SSA-3380 Function Report -- Adult Third Party

FUNCTION REPORT - ADULT - THIRD PARTY Form SSA-3380-BK
READ ALL OF THIS INFORMATION BEFORE
YOU BEGIN COMPLETING THIS FORM
IF YOU NEED HELP

HOW TO COMPLETE THIS FORM
The information that you give on this form will be used to make a decision on the disabled
person's claim. You can help by completing as much of the form as you can. When a
question refers to the "disabled person," it refers to the person who is applying for or
receiving disability benefits.
It is important that you tell us what you know about the disabled person's activities and
abilities.
DO NOT ASK THE DISABLED PERSON TO GIVE YOU ANSWERS
• Print or type.
• DO NOT LEAVE ANSWERS BLANK. If you do not know the answer or the
answer is "none" or "does not apply," please write "don't know" or "none" or "does
not apply."
• Do not ask a doctor or hospital to complete this form.
• Be sure to explain an answer if the question asks for an explanation,
or if you think you need to explain an answer.
• If you need more space to answer any questions, use the "REMARKS"
section on Page 8, and show the number of the question being answered.

REMEMBER TO GIVE US THE NAME AND ADDRESS OF THE PERSON
COMPLETING THIS FORM ON PAGE 8

Function Report - Adult - Third Party Form SSA-3380-BK

If you need help with this form, complete as much of it as you can and call the phone number
provided on the letter sent with the form, or contact the person who asked you to complete
the form. If you need the address or phone number for the office that provided the form, you
can get it by calling Social Security at 1-800-772-1213 (TTY 1-800-325-0778).

Privacy Act and Paperwork Reduction Act Statements
Sections 205(a), 1631(d)(1) and 1631(e)(1) of the Social Security Act, as amended, authorize us
to collect this information. We will use this information to process the named claimant's claim.
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 named
claimant's claim.
We rarely use this 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 Social
Security programs. We may also disclose information 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 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 our records (e.g.,
to the Government Accountability Office 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 investigatory activities necessary to assure the
integrity and improvement 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 and administered benefit programs and for repayment of payments or
delinquent debts under these programs.
A complete list of routine uses of this information is available in our Privacy Act Systems of
Records Notices entitled, Claims Folders Systems, 60-0089, and Electronic Disability (eDib) Claim
File, 60-0320. These notices, additional information regarding our programs and systems, are
available online at www.socialsecurity.gov or at any local 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
(OMB) control number. We estimate that it will take about 61 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 21235-6401.

PLEASE REMOVE THIS SHEET BEFORE RETURNING
THE COMPLETED FORM.

SOCIAL SECURITY ADMINISTRATION

FUNCTION REPORT- ADULT - THIRD PARTY

Form Approved
OMB No. 0960-0635

How the disabled person's illnesses, injuries, or conditions limit his/her activities
For SSA Use Only
Do not write in this box.
Related SSN
Number Holder
Anyone who makes or causes to be made a false statement or representation of material fact for use in determining a payment under the
Social Security Act, or knowingly conceals or fails to disclose an event with an intent to affect an initial or continued right to payment,
commits a crime punishable under Federal law by fine, imprisonment, or both, and may be subject to administrative sanctions.

SECTION A - GENERAL INFORMATION
1. NAME OF DISABLED PERSON (First, Middle, Last)

2. YOUR NAME (Person completing the form)

3. RELATIONSHIP
(To disabled person)

4 . DATE (Month, Day, Year)

5. YOUR DAYTIME TELEPHONE NUMBER (If there is no telephone number where you can be reached, please give
us a daytime number where we can leave a message for you.)
Your Number
Area Code

Message Number

None

Phone Number

6. a. How long have you known the disabled person?
b. How much time do you spend with the disabled person and what do you do together?

7. a. Where does the disabled person live? (Check one.)
House

Apartment

Boarding House

Shelter

Group Home

Other (What?)

Nursing Home

b. With whom does he/she live? (Check one.)
Alone

With Family

With Friends

Other (describe relationship)

SECTION B - INFORMATION ABOUT ILLNESSES, INJURIES, OR CONDITIONS
8. How do this person's illnesses, injuries, or conditions limit his/her ability to work?

Form SSA-3380-BK (03-2015) ef (03-2015)
Use (12-2009) Edition Until Supply Exhausted

Page 1

SECTION C - INFORMATION ABOUT DAILY ACTIVITIES
9. Describe what the disabled person does from the time he/she wakes up until going to bed.

10. Does this person take care of anyone else such as a wife/husband, children,
grandchildren, parents, friend, other?

Yes

No

Yes

No

Yes

No

If "YES," for whom does he/she care, and what does he/she do for them?

11. Does he/she take care of pets or other animals?
If "YES," what does he/she do for them?

12. Does anyone help this person care for other people or animals?
If "YES," who helps, and what do they do to help?

13. What was the disabled person able to do before his/her illnesses, injuries, or conditions that he/she can't do now?

14. Do the illnesses, injuries, or conditions affect his/her sleep?
If "YES," how?

15. PERSONAL CARE

(Check here

if NO PROBLEM with personal care.)

a. Explain how the illnesses, injuries, or conditions affect this person's ability to:
Dress
Bathe
Care for hair
Shave
Feed self
Use the toilet
Other
Form SSA-3380-BK (03-2015) ef (03-2015)

Page 2

Yes

No

b. Does he/she need any special reminders to take care of
personal needs and grooming?

Yes

No

Yes

No

Yes

No

If "YES," what type of help or reminders are needed?

c. Does he/she need help or reminders taking medicine?
If "YES," what kind of help does he/she need?

