Form SSA-3373-BK Function Report - Adult

What Is Form SSA-3373-BK?

Form SSA-3373-BK, Function Report - Adult is a form used to determine whether an individual was eligible for Social Security disability benefits. The form - also known as the SSA Function Report form - was issued by the Social Security Administration (SSA).

The latest version of the document was released in October 2015. An SSA-3373-BK fillable form ‚Äčis available for download and digital filing below or on the SSA website.

How to Fill out Form SSA-3373-BK?

Filling out the form may be complicated and time-consuming. If you experience any difficulties, fill out the answers you are sure about and contact your local Social Security office for help. Besides, you can consult with the disability attorney or advocate about the case. Various SSA-3373-BK sample answers are available online to facilitate the completion process.

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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
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
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
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(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
SOCIAL SECURITY ADMINISTRATION
OMB No. 0960-0681
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
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.)
Your Number
Message Number
None
Area Code
Phone Number
4. a. Where do you live? (Check one.)
House
Apartment
Boarding House
Nursing Home
Shelter
Group Home
Other (What?)
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?
Form SSA-3373-BK (10-2015) UF (10-2015)
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Use (01-2013) ef (01-2013) Edition until Stock is Exhausted
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,
Yes
No
parents, friend, other?
If "YES," for whom do you care, and what do you do for them?
Yes
No
8. Do you take care of pets or other animals?
If "YES," what do you do for them?
Yes
No
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?
Yes
No
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
Form SSA-3373-BK (10-2015) UF (10-2015)
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b. Do you need any special reminders to take care of personal
Yes
No
needs and grooming?
If "YES," what type of help or reminders are needed?
Yes
No
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?
Yes
No
If "YES," what help is needed?
Form SSA-3373-BK (10-2015) UF (10-2015)
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Download Form SSA-3373-BK Function Report - Adult

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Form SSA-3373-BK Instructions

The SSA-3373-BK is a ten-page form that should be completed as follows:

  1. Section A. General Information. Provide your basic personal and contact information;
  2. Section B. Information about Your Illnesses, Injuries, or Conditions. Enumerate all your illnesses, injuries, and conditions. Describe how they affect your ability to work;
  3. Section C. Information about Daily Activities. Describe how your condition affects your daily routine. If you need help with daily activities, specify the help you need.;
  4. Section D. Information about Abilities. Provide the information about your abilities and the medications you are taking;
  5. Section E. Remarks. Add any information you think important that does not seem to fit in previous sections. Make sure to provide as much details as possible.

The last part of the form requires your name, completion date, and full mailing address. Send or take the document to the office that requested it. You can specify the address by calling the SSA.

Tips for Filling out SSA-3373-BK

Look through the useful tips that may facilitate the filing process below:

  • Read the whole form before completing it;
  • Answer every question. Do not leave blank boxes. If your answer is "None" or "Don't know" indicate it anyway;
  • Print or type your answers;
  • Provide all the required explanations. If the space provided is not enough, continue in the "Remarks" section;
  • When providing the explanations, concentrate on your disabilities rather than abilities;
  • Try to be consistent and do not provide unrelated information;
  • Be honest. The SSA will compare your answers to your medical records. Willful representation of false statements may result in fine or imprisonment;
  • Double-check your answers;
  • Your doctor or hospital are not allowed to complete the form;
  • Make a copy of the completed form for your records.

SSA-3373-BK Related Forms

  1. SSA-3375-BK, Function Report - Child Birth to 1st Birthday. The form is used to provide the SSA with information about children's injuries or illness. The SSA uses this information to make a decision on the disability claim. The form is applicable for children before age 1;
  2. SSA-3376-BK, Function Report - Child age 1 to 3rd Birthday. The document is used to report disabilities of child age 1 to 3. Based on this information, the SSA makes the decision about the Social Security benefits request;
  3. SSA-3377-BK, Function Report - Child age 3 to 6th Birthday. The form is submitted on the behalf of a minor child age 3 to 6 to report injuries and illnesses. The SSA uses this information to determine a child's eligibility for disability benefits;
  4. SSA-3378-BK, Function Report - Child age 6 to 12th Birthday. The form is used to specify how the illnesses and injuries children have affected their everyday life. This report is the basis of the SSA decision on a child's disability claim;
  5. SSA-3379-BK, Function Report - Child age 12 to 18th Birthday. The SSA uses the form to determine if the child is eligible for disability benefits. The document should contain detailed information on how disabilities affect the everyday life of a child age 12 to 18;
  6. SSA-3380-BK, Function Report - Adult - Third Party Form. The form is used to make a decision on an application for disability benefits. The form should provide all requested information.
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