The SSA SSA-3380-BK form, issued by the Social Security Administration, is a crucial document for individuals seeking disability benefits. This form allows applicants to provide detailed information about their medical conditions, treatments, and how these impairments affect their daily lives. To streamline your application process for disability benefits, complete the SSA SSA-3380-BK form by clicking the button below.
Navigating through the maze of paperwork when applying for disability benefits can prove to be a daunting task for many. Among the various forms required by the Social Security Administration, the SSA-3380-BK form stands out as an essential tool in providing comprehensive information regarding an individual's medical condition and its impact on their ability to work. This form is designed to collate detailed information from third parties who are well-acquainted with the applicant's daily life and health issues, offering the Social Security Administration (SSA) insights that might not be available through medical records alone. The importance of this form lies in its ability to paint a fuller picture of the applicant’s limitations, including an assessment of mental, emotional, and physical capacities. Filling out this form accurately is crucial, as it aids in the decision-making process for disability benefits, ensuring that applicants receive the support they need based on a thorough understanding of their condition.
Form SSA-3380 (06-2020)
Discontinue Prior Editions
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Social Security Administration
OMB No. 0960-0635
FUNCTION REPORT - ADULT - THIRD PARTY Form SSA-3380-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 (TTY 1-800-325-0778).
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 10, and show the number of the question being answered.
Function Report - Adult - Third Party Form SSA-3380-BK
REMEMBER TO GIVE US THE NAME AND ADDRESS OF THE PERSON
COMPLETING THIS FORM ON PAGE 10
Form SSA-3380-BK (06-2020)
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Privacy Act and Paperwork Reduction Act Statements
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 you provide to make a determination of 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 Systems, 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 December 22, 2003, at 68 FR 71210. Additional information, and a full listing of all of our SORNs, is available on our website at https://www.ssa.gov/privacy.
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 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.
PLEASE REMOVE THIS SHEET BEFORE RETURNING
THE COMPLETED FORM.
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FUNCTION REPORT- ADULT - THIRD PARTY
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 (MM/DD/YYYY)
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.)
-
Area Code
Phone Number
Your Number
Message Number
None
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
Other (describe relationship)
With Friends
SECTION B - INFORMATION ABOUT ILLNESSES, INJURIES, OR CONDITIONS
8. How does this person's illnesses, injuries, or conditions limit his/her ability to work?
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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?
If "YES," for whom does he/she care, and what does he/she do for them?
Yes
No
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?
Yes No
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
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b. Does he/she need any special reminders to take care of personal needs and grooming?
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?
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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
Ride a bicycle
Use public transportation
Other (Explain)
c. When going out, can he/she go out alone?
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
Count change
Explain all "NO" answers.
Handle a savings account
Use a checkbook/money orders
Yes Yes
No No
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b. Has the disabled person's ability to handle money changed since
the illnesses, injuries, or conditions began?
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 does the disabled person spend time with others? (Check all that apply.)
In person
On the phone
Email
Texting
Mail
Video Chat (for example Skype or Facetime)
b. Describe the kinds of things he/she does with others.
How often does he/she do these things?
c. 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?
How often does he/she go and how much does he/she take part?
Does he/she need someone to accompany him/her?
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d. Does this person have any problems getting along with family, friends, neighbors, or others?
If "YES," explain.
e. 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
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 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?
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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 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
Which of these were prescribed by a doctor?
When was it prescribed?
When does this person need to use these aids?
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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?
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.
Name of person completing this form (Please print)
Address (Number and Street)
Date (MM/DD/YYYY)
Email address (optional)
City
State
ZIP Code
Filling out the SSA SSA-3380-BK form is a crucial step in providing necessary information to the Social Security Administration (SSA) when someone applies for disability benefits. It's designed to gather comprehensive details about the applicant's medical conditions, treatments, and how these impairments affect their daily lives and ability to work. The process might seem complex at first, but breaking it down into manageable steps can make it much easier. Below are the steps you need to follow to fill out this form correctly.
After submitting the SSA SSA-3380-BK form, the SSA will review the information provided, possibly in conjunction with other forms and documents submitted as part of the disability benefits application. It's important to respond promptly to any requests from the SSA for additional information or clarification to ensure the process moves forward without unnecessary delays. Knowing what happens after submitting the form can provide peace of mind during what can be an anxious waiting period.