16. MEALS
a. Does the disabled person prepare his/her own meals?

If "Yes," what kind of food is prepared? (For example, sandwiches, frozen dinners, or complete meals with
several courses.)

How often does he/she prepare food or meals? (For example, daily, weekly, monthly.)

How long does it take him/her?
Any changes in cooking habits since the illness, injuries, or conditions began?

b. If "No," explain why he/she cannot or does not prepare meals.

17. HOUSE AND YARD WORK
a . List household chores , both indoors and outdoors , that the disabled person is able to do .
(For example, cleaning, laundry, household repairs, ironing, mowing, etc.)

b. How much time do chores take, and how often does he/she do each of these things?

c. Does he/she need help or encouragement doing these things?
If "YES," what help is needed?

Form SSA-3380-BK (03-2015) ef (03-2015)

Page 3

Yes

No

d. If the disabled person doesn't do house or yard work, explain why not.

18. GETTING AROUND
a. How often does this person go outside?
If he/she doesn't go out at all, explain why not.

b. When going out, how does he/she travel? (Check all that apply.)
Walk

Drive a car

Ride in a car

Use public transportation

Ride a bicycle

Other (Explain)

c. When going out, can he/she go out alone?

Yes

No

Yes

No

If "NO," explain why he/she can't go out alone.

d. Does the disabled person drive?
If he/she doesn't drive, explain why not.

19. SHOPPING
a. If the disabled person does any shopping, does he/she shop: (Check all that apply.)
In stores

By phone

By mail

By computer

b. Describe what he/she shops for.

c. How often does he/she shop and how long does it take?

20. MONEY
a. Is he/she able to:
Pay bills

Yes

No

Handle a savings account

Yes

No

Count change

Yes

No

Use a checkbook/money orders

Yes

No

Explain all "NO" answers.

Form SSA-3380-BK (03-2015) ef (03-2015)

Page 4

b. Has the disabled person's ability to handle money changed since
the illnesses, injuries, or conditions began?

Yes

No

Yes

No

If "YES," explain how the ability to handle money has changed.

21. HOBBIES AND INTERESTS
a. What are his/her hobbies and interests? (For example, reading, watching TV, sewing, playing
sports, etc.)

b. How often and how well does he/she do these things?

c. Describe any changes in these activities since the illnesses, injuries, or conditions began.

22. SOCIAL ACTIVITIES
a. Does the disabled person spend time with others? (In person, on the phone,
on the computer, etc.)
If "YES," describe the kinds of things he/she does with others.

How often does he/she do these things?
b. List the places he/she goes on a regular basis. (For example, church, community center, sports
events, social groups, etc.)

Does he/she need to be reminded to go places?

Yes

No

Yes

No

How often does he/she go and how much does he/she take part?

Does he/she need someone to accompany him/her?

Form SSA-3380-BK (03-2015) ef (03-2015)

Page 5

c. Does this person have any problems getting along with family, friends,
neighbors, or others?

Yes

No

If "YES," explain.

d. Describe any changes in social activities since the illnesses, injuries, or conditions began.

SECTION D - INFORMATION ABOUT ABILITIES
23. a. Check any of the following items the disabled person's illnesses, injuries, or conditions affect:
Lifting

Walking

Stair Climbing

Understanding

Squatting

Sitting

Seeing

Following Instructions

Bending

Kneeling

Memory

Using Hands

Standing

Talking

Completing Tasks

Getting Along with Others

Reaching
Hearing
Concentration
Please explain how his/her illnesses, injuries, or conditions affect each of the items you checked. (For example,
he/she can only lift [how many pounds], or he/she can only walk [how far])

b. Is the disabled person:

Right Handed?

Left Handed?

c. How far can he/she walk before needing to stop and rest?
If he/she has to rest, how long before he/she can resume walking?

d. For how long can the disabled person pay attention?
e. Does the disabled person finish what he/she starts? ( For example, a conversation,
chores, reading, watching a movie.)
f. How well does the disabled person follow written instructions? (For example, a recipe.)

g. How well does the disabled person follow spoken instructions?

Form SSA-3380-BK (03-2015) ef (03-2015)

Page 6

Yes

No

h. How well does the disabled person get along with authority figures? (For example, police, bosses, landlords or
teachers.)

i. Has he/she ever been fired or laid off from a job because of problems
getting along with other people?

Yes

No

Yes

No

If "YES," please explain.

If "YES," please give name of employer.
j . How well does the disabled person handle stress?

k. How well does he/she handle changes in routine?

l. Have you noticed any unusual behavior or fears in the disabled person?
If "YES," please explain.

24. Does the disabled person use any of the following? (Check all that apply.)
Crutches

Cane

Hearing Aid

Walker

Brace/Splint

Glasses/Contact Lenses

Wheelchair

Artificial Limb

Artificial Voice Box

Other (Explain)
Which of these were prescribed by a doctor?

When was it prescribed?

When does this person need to use these aids?

Form SSA-3380-BK (03-2015) ef (03-2015)

Page 7

Yes

25. Does the disabled person currently take any medicines for his/her illnesses,
injuries, or conditions?
If " YES," do any of the medicines cause side effects?

No

Yes
No
If "YES," please explain. (Do not list all of the medicines that the disabled person takes. List only the medicines
that cause side effects for the disabled person.)
SIDE EFFECTS PERSON HAS

NAME OF MEDICINE

SECTION E - REMARKS
Use this section for any added information you did not show in earlier parts of this form. When you are done
with this section (or if you didn't have anything to add), be sure to complete the fields at the bottom of this
page.

Name of person completing this form (Please print)

Date (month, day, year)

Address (Number and Street)

Email address (optional)

City

State

Form SSA-3380-BK (03-2015) ef (03-2015)

Page 8

Zip Code