The SSA SSA-3373-BK form, also known as the Function Report - Adult, is a document used by the Social Security Administration to assess an individual's ability to perform daily activities and work, following a claim for disability benefits. This form provides crucial information that helps determine eligibility for disability payments. For those looking to complete this essential step in the disability benefits application process, clicking the button below will guide you on how to fill out the form accurately and efficiently.
Navigating the complexities of the Social Security Administration's (SSA) processes can be challenging, especially when it comes to providing detailed information about one's disability. The SSA-3373-BK form plays a pivotal role in this scenario, serving as a crucial piece of documentation that individuals must complete as part of their application for disability benefits. This form, often referred to as the Function Report, asks for comprehensive details about how an applicant's disability affects their daily life and ability to work. It covers various aspects of day-to-day living, such as personal care, meal preparation, mobility, and social activities, among others. Completing the SSA-3373-BK accurately and thoroughly is vital for applicants, as it provides the SSA with a deep understanding of the extent of the applicant's limitations and their impact on the applicant's capacity to perform work-related activities. Despite its importance, the form's length and the specificity of the questions can be daunting. Hence, understanding its structure, the type of information required, and how it fits into the broader disability determination process is fundamental for individuals looking to accurately convey the severity of their condition to the SSA.
Form SSA-3373 (10-2020)
Discontinue Prior Editions
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Social Security Administration
OMB No. 0960-0681
FUNCTION REPORT - ADULT
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 10, and show the number of the question being answered.
Function Report - Adult - Form SSA-3373-BK
REMEMBER TO GIVE US THE NAME AND ADDRESS OF THE PERSON
COMPLETING THIS FORM ON PAGE 10
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Privacy Act Statements
Collection and Use of Personal Information
Sections 205(a), 223(d), and 1631 of the Social Security 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 System, as published in the Federal Register (FR) on April 1, 2003, at FR 15784, and 60-0320, entitled Electronic Disability Claim File, as published in the FR on December 22, 2003, at 68 FR 71210. Additional information, and a full listing of all our SORNs, is available on our website at https://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 regarding this burden estimate or any other aspect of this collection, including suggestions for reducing this burden 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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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?
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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?
8. Do you take care of pets or other animals?
If "YES," what do you do for them?
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?
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
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b. Do you need any special reminders to take care of personal
needs and grooming?
If "YES," what type of help or reminders are needed?
c. Do you need help or reminders taking medicine?
If "YES," what kind of help do you need?
13. MEALS
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?
If "YES," what help is needed?
d. If you don't do house or yard work, explain why not.
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15. GETTING AROUND
a. How often do you go outside?
If you don't go out at all, explain why not.
b. When going out, how do you 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 you go out alone?
If "NO," explain why you can't go out alone.
d. Do you drive?
If you don't drive, explain why not.
16.SHOPPING
a. If you do any shopping, do you shop: (Check all that apply.)
In stores
By phone
By mail
By computer
b. Describe what you shop for.
c. How often do you shop and how long does it take?
17. MONEY
a. Are you able to:
Pay bills
Handle a savings account
Count change
Use a checkbook/money orders
Explain all "NO" answers.
b. Has your ability to handle money changed since the illnesses,
injuries, or conditions began?
If "YES," explain how the ability to handle money has changed.
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18.HOBBIES AND INTERESTS
a.What are your hobbies and interests? (For example, reading, watching TV, sewing, playing sports, etc.)
b.How often and how well do you do these things?
c.Describe any changes in these activities since the illnesses, injuries, or conditions began.
19.SOCIAL ACTIVITIES
a. How do you 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 you do with others.
How often do you do these things?
c. List the places you go on a regular basis. (For example, church, community center, sports events, social groups, etc.)
Do you need to be reminded to go places?
How often do you go and how much do you take part?
Do you need someone to accompany you?
If "YES", explain.
d. Do you 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.
Form SSA-3373 (10-2020)Page 8 of 10
SECTION D - INFORMATION ABOUT ABILITIES
20. a. Check any of the following items that your illnesses, injuries, or conditions affect:
Lifting
Walking
Stair Climbing
Understanding
Squatting
Sitting
Seeing
Following Instructions
Bending
Kneeling
Memory
Using Hands
Standing
Talking
Completing Tasks
Getting Along With Others
Reaching
Hearing
Concentration
Please explain how your illnesses, injuries, or conditions affect each of the items you checked. (For example, you can only lift [how many pounds], or you can only walk [how far])
b. Are you:
Right Handed?
Left Handed?
c. How far can you walk before needing to stop and rest?
If you have to rest, how long before you can resume walking?
d. For how long can you pay attention?
e. Do you finish what you start? (For example, a conversation, chores,
reading, watching a movie.)
f. How well do you follow written instructions? (For example, a recipe.)
g. How well do you follow spoken instructions?
h. How well do you get along with authority figures? (For example, police, bosses, landlords
or teachers.)
i. Have you ever been fired or laid off from a job because of problems getting
along with other people?
If "YES," please explain.
If "YES," please give name of employer.
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j. How well do you handle stress?
k. How well do you handle changes in routine?
l. Have you noticed any unusual behavior or fears?
