SSA-3378-BK 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.

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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.

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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 (03-2014) ef (03-2014)
Use (05-2006) ef (01-2007) edition until exhausted

Continued on the Reverse

Privacy Act Statement
Collection and Use of Personal Information
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
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 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 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 (03-2014) ef (03-2014)

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
Form SSA-3378-BK (03-2014) ef (03-2014)
Use (05-2006) ef (01-2007) edition until exhausted

STATE
Page 1

ZIP CODE

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)
NO (Go to 2.C.)

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:

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 (03-2014) ef (03-2014)

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2. C. Is the child totally

Does the child have problems talking clearly?

unable to talk?
YES (Go to 2.D.)

Yes (answer questions below)
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 (03-2014) ef (03-2014)

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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
marking "yes" or "no" for each of the following:

Yes

No Deliver telephone messages

NO (Go to 2.E.)

Yes

No Repeat stories he or she has heard

NOT SURE
(Continue)

Yes

No Tell jokes or riddles accurately

Yes

No Explain why he or she did something

Yes

No

Yes

No Talks with family

Yes

No Talks with friends

YES (Continue)

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

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 (03-2014) ef (03-2014)

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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

No Read capital letters of alphabet

NO (Go to 2.F.)

Yes

No Read capital letters and small letters

NOT SURE
(Continue)

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

YES (Continue)

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

Form SSA-3378-BK (03-2014) ef (03-2014)

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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 Walk

NO (Go to 2.G.)

Yes

No Run

NOT SURE
(Continue)

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

YES (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 (03-2014) ef (03-2014)

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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 (Continue)

Yes

No Can make new friends

NO (Go to 2.H.)

Yes

No Generally gets along with you or other adults

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 (03-2014) ef (03-2014)

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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 (Continue)

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

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 (03-2014) ef (03-2014)

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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 (Continue)

Yes

No Finishes things he or she starts

NO (Go to 2.J.)

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

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 (03-2014) ef (03-2014)

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SECTION 3 - REMARKS

Form SSA-3378-BK (03-2014) ef (03-2014)

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