SSA-3373 - Current Version

FUNCTION REPORT - ADULT - Form SSA-3373-BK

READ ALL OF THIS INFORMATION BEFORE
YOU BEGIN COMPLETING THIS FORM
IF YOU NEED HELP
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.

The information that you give us on this form will be used by the office that makes the
disability decision on your disability claim. You can help them by completing as much of
the form as you can.
It is important that you tell us about your activities and abilities.
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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 more space is needed 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 - Form SSA-3373-BK

HOW TO COMPLETE THIS FORM

Privacy Act Statements
Collection and Use of Personal Information
Sections 205(a), 223(d)(5)(A), 1631(d)(1), and 1631(e)(1) of the Social Security Act, as
amended, authorize us to collect this information. We will use the information you provide to
assist us in making a decision on your claim.
Furnishing us this information is voluntary. However, failing to provide us with all or part of the
information could prevent us from making a decision on your claim.
We rarely use the information you supply for any purpose other than the reason stated above.
However, we may use it for the administration and integrity of Social Security programs. We
may also disclose information to another person or to another agency in accordance with
approved routine uses, which include but are not limited to:
1. 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); and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure
the integrity and improvement of our programs (e.g., to the Bureau of the
Census and private entities under contract with us).
A list of when we may share your information with others, called routine uses, is available in
our System of Records Notices entitled, Master Files of Social Security Number (SSN) Holders
and SSN Applications System, 60-0058; Claims Folders System, 60-0089; and Master
Beneficiary Record, 60-0090. Additional information about these and other system of records
notices and our programs are available online at www.socialsecurity.gov or at your local Social
Security office.
We may also share the information you provide to other agencies through 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 or administered benefit programs and for
repayment of incorrect payments or delinquent debts under these programs.
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
THE OFFICE THAT REQUESTED IT. If you do not have that address, 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 21235-6401. Send only
comments relating to our time estimate to this address, not the completed form.

PLEASE REMOVE THIS SHEET BEFORE RETURNING
THE COMPLETED FORM.

Form Approved
OMB No. 0960-0681

SOCIAL SECURITY ADMINISTRATION

FUNCTION REPORT - ADULT
How your illnesses, injuries, or conditions limit your 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
2. SOCIAL SECURITY NUMBER

1. NAME OF DISABLED PERSON (First, Middle Initial, Last)

3. 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

4. a. Where do you live? (Check one.)
House

Apartment

Boarding House

Shelter

Group Home

Other (What?)

Nursing Home

b. With whom do you live? (Check one.)
Alone

With Family

With Friends

Other (Describe relationship.)

SECTION B - INFORMATION ABOUT YOUR ILLNESSES, INJURIES, OR CONDITIONS
5. How do your illnesses, injuries, or conditions limit your ability to work?

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SECTION C - INFORMATION ABOUT DAILY ACTIVITIES
6. Describe what you do from the time you wake up until going to bed.

7. Do you 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 do you care, and what do you do for them?

8. Do you take care of pets or other animals?
If "YES," what do you do for them?

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

10. What were you able to do before your illnesses, injuries, or conditions that you can't do now?

11. Do the illnesses, injuries, or conditions affect your sleep?
If "YES," how?

12. PERSONAL CARE (Check here

if NO PROBLEM with personal care.)

a. Explain how your illnesses, injuries, or conditions affect your ability to:
Dress
Bathe
Care for hair
Shave
Feed self
Use the toilet
Other

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Yes

No

b. Do you need any special reminders to take care of personal
needs and grooming?

Yes

No

Yes

No

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

c. Do you need help or reminders taking medicine?
If "YES," what kind of help do you need?

13. MEALS
Yes
No
a. Do you prepare your own meals?
If "Yes," what kind of food do you prepare? (For example, sandwiches, frozen dinners, or complete
meals with several courses.)

How often do you prepare food or meals? (For example, daily, weekly, monthly.)

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

b. If "No," explain why you cannot or do not prepare meals.

14. HOUSE AND YARD WORK
a. List household chores, both indoors and outdoors, that you are able to do. (For example,
cleaning, laundry, household repairs, ironing, mowing, etc.)

b. How much time does it take you, and how often do you do each of these things?

c. Do you need help or encouragement doing these things?
If "YES," what help is needed?

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Yes

No

d. If you don't do house or yard work, explain why not.

15. GETTING AROUND
a. How often do you go outside?
If you don't go out at all, explain why not.

b. When going out, how do you travel? (Check all that apply.)
Walk

Drive a car

Ride in a car

Ride a bicycle

Other (Explain)

Use public transportation
c. When going out, can you go out alone?

Yes

No

Yes

No

If "NO," explain why you can't go out alone.

d. Do you drive?
If you don't drive, explain why not.

16. SHOPPING
a. If you do any shopping, do you shop: (Check all that apply.)
In stores

By phone

By mail

By computer

b. Describe what you shop for.

c. How often do you shop and how long does it take?

17. MONEY
a. Are you 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.

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b. Has your ability to handle money changed since the illnesses,
injuries, or conditions began?
If "YES," explain how the ability to handle money has changed.

Yes

No

18. HOBBIES AND INTERESTS
a. What are your hobbies and interests? (For example, reading, watching TV, sewing, playing sports, etc.)

b. How often and how well do you do these things?

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

19. SOCIAL ACTIVITIES
a. Do you spend time with others? (In person, on the phone, on the computer, etc.)

Yes

No

If "YES," describe the kinds of things you do with others.

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

Do you need to be reminded to go places?

Yes

No

Yes

No

How often do you go and how much do you take part?

Do you need someone to accompany you?

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c. Do you 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
20. a. Check any of the following items that your 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 your illnesses, injuries, or conditions affect each of the items you checked. (For
example, you can only lift [how many pounds], or you can only walk [how far])

b. Are you:

Right Handed?

Left Handed?

c. How far can you walk before needing to stop and rest?
If you have to rest, how long before you can resume walking?

d. For how long can you pay attention?
e. Do you finish what you start? (For example, a conversation, chores,
reading, watching a movie.)
f. How well do you follow written instructions? (For example, a recipe.)

g. How well do you follow spoken instructions?

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Yes

No

h. How well do you get along with authority figures? (For example, police, bosses, landlords
or teachers.)

i. Have you 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 do you handle stress?

k. How well do you handle changes in routine?

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

21. Do you 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 do you need to use these aids?

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22. Do you currently take any medicines for your illnesses, injuries, or conditions?
If "YES, "do any of your medicines cause side effects?

Yes

No

Yes

No

If "YES," please explain. (Do not list all of the medicines that you take. List only the medicines that
cause side effects.)
NAME OF MEDICINE

SIDE EFFECTS YOU HAVE

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

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ZIP Code