will insert the following revised Privacy Act and PRA Statements into the form
at its next scheduled reprinting:
Function - Child Age 12 to 18th Birthday, Form SSA-3379-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 | S3379-1.xft |
| Author | 191869 |
| File Modified | 2010-07-01 |
| File Created | 2005-03-07 |