FUNCTION REPORT - ADULT - Form SSA-3373-BK

FUNCTION REPORT - ADULT - Form SSA-3373-BK
YOU BEGIN COMPLETING THIS FORM
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HOW TO COMPLETE THIS FORM

Always ensure you SAVE your work if you plan to take breaks! SAVE button at bottom of page.
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.
- • 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
Privacy Act Statements Collection and Use of Personal Information
Sections 205(a), 223(d5A), 1631(d1), and 1631(e1) 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.
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.

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
FUNCTION REPORT - ADULT
SECTION A - GENERAL INFORMATION
1. NAME OF DISABLED PERSON (First, Middle Initial, Last) who is filing for benefits?
If you are NOT the Disabled Person, what is your name?
What is your relation to the Disabled Person? (family, friend, etc)
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 Phone Number (area code first)
4. a. Where does disabled person live? Check one

Your NumberHouseApartmentBoarding HouseNursing HomeShelterGroup HomeWith FamilyWith FriendsOther
b. With whom do they live? Check one

AloneOther
SECTION B - INFORMATION ABOUT DISABLEDS ILLNESSES, INJURIES, OR CONDITIONS
5. How does disabled's illnesses, injuries, or conditions limit the ability to work?
Form SSA-3373-BK (10-2015) UF (10-2015) Use (01-2013) ef (01-2013) Edition until Stock is Exhausted
SECTION C - INFORMATION ABOUT DAILY ACTIVITIES
6. Describe what disabled person does from the time of wake up until going to bed.
7. Does disabled take care of anyone else such as a wife/husband, children, grandchildren,

YesNo
If "YES," for whom does disabled care, and what does disabled do for them?
8. Does disabled person take care of pets or other animals?

YesNo
If "YES," what does disabled do for them?
9. Does anyone help the disabled person care for other people or animals?

YesNo
If "YES," who helps, and what do they do to help?
10. What was disabled person able to do before the illnesses, injuries, or conditions that you can't do now?
11. Do the illnesses, injuries, or conditions affect the disabled persons sleep?

YesNo
If "YES," how?
12. PERSONAL CARE

Check here if
a. Explain how the disabled person's illnesses, injuries, or conditions affect their ability to:
Dress
Bathe
Care for hair
Shave
Feed self
Use the toilet
Other
Form SSA-3373-BK (10-2015) UF (10-2015)
b. Does the disabled person need any special reminders to take care of personal

YesNo
If "YES," what type of help or reminders are needed?
c. Does the disabled person need help or reminders taking medicine?

YesNo
If "YES," what kind of help do they need?
a. Does the disabled person prepare their own meals?

YesNo
If "Yes," what kind of food do they prepare? For example, sandwiches, frozen dinners, or complete meals with several courses
How often do they prepare food or meals? For example, daily, weekly, monthly
How long does it take the disabled person to do?
Any changes in cooking habits since the illness, injuries, or conditions began?
b. If "No," explain why they cannot or do not prepare meals.
a. List household chores, both indoors and outdoors, that the disabled person is ABLEto do. For example, cleaning, laundry, household repairs, ironing, mowing, etc
b. How much time does it take the disabled person, and how often do they do each of these things?
c. Does disabled need help or encouragement doing these things?

YesNo
If "YES," what help is needed?
Form SSA-3373-BK (10-2015) UF (10-2015)
d. If disabled doesn't do house or yard work, explain why not.
a. How often does disabled 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

WalkDrive a carRide in a carRide a bicycleUse public transportationOther
When going out, can he/she go out alone?

YesNoOther
If "NO," explain why he/she can't go out alone.
d. Does disabled person drive?

YesNo
If disabled person doesn't drive, OR drives less, explain why not.
a. If disabled person does any shopping, does he/she shop: Check all that apply

In storesBy phoneBy mailBy computer
b. Describe what he/she is able to shop for (details!):
c. How often does he/she shop and how long does it take?
Explain all "NO" answers.
Form SSA-3373-BK (10-2015) UF (10-2015)
b. Has his/her ability to handle money changed since the illnesses,

YesNo
injuries, or conditions began?
If "YES," explain how the ability to handle money has changed.
a. What are/were disabled person's hobbies and interests? For example, reading, watching TV, sewing, playing sports, etc (Even if no longer able to do them!)
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.
a. Does disabled person spend time with others? In person, on the phone, on the computer, etc

YesNo
If "YES," describe the kinds of things he/she does with others.
How often does he/she do these things?
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?

YesNo
How often does he/she go and how much do you take part?
Does he/she need someone to accompany him/her when going out of the house?

YesNo
Form SSA-3373-BK (10-2015) UF (10-2015)
c. Does he/she have any problems getting along with family, friends, neighbors,

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 his/her illnesses, injuries, or conditions affect:

LiftingWalkingStair ClimbingUnderstandingSquattingSittingSeeingFollowing InstructionsBendingKneelingMemoryUsing HandsStandingTalkingCompleting TasksGetting Along With OthersReachingHearingConcentration
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 Disabled Person R or L handed?:

Right HandedLeft 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 he/she pay attention?
e. Does he/she finish what they start? For example, a conversation, chores,

YesNo
f. How well does disabled person follow written instructions? For example, a recipe
g. How well does the disabled person follow spoken instructions?
Form SSA-3373-BK (10-2015) UF (10-2015)
h. How well does the disabled person get along with authority figures? For example, police, bosses, landlords or teachers
i. Has the disabled person ever been fired or laid off from a job because of problems getting along with others?

YesNo
If "YES," please explain.
If "YES," please give name of employer.
j. How well does the disabled person handle stress?
k. How well does the disabled person handle changes in routine?
l. Have you noticed any unusual behavior or fears?

YesNo
If "YES," please explain.
21. Does disabled person use any of the following? Check all that apply

CrutchesCaneHearing AidWalkerBrace/SplintGlasses/Contact LensesWheelchairArtificial LimbArtificial Voice BoxOther
Which of these were prescribed by a doctor?
When was it prescribed?
When does disabled person need to use these aids?
Form SSA-3373-BK (10-2015) UF (10-2015)
22. Does disabled person currently take any medicines for your illnesses, injuries, or conditions?

YesNoYesNo
If "YES, "do any of your medicines cause side effects?

If "YES," please explain. (Do NOT list all of the medicines that he/she 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.
Is there anything else you would like us to know about why THE DISABLED PERSON cannot work FULL time?
FULL LEGAL NAME of person completing this form (Please print)
Date (month, day, year)

MonthDayYear
Date
Address (Number and Street)
City
State
ZIP Code
Email address
example@example.com
Form SSA-3373-BK (10-2015) UF (10-2015)
Should be Empty:

FUNCTION REPORT - ADULT - Form SSA-3373-BK

YOU BEGIN COMPLETING THIS FORM

IF YOU NEED HELP

HOW TO COMPLETE THIS FORM

REMEMBER TO GIVE US THE NAME AND ADDRESS OF THE PERSON COMPLETING THIS FORM ON PAGE 8

Privacy Act Statements Collection and Use of Personal Information

FUNCTION REPORT - ADULT

SECTION A - GENERAL INFORMATION

SECTION B - INFORMATION ABOUT DISABLEDS ILLNESSES, INJURIES, OR CONDITIONS

SECTION C - INFORMATION ABOUT DAILY ACTIVITIES

SECTION D - INFORMATION ABOUT ABILITIES

SECTION E - REMARKS