What is the SSA-3380-BK form used for?
The SSA-3380-BK form, also known as the Function Report - Adult - Third Party form, is used by the Social Security Administration (SSA) to gather additional information about an individual’s ability to function and perform everyday activities. This information helps the SSA in making a determination on disability benefits claims. It is filled out by someone who knows the applicant well, such as a family member, close friend, or caregiver, to provide an external perspective on the applicant's condition.
Who should complete the SSA-3380-BK form?
This form should be completed by a third party who has close and regular contact with the applicant for Social Security Disability benefits. The respondent should have detailed knowledge of the applicant’s daily activities, medical condition, and how these impact their ability to work and perform other activities. The SSA values input from someone who can provide observations and examples to support the applicant's claim.
How can one obtain the SSA-3380-BK form?
The SSA-3380-BK form can be obtained in several ways. Individuals can download it directly from the Social Security Administration's official website. Alternatively, they can request a paper copy by calling the SSA or visiting a local Social Security office. Assistance with obtaining and completing the form is also available at these offices.
What information is required on the SSA-3380-BK form?
The form requests detailed information about the applicant's daily activities, including how their condition affects their ability to perform tasks such as personal care, cooking, cleaning, shopping, using transportation, and maintaining social activities. It also asks for information about the applicant's abilities to follow instructions, get along with others, and handle stress and changes in routine. Specific examples and the need for prompts or reminders in completing tasks should be included wherever possible.
Can the information provided in the SSA-3380-BK form affect the outcome of a disability benefits claim?
Yes, the information provided in the SSA-3380-BK form can significantly affect the outcome of a disability benefits claim. Accurate and detailed descriptions of the applicant's daily life and limitations offer the SSA valuable insight into how their condition affects their ability to work and perform other activities. This third-party perspective is crucial in the evaluation of the disability claim. Lack of detail or inconsistency in the information provided can lead to delays or denials in the claims process.
How should the SSA-3380-BK form be submitted?
Once completed, the SSA-3380-BK form can be submitted in several ways. It can be mailed directly to the Social Security Administration, handed in at a local SSA office, or, in some cases, uploaded through the online Social Security account of the person applying for benefits. It's important to keep a copy of the completed form for personal records.
Is there a deadline for submitting the SSA-3380-BK form?
While there is not a specific deadline for submitting the SSA-3380-BK form, it is important to submit it as soon as possible after receiving a request from the Social Security Administration. Delays in submission can result in delays in the processing and determination of disability benefits. If a respondent encounters any issues that prevent timely submission, they should contact the SSA to inform them of these circumstances.
What should be done if assistance is needed in completing the SSA-3380-BK form?
Individuals who need assistance in completing the SSA-3380-BK form can seek help in several ways. The Social Security Administration offers guidance through their helpline and local offices where staff can provide information and support. Additionally, various disability advocacy groups and nonprofit organizations offer assistance and advice in completing disability benefits paperwork, including the SSA-3380-BK form.
Filling out the SSA SSA-3380-BK form, which is used for gathering information about your medical condition from people who know you well, can often be challenging. To ensure accuracy and improve the chances of a successful outcome, it’s important to avoid common pitfalls. Here are seven mistakes frequently made:
By diligently avoiding these mistakes, you can improve the quality of your submission and help the SSA better understand your situation, thereby increasing the likelihood of a successful outcome for your benefits claim.
When applying for Social Security disability benefits, the SSA-3380-BK form, which helps gather information about an individual's work history and how their disability affects their ability to work, is just the beginning. The journey often requires several other forms and documents to support a claim. Understanding these accompanying forms can streamline the application process, making it a little less daunting.
Navigating the numerous forms and documents attached to the SSA-3380-BK can be overwhelming, but each plays a vital role in painting a complete picture of your situation. Proper and thorough completion of these forms can significantly impact the success of a disability claim. Knowing what each document is for can help demystify the process, allowing applicants to approach their disability claim with confidence and clarity.
