Form 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), 223(d), 1631(d) and 1631(e) of the Social Security Act, allow us to collect
this information. Furnishing us this information is voluntary. However, failing to provide all or
part of the information may prevent an accurate and timely decision on any claim filed.
We will use the information you provide to make a determination of eligibility for Social
Security benefits. We may also share your information for the following purposes, called
routine uses:
• To third party contacts in situations where the party to be contacted has, or is
expected to have, information relating to the individual’s capability to manage
his/her affairs or his/her eligibility for or entitlement to benefits; and
• To a congressional office in response to an inquiry from that office made at the
request of the subject of a record.
In addition, we may share this information in accordance with the Privacy Act and other
Federal laws. For example, where authorized, we may use and disclose this information in
computer matching programs, in which our records are compared with other records to
establish or verify a person’s eligibility for Federal benefit programs and for repayment of
incorrect or delinquent debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices
(SORN) 60-0089, entitled Claims Folders Systems, as published in the Federal Register
(FR) on April 1, 2003, at 68 FR 15784, and 60-0320, entitled Electronic Disability (eDIB)
Claim File, as published in the FR December 22, 2003, at 68 FR 71210. Additional
information, and a full listing of all our SORNs, is available on our website at See Revised Privacy Act
https://www.ssa.gov/privacy.
and PRA Statements
Attached
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 61 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 21235-0001. Send only comments relating to
our time estimate to this address, not the completed form.

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.

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 does this person's illnesses, injuries, or conditions limit his/her ability to work?

Form SSA-3380-BK (09-2017)
Use (12-2015) 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 (09-2017)

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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 (09-2017)

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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 (09-2017)

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

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. How dDoes the disabled person spend time with others? (Check all that apply In person, on the phone,
on the computer, etc.)
Yes

No

__ in person
__ on the phone
__ email
__ texting
__ mail
__ video chat (for example: Skype or Facetime)
__ other: ______________________________

b. If "YES," dDescribe the kinds of things he/she does with others.

How often does he/she do these things?
c. 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 (09-2017)

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

Yes

No

If "YES," explain.

e. 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 (09-2017)

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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 (09-2017)

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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?

Yes

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.)
NAME OF MEDICINE

SIDE EFFECTS PERSON HAS

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.

Date (month, day, year)

Name of person completing this form (Please print)

Address (Number and Street)

Email address (optional)

City

State

Form SSA-3380-BK (09-2017)

Page 8

ZIP Code

SSA will insert the following revised Privacy Act Statement into the form as soon
as possible:
Privacy Act Statement
Collection and Use of Personal Information

Sections 205(a), 223(d), and 1631 of the Social Security Act (Act), as amended, allow us to
collect this information. Furnishing us this information is voluntary. However, failing to
provide all or part of the information may prevent an accurate and timely decision on any claim
filed.
We will use the information to determine eligibility for benefits. We may also share your
information for the following purposes, called routine uses:
•

To contractors and other Federal agencies, as necessary, for the purpose of assisting the
Social Security Administration (SSA) in the efficient administration of its programs; and

•

To applicants, claimants, prospective applicants or claimants, other than the data subject,
their authorized representatives or representative payees to the extent necessary to pursue
Social Security claims and to representative payees when the information pertains to
individuals for whom they serve as representative payees, for the purpose of assisting
SSA in administering its representative payment responsibilities under the Act and
assisting the representative payees in performing their duties as payees, including
receiving and accounting for benefits for individuals for whom they serve as payees.

In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notices
(SORN) 60-0089, entitled Claims Folders System, as published in the Federal Register (FR) on
April 1, 2003, at 68 FR 15784, and 60-0320, entitled Electronic Disability Claim File, as
published in the FR on December 22, 2003, at 68 FR 71210. Additional information, and a full
listing of all of our SORNs, is available on our website at www.ssa.gov/privacy.

SSA will insert the following revised PRA Statement into the form as soon
as possible:
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 61
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 1800-325-0778). You may send comments regarding this burden estimate or any other
aspect of this collection, including suggestions for reducing this burden to: SSA, 6401
Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time
estimate to this address, not the completed form.