SSA-3377-BK Function Report-Child Age 3 to 6th Birthday

Function Report Child Age 3 to 6th 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-3377-BK (06-2014) ef (06-2014)
Prior edition may be used until stock is exhausted

Continued on the Reverse

The Privacy And
Paperwork
Reduction Acts

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.

See Revised Privacy Act Statement Attached

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.
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 TAKE
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
(TTY1-800-325-0778). 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-3377-BK (06-2014) ef (06-2014)

Form Approved OMB
No. 0960-0542

SOCIAL SECURITY ADMINISTRATION

FUNCTION REPORT - CHILD AGE 3 TO 6th 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-3377-BK (06-2014) ef (06-2014)
Prior edition may be used until stock is exhausted

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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:

YES (Continue)

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?

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-3377-BK (06-2014) ef (06-2014)

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2. C. Is the child totally
unable to talk?

Does the child have problems talking clearly?

Yes (answer questions below)

YES (Go to 2.D.)

NO (Continue)

No (continue to question 2.D.)
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-3377-BK (06-2014) ef (06-2014)

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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 checking "yes" or "no" for each of the following:
Yes

No

Asks a lot of what, why, and where questions

NO (Go to 2.E.)

Yes

No

Uses complete sentences of more than 4
words most of the time

NOT SURE
(Continue)

Yes

No

Talks about what he or she is doing

Yes

No

Takes part in conversations with other children

Yes

No

Asks for what he or she wants

Yes

No

Tells about things and activities that happened
in the past

Yes

No

Can tell a made up or familiar short story

Yes

No

Can answer questions about a short readaloud children's story or TV story like
"Little Red Ridinghood"

Yes

No

Can deliver simple messages such as
telephone messages

YES (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-3377-BK (06-2014) ef (06-2014)

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2. E. Does the child's

impairment(s) limit his or
her 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.F.)
NOT SURE
(Continue)

Yes

No

Recite numbers to 3

Yes

No

Count three objects (like blocks, cars or
dolls)

Yes

No

Recite numbers to 10

Yes

No

Identify most colors, such as purple, and
shapes, such as a star

Yes

No

Knows his or her age

Yes

No

Asks what words mean

Yes

No

Knows his or her birthday

Yes

No

Knows his or her telephone number

Yes

No

Can define common words

Yes

No

Can read capital letters of the alphabet

Yes

No

Understands a joke

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:

Form SSA-3377-BK (06-2014) ef (06-2014)

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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

No

Catch a large ball, like a beach ball

Yes

No

Yes

No

Ride a big wheel, tricycle, or bike with
training wheels
Wind up a toy

NO (Go to 2.G.)

Yes

No

Print at least some letters

NOT SURE
(Continue)

Yes

No

Copy first name

Yes

No

Use scissors fairly well

YES (Continue)

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

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

Yes

No

Enjoys being with other children the same age

Yes

No

Shows affection towards other children

Yes

No

Is affectionate towards parents

Yes

No

Shares toys

Yes

No

Takes turns

Yes

No

Plays "pretend" with other children

Yes

No

Plays games like tag, hide-and-seek

Yes

No

Plays board games (like checkers or
Candyland)

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-3377-BK (06-2014) ef (06-2014)

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2. H. Does the child's

impairment(s) affect his
or her habits and ability
to take 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. Check "yes"
if it is something the child used to do but doesn't do any more just
because he or she is older. For example, if the child used to dress
with help but now dresses without help, check "yes" for both.

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

Yes

No

Yes

No

Usually controls bowels and bladder
during the day
Eats using a fork and spoon by self

Yes

No

Dresses self with help

Yes

No

Dresses self without help (except tying shoes)

Yes

No

Washes or bathes without help

Yes

No

Brushes teeth with help

Yes

No

Brushes teeth without help

Yes

No

Puts toys away

If necessary, please explain. In addition, please tell us anything else
you think we should know about the child's habits and ability to take
care of personal needs:

I. Is the child's ability to
pay attention and stick
with a task limited?
YES (Continue)
NO (Go to 2.J.)

If " yes," or " not sure," how long can the child pay attention to
TV, music, reading aloud or games?
15 minutes

30 minutes

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:

NOT SURE
(Continue)

Form SSA-3377-BK (06-2014) ef (06-2014)

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

SECTION 3 - REMARKS

Form SSA-3377-BK (06-2014) ef (06-2014)

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