SSA-3368-BK: Adult Disability Report Form - Like the SSA-3380-BK, which collects information about someone's medical conditions and how they affect their ability to work, the SSA-3368-BK serves a similar purpose. It focuses on capturing detailed personal, vocational, and medical information directly from the individual applying for disability benefits. Both forms are integral to the Social Security Administration's process for evaluating the eligibility of applicants for disability benefits.
SSA-827: Authorization to Disclose Information to the Social Security Administration - This form is similar to the SSA-3380-BK because it deals with the handling of personal, medical information. While SSA-3380-BK gathers third-party insights into an applicant's condition, the SSA-827 allows the SSA to obtain medical records directly from healthcare providers. Both forms ensure that the SSA has comprehensive data to make informed decisions regarding disability claims.
SSA-3820-BK: Disability Report - Child - The SSA-3820-BK collects detailed information about a child's medical condition and how it affects their daily life, drawing parallels to the SSA-3380-BK's function for third-party reports on adults. Both forms play crucial roles in the assessment process for disability benefits, but they target different age groups, highlighting the SSA's tailored approach to evaluating disability across the lifespan.
SSA-3441-BK: Disability Report - Appeal - Necessary for individuals who are appealing a decision about their disability benefits, the SSA-3441-BK is similar to the SSA-3380-BK in that it gathers updated information regarding the applicant's medical condition and its impact on their ability to work. Both forms contribute vital information needed by the SSA to reassess an individual's eligibility for benefits under new evidence or changed circumstances.
SSA-1696: Appointment of Representative - This form differs in purpose but is indirectly related to the SSA-3380-BK process. By designating a representative, an individual provides explicit consent for someone else to handle matters related to their disability claim, including the submission and management of necessary documentation like the SSA-3380-BK. While SSA-1696 facilitates representation, SSA-3380-BK collects third-party observations, both serving the goal of supporting the individual's case for disability benefits.
The SSA-3380-BK form, crucial for documenting the impact of one's disability on their daily life, plays a significant role in the application process for Social Security benefits. It's essential to approach this form with care, ensuring that all information provided accurately reflects the individual's situation. Below are carefully curated guidelines composed of 10 do's and don'ts to assist individuals in completing this form adequately.
Read the instructions carefully before you start filling out the form, to ensure you understand what is required.
Provide detailed descriptions of how your condition affects your daily activities, rather than just stating the diagnosis.
Include specific examples of daily tasks you find challenging to complete because of your disability.
Reach out to any healthcare professionals or care providers who can offer insights into your condition, to gather accurate information for the form.
Review your answers for completeness and accuracy before submitting the form, ensuring that all relevant information is included.
Rush through filling out the form without giving thoughtful responses to each question.
Omit details about how your disability affects your mental and emotional well-being, in addition to physical limitations.
Forget to include any assistive devices or accommodations you use daily that help you manage your condition.
Assume that the reviewer knows specific medical terms or the implications of your condition; always explain in clear, accessible language.
Overlook the opportunity to have someone review your form before submission, as another perspective can help ensure the clarity and completeness of your responses.
Adhering to these guidelines when filling out the SSA-3380-BK form will help convey the full impact of your disability on your life, aiding those reviewing your application in understanding your needs. It's about painting a clear and complete picture of your day-to-day challenges, thereby increasing the likelihood of your application being accurately assessed and favorably considered.
Understanding the SSA-3380-BK form, also known as the Function Report - Adult, is crucial for those involved in applying for Social Security Disability benefits. However, several misconceptions surround this form, leading to confusion and potential mistakes in the application process. Let's clarify five common misunderstandings:
Correcting these misconceptions can make a significant difference in the SSA disability application process, ensuring that applicants provide the fullest and most accurate depiction of their disability and how it affects their daily life and work ability.
When dealing with the Social Security Administration (SSA), understanding the purpose and process of filling out forms such as the SSA SSA-3380-BK is crucial. This particular form is essential for providing detailed information about an individual's medical condition and the way it affects their ability to work. Here are key takeaways to help individuals complete and use the form effectively.
Completing the SSA SSA-3380-BK form thoroughly and accurately can significantly impact the outcome of your disability claim. By following these takeaways, individuals can better navigate the process and improve their chances of receiving the support they need.
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