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Fillable Printable Form SSA-3373-BK

Fillable Printable Form SSA-3373-BK

Form SSA-3373-BK

Form SSA-3373-BK

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.
HOW TO COMPLETE THIS FORM
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.
• Print or type.
DO NOT LEAVE ANSWERS BLANK. If you do not know the answer or the
answeris "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
- 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 thesequestions unless we display a valid Office of Management and
Budget control number. We estimate that it willtake 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 commentson our time
estimate above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401.Send only
commentsrelating to our time estimate to this address, not the completed form.
Privacy Act Statements
Collection and Use of Personal Information
Paperwork Reduction Act Statement
PLEASE REMOVE THIS SHEET BEFORE RETURNING
THE COMPLETED FORM.
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.
Form SSA-3373-BK (10-2015) UF (10-2015)
Use (01-2013) ef (01-2013) Edition until Stock is Exhausted
SOCIAL SECURITY ADMINISTRATION
FUNCTION REPORT - ADULT
How your illnesses, injuries, or conditions limit your activities
Form Approved
OMB No. 0960-0681
Page 1
For SSA Use Only
Do not write in this box.
SECTION A - GENERAL INFORMATION
1. NAME OF DISABLED PERSON(First, Middle Initial, Last)
2. SOCIAL SECURITY NUMBER
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.)
Area CodePhone Number
Your NumberMessage NumberNone
4. a. Where do you live? (Check one.)
HouseApartmentBoarding HouseNursing Home
ShelterGroup HomeOther
(What?)
b. With whom do you live? (Check one.)
AloneWith FamilyWith 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?
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.
Page 2
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?
YesNo
If "YES," for whom do you care, and what do you do for them?
8. Do you take care of pets or other animals?
YesNo
If "YES," what do you do for them?
9. Does anyone help you care for other people or animals?
YesNo
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?
YesNo
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
Form SSA-3373-BK (10-2015) UF (10-2015)
Page 3
b. Do you need any special reminders to take care of personal
needs and grooming?
YesNo
If "YES," what type of help or reminders are needed?
c. Do you need help or reminders taking medicine?
YesNo
If "YES," what kind of help do you need?
13. MEALS
a. Do you prepare your own meals?
YesNo
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?
YesNo
If "YES," what help is needed?
Form SSA-3373-BK (10-2015) UF (10-2015)
Page 4
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.)
WalkDrive a carRide in a carRide a bicycle
Use public transportationOther
(Explain)
c. When going out, can you go out alone?
YesNo
If "NO," explain why you can't go out alone.
d. Do you drive?
YesNo
If you don't drive, explain why not.
16. SHOPPING
a. If you do any shopping, do you shop: (Check all that apply.)
In storesBy phoneBy mailBy 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
YesNo
Count change
YesNo
Handle a savings account
YesNo
Use a checkbook/money orders
YesNo
Explain all "NO" answers.
Form SSA-3373-BK (10-2015) UF (10-2015)
Page 5
b. Has your ability to handle money changed since the illnesses,
injuries, or conditions began?
YesNo
If "YES," explain how the ability to handle money has changed.
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.)
YesNo
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?
YesNo
How often do you go and how much do you take part?
Do you need someone to accompany you?
YesNo
Form SSA-3373-BK (10-2015) UF (10-2015)
Page 6
c. Do you have any problems getting along with family, friends, neighbors,
or others?
YesNo
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
Squatting
Bending
Standing
Reaching
Walking
Sitting
Kneeling
Talking
Hearing
Stair Climbing
Seeing
Memory
Completing Tasks
Concentration
Understanding
Following Instructions
Using Hands
Getting Along With Others
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.)
YesNo
f. How well do you follow written instructions? (For example, a recipe.)
g. How well do you follow spoken instructions?
Form SSA-3373-BK (10-2015) UF (10-2015)
Page 7
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?
YesNo
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?
YesNo
If "YES," please explain.
21. Do you use any of the following? (Check all that apply.)
Crutches
Cane
Hearing Aid
WalkerBrace/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?
Form SSA-3373-BK (10-2015) UF (10-2015)
Page 8
YesNo
If "YES, "do any of your medicines cause side effects?
YesNo
If "YES," please explain. (Do not list all of the medicines that you take. List only the medicines that
cause side effects.)
NAME OF MEDICINESIDE 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)
Email address (optional)Address (Number and Street)
CityStateZIP Code
Form SSA-3373-BK (10-2015) UF (10-2015)
22. Do you currently take any medicines for your illnesses, injuries, or conditions?
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