Form SSA-3881-bk Questionnaire for Children Claiming Ssi Benefits

Form SSA-3881-bk or the "Questionnaire For Children Claiming Ssi Benefits" is a form issued by the U.S. Social Security Administration.

The form was last revised in June 1, 2018 and is available for digital filing. Download an up-to-date Form SSA-3881-bk in PDF-format down below or look it up on the U.S. Social Security Administration Forms website.

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Form SSA-3881-BK (06-2018) UF
Discontinue Prior Editions
Page 1 of 8
OMB No. 0960-0499
Social Security Administration
QUESTIONNAIRE FOR CHILDREN CLAIMING SSI BENEFITS
Please print, type, or write clearly and answer all items to the best of your ability. If you need help
completing any part of this form, we will help you. If you are filing on behalf of someone else, enter his or her
name and social security number in the space provided and answer all questions. If you do not know the
answer, enter "unknown." If the question does not apply, enter "N/A." If you need more space to answer any
of the questions, please use "REMARKS" and enter the number of the question next to your answer.
Child's Full Name
Social Security Number
Date (mm/dd/yyyy)
Informant's Name
Relationship to Child
Daytime Telephone Number
(including Area Code)
1. Is (was) the child cared for by a baby sitter? Does (did) the child attend any type of preschool, daycare and/or after
school program? If so, please specify. If more than one of the above, use the "REMARKS" section.
Name
Address (Number, Street, City, State, ZIP Code)
Telephone Number (including Area Code)
Dates Attended
Yes
No
2. a. Is (was) the child in school?
If "yes," and the school was not listed in Item 12A of the SSA-3820-F6, please show it here.
(If more than one, use the "REMARKS" section.)
Name
Address (Number, Street, City, State, ZIP Code)
Telephone Number (including Area Code)
Dates Attended
Grade Level Completed
Last Teacher's Name
Form SSA-3881-BK (06-2018) UF
Discontinue Prior Editions
Page 1 of 8
OMB No. 0960-0499
Social Security Administration
QUESTIONNAIRE FOR CHILDREN CLAIMING SSI BENEFITS
Please print, type, or write clearly and answer all items to the best of your ability. If you need help
completing any part of this form, we will help you. If you are filing on behalf of someone else, enter his or her
name and social security number in the space provided and answer all questions. If you do not know the
answer, enter "unknown." If the question does not apply, enter "N/A." If you need more space to answer any
of the questions, please use "REMARKS" and enter the number of the question next to your answer.
Child's Full Name
Social Security Number
Date (mm/dd/yyyy)
Informant's Name
Relationship to Child
Daytime Telephone Number
(including Area Code)
1. Is (was) the child cared for by a baby sitter? Does (did) the child attend any type of preschool, daycare and/or after
school program? If so, please specify. If more than one of the above, use the "REMARKS" section.
Name
Address (Number, Street, City, State, ZIP Code)
Telephone Number (including Area Code)
Dates Attended
Yes
No
2. a. Is (was) the child in school?
If "yes," and the school was not listed in Item 12A of the SSA-3820-F6, please show it here.
(If more than one, use the "REMARKS" section.)
Name
Address (Number, Street, City, State, ZIP Code)
Telephone Number (including Area Code)
Dates Attended
Grade Level Completed
Last Teacher's Name
Form SSA-3881-BK (06-2018) UF
Page 2 of 8
2.b. Is the child in a special education program?
Yes
No
Don't Know
c. Does the school make any special accommodations for the
child; e.g., adaptive furniture, wheelchair ramps, extra
Yes
No
Don't Know
assistance or attention?
If "yes" in 2.b. or 2.c., indicate type of program and/or
Specify number of hours per week the child is
accommodations:
in special education program:
d. Do you have a copy of the child's individual education plan
(IEP), the report in which the teacher outlines the child's
Yes
No
problems and lists the plans for correcting them?
If "yes," please provide a copy.
3. Does the child receive any special counseling or tutoring?
Yes
No
a. In school
b. Outside school
Yes
No
If "yes," in 3.a. or 3.b., please indicate: (If more than one, use the "REMARKS" section.)
Type of Counseling, Tutoring
Date Began and Ended (If completed)
Frequency of Visits
Counselor's or Tutor's Name
Telephone Number (including Area Code)
Address (Number, Street, City, State, ZIP Code)
4. Does the child or family have a child welfare, social services or
Yes
No
early intervention caseworker?
If "yes," please provide the following information: (If more than one, use the "REMARKS" section.)
Caseworker's Name
Organization
Address (Number, Street, City, State, ZIP Code)
Telephone Number (including Area Code)
File or Record Number
Date First Saw/Last Saw Caseworker
Form SSA-3881-BK (06-2018) UF
Page 3 of 8
5. Has the child ever been tested or evaluated by any of the following agencies or organizations? If "yes," indicate in
the space provided below the agency name, address, telephone number, record number, and the type and date of
test or evaluation performed (e.g., vision, hearing, speech, physical).
a. Public/Community Health Department
Yes
No
b. Child Welfare/Social Services Agency
Yes
No
c. Developmental Evaluation Center
Yes
No
d. Mental Health/Intellectual Disability
Yes
No
e. Special Needs/Crippled Children Agency
Yes
No
f. Speech and Hearing Center
Yes
No
g. Women, Infants, and Children (WIC) Program
Yes
No
Use the letter designation (5a, 5b, etc.) to identify the agency.
If additional space is needed, use "REMARKS" section.
Form SSA-3881-BK (06-2018) UF
Page 4 of 8
6. Does (did) the child receive any special therapy (physical, speech and
language, occupational), exercises, or any other services for his/her
impairments?
Yes
No
Include information about any therapy or exercises the parent,
guardian or caregiver provides the child.
If "yes," indicate below the therapist's name, the name of the person who PRESCRIBED AND/OR DESIGNED the
therapy program, the type(s) and frequency of treatment, when treatment began and ended (if completed), and
where treatment was received (e.g., home, hospital, therapist's office, clinic.)
Therapist's Name
Telephone No. (including Area Code)
Address (Number, Street, City, State, ZIP Code)
Person Who Prescribed/Designed Therapy
Information about Therapy:
Therapist's Name
Telephone No. (including Area Code)
Address (Number, Street, City, State, ZIP Code)
Person Who Prescribed/Designed Therapy
Information about Therapy:
Form SSA-3881-BK (06-2018) UF
Page 5 of 8
7. Does (did) the child receive vocational rehabilitation services?
Yes
No
If "yes," describe services received below the rehabilitation counselor's
information. Include dates and record number.
Rehabilitation Counselor's Name
Telephone No. (including Area Code)
Address (Number, Street, City, State, ZIP Code)
Services received:
(If additional space is needed, use "REMARKS" section.)
NOTE: PROVIDING INFORMATION ABOUT THE CHILD'S
INVOLVEMENT WITH THE COURT SYSTEM IS OPTIONAL
8. Has the child ever been involved with the court system other than
in custody proceedings?
Yes
No
If "yes," please explain involvement, including testing and evaluation.
Youth Development Center's Name
Address (Number, Street, City, State, ZIP Code)
Probation or Parole Officer's Name
Telephone No. (including Area Code)
Address (Number, Street, City, State, ZIP Code)
Involvement including any testing and evaluation:

Download Form SSA-3881-bk Questionnaire for Children Claiming Ssi Benefits

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