FUNCTION REPORT - ADULT - THIRD PARTY Form SSA-3380-BK/Impact Disability Law

FUNCTION REPORT - ADULT - THIRD PARTY Form SSA-3380-BK
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
- 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.
FUNCTION REPORT- ADULT - THIRD PARTY

How the disabled person's illnesses, injuries, or conditions limit his/her activities
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 NameMiddle NameLast Name
2. YOUR NAME (Person completing the form)

First NameLast Name
3. RELATIONSHIP
(To disabled person)
4. DATE

MonthDayYear
Date
5. YOUR DAYTIME TELEPHONE NUMBER

Your NumberMessage NumberNone
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.)Format: (000) 000-0000.
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.)

HouseApartmentBoarding HouseNursing HomeShelterGroup HomeOther(What?)
b. With whom does he/she live? (Check one.)

AloneWith FamilyWith FriendsOther (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?
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?

YesNo
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?

YesNo
What does he/she do for them?
12. Does anyone help this person care for other people or animals?

YesNo
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?

YesNo
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:
b. Does he/she need any special reminders to take care of personal needs and grooming?

YesNo
What type of help or reminders are needed?
c. Does he/she need help or reminders taking medicine?

YesNo
What kind of help does he/she need?
16. MEALS
Does the disabled person prepare his/her own meals?

YesNo
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?
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?

YesNo
What help is needed?
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.)

WalkDrive a carRide in a carRide a bicycleUse public transportationOther (Explain)
c. When going out, can he/she go out alone?

YesNo
Explain why he/she can't go out alone.
d. Does the disabled person drive?

YesNo
Explain why not.
19. SHOPPING
a. If the disabled person does any shopping, does he/she shop: (Check all that apply.)

In storesBy phoneBy mailBy 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:
Type a question

YesNo
Handle a savings account

YesNo
Count change

YesNo
Use a checkbook/money orders

YesNo
Explain all "NO" answers.
b. Has the disabled person's ability to handle money changed since the illnesses, injuries, or conditions began?

YesNo
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. Does the disabled person spend time with others? (In person, on the phone, on the computer, etc.)

YesNo
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 does he/she take part?
Does he/she need someone to accompany him/her?

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

YesNo
Explain.
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:

LiftingSquattingBendingStandingReachingWalkingSittingKneelingTalkingHearingStair ClimbingSeeingMemoryCompleting TasksConcentrationUnderstandingFollowing InstructionsUsing HandsGetting 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:

Left HandedRight 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.)

YesNo
f. How well does the disabled person follow written instructions? (For example, a recipe.)
g. How well does the disabled person follow spoken instructions?
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?

YesNo
Please explain.
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?

YesNo
Please explain.
24. Does the disabled person use any of the following? (Check all that apply.)

CrutchesCaneHearing AidWalkerBrace/SplintGlasses/Contact LensesWheelchairArtificial LimbArtificial Voice BoxOther (Explain)
Which of these were prescribed by a doctor?
When was it prescribed?
When does this person need to use these aids?
25. Does the disabled person currently take any medicines for his/her illnesses, injuries, or conditions?

YesNo
Do any of the medicines cause side effects?

YesNo

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:
Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Should be Empty:

Rows	NAME OF MEDICINE	SIDE EFFECTS PERSON HAS
1
2
3
4

FUNCTION REPORT - ADULT - THIRD PARTY Form SSA-3380-BK

HOW TO COMPLETE THIS FORM

FUNCTION REPORT- ADULT - THIRD PARTY

SECTION A - GENERAL INFORMATION

SECTION B - INFORMATION ABOUT ILLNESSES, INJURIES, OR CONDITIONS

SECTION C - INFORMATION ABOUT DAILY ACTIVITIES

15. PERSONAL CARE

a. Explain how the illnesses, injuries, or conditions affect this person's ability to:

16. MEALS

17. HOUSE AND YARD WORK

18. GETTING AROUND

19. SHOPPING

20. MONEY

21. HOBBIES AND INTERESTS

22. SOCIAL ACTIVITIES

SECTION D - INFORMATION ABOUT ABILITIES

SECTION E - REMARKS