SSA-3378-BK Function Report-Child Age 6 to 12th Birthday

Form SSA-3378-BK (10-2016) UF
Discontinue Prior Editions
Social Security Administration

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.

•

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.

Continued on the Reverse

Form SSA-3378-BK (10-2016) UF

Privacy Act Statement

See Revised Privacy Act
Statement Attached

Collection and Use of Personal Information
Sections 205(a), 223(d), and 1631(e)(1), of the Social Security Act, as amended, authorize us to
collect this information. We will use the information you provide on behalf of the minor child to
determine his or her benefit eligibility.
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 claim.
We rarely use the 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 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 assure 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
Notices entitled, Claims Folders Systems, 60-0089. Additional information about this and other
system of records notices and our programs are 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 (10-2016) UF
Discontinue Prior Editions
Social Security Administration

Page 1 of 10
OMB No. 0960-0542

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

Form SSA-3378-BK (10-2016) UF

Page 2 of 10

SECTION 2 - FUNCTION DETAILS
2. A. Does the child have
problems seeing?
YES (Continue)
NO (Go to 2.B.)

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:

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?
YES (Continue)
NO (Go to 2.C.)

If "yes," please mark every statement below that is generally true
about the child:
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 (10-2016) UF

2. C. Is the child totally
unable to talk?
YES (Go to 2.D.)
NO (Continue)

Page 3 of 10

Does the child have problems talking clearly?
Yes (answer questions below)
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-3378-BK (10-2016) UF

2. D. Is the child 's ability to
communicate limited?

Page 4 of 10

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 (Continue)

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

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 (10-2016) UF

2. E. Is the child's ability
to progress in
learning limited?

Page 5 of 10

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

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

Yes

No Tells time

YES (Continue)

Read and understands stories in books
or magazines

Understands money - can make correct
change

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 (10-2016) UF

2. F. Are the child's physical
abilities limited?

Page 6 of 10

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

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

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 (10-2016) UF

2. G. Does the child's
impairment(s) affect his
or her behavior with
other people?

Page 7 of 10

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

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 with
other people:

Form SSA-3378-BK (10-2016) UF

Page 8 of 10

2. H. Does the child's
If "yes," or "not sure," please tell us what the child does or can do
impairment(s) affect his by checking "yes" or "no" for each of the following:
or her ability to help
Yes
No Uses zipper by self
himself or herself and
cooperate with others
Yes
No Buttons clothes by self
in taking care of
personal needs?
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 (10-2016) UF

2. I. Is the child's ability to
pay attention and stick
with a task limited?
YES (Continue)
NO (Go to 2.J.)
NOT SURE
(Continue)

Page 9 of 10

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

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 (10-2016) UF

Page 10 of 10

SECTION 3 - REMARKS