21. Do you 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 do you need to use these aids?
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22. Do you currently take any medicines for your illnesses, injuries, or conditions?
If "YES, "do any of your medicines cause side effects?
If "YES," please explain. (Do not list all of the medicines that you 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.
Name of person completing this form (Please print)
Address (Number and Street)
Date (MM/DD/YYYY)
Email address (optional)
City
State
ZIP Code
Completing the SSA SSA-3373-BK form, also known as the Function Report - Adult, is a step towards providing the Social Security Administration (SSA) with detailed insights into how your medical condition affects your daily life and ability to work. This paperwork is instrumental in helping SSA determine your eligibility for disability benefits by illustrating the limitations caused by your disability. Drafted accurately, it shines a light on the challenges faced in everyday activities, underlining the necessity and legitimacy of your claim. Following the steps below will guide you through the process of filling out the form correctly, ensuring your responses enhance your disability claim.
After you’ve submitted the SSA SSA-3373-BK form, the SSA will review the information provided in conjunction with medical records and possibly other documents you've submitted to make a determination on your disability claim. It’s a crucial component of your application, offering a comprehensive view of how your condition affects everyday life. Preparing this form with attention to detail and accuracy helps ensure that the impact of your disability is fully understood by the decision-makers at the SSA.
What is the SSA SSA-3373-BK form used for?
The SSA SSA-3373-BK form is a vital document in the process of obtaining disability benefits through the Social Security Administration (SSA). Officially known as the "Function Report - Adult," this form is designed to collect detailed information about how an individual's disability affects their daily activities and ability to work. By providing a comprehensive picture of the person's daily life, it helps the SSA assess the severity of the disability and make an informed decision regarding their benefits eligibility.
Who needs to fill out the SSA SSA-3373-BK form?
Individuals who are applying for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) due to a disability are required to complete the SSA SSA-3373-BK form. It can also be requested from current beneficiaries whose cases are up for review. The form plays a crucial role in demonstrating how their conditions limit their functional capabilities.
How can one obtain the SSA SSA-3373-BK form?
The SSA SSA-3373-BK form can be obtained through several methods. It's available for download on the Social Security Administration's official website. Alternatively, individuals can request a paper copy by contacting their local SSA office or by calling the SSA's national customer service hotline. Representatives there can provide the form and guidance on how to fill it out.
What information is required to complete the form?
Completing the SSA SSA-3373-BK form requires detailed information about the individual's daily activities, medical conditions, and how these affect their capacity to perform work-related tasks. Respondents are asked to describe their typical day, including personal care, meals, chores, and hobbies, as well as their ability to lift, stand, walk, sit, and remember instructions. Accuracy and thoroughness in describing the limitations and impacts of the disability are essential for a fair assessment.
Are there any tips for filling out the SSA SSA-3373-BK form effectively?
When filling out the SSA SSA-3373-BK form, it is critical to be honest and precise. Avoid underestimating or exaggerating the impact of your disability. Provide specific examples of how your condition affects your daily activities and, if possible, include information on how your abilities may vary day-to-day. It's also helpful to discuss your submission with a healthcare provider or a legal representative to ensure the information is accurate and well-documented.
What happens after the SSA SSA-3373-BK form is submitted?
After the SSA SSA-3373-BK form is submitted, the Social Security Administration reviews the information provided as part of the broader disability determination process. This review may include follow-up questions or requests for additional documentation. The SSA may also schedule consultations with medical professionals to further assess the disability. The decision regarding benefits eligibility typically takes several months, depending on the complexity of the case.
Can the SSA SSA-3373-BK form be submitted online?
Yes, the SSA SSA-3373-BK form can be submitted online through the Social Security Administration's website. This method provides a convenient option for applicants to send in their information. To submit the form online, users need to log into their SSA account or create a new one. It is important to follow all on-screen instructions carefully to ensure the submission is successful.
What should one do if they need help with the SSA SSA-3373-BK form?
If assistance is needed in completing the SSA SSA-3373-BK form, several resources are available. The Social Security Administration can provide guidance and answer questions related to the form. Legal assistance through a disability attorney or advocate is also highly beneficial, especially for complex cases or appeals. Local non-profit organizations focusing on disability rights and services may offer additional support and resources.
One common mistake many make when filling out the SSA SSA-3373-BK form, also known as the Function Report - Adult, is not providing enough detail. This form is a vital part of your disability claim, as it gives an insight into how your condition impacts your daily life. By not being thorough in your explanations, you might miss the opportunity to showcase the extent of your limitations.
Another error is not taking the form's questions seriously. Sometimes, individuals might rush through the questionnaire, possibly because they find it stressful or overwhelming. This hurried approach can lead to incomplete or vague answers that fail to accurately represent one's daily challenges. It's essential to take your time and consider each question carefully.
Sometimes, people are not consistent with the information they provide in the SSA SSA-3373-BK form compared to other documents submitted for their disability claim. Inconsistencies, whether accidental or not, can raise questions about the credibility of your entire claim. Ensure that the details you provide on this form align with the information found in your medical records and your Social Security Disability Insurance application.
Many individuals make the mistake of underestimating the importance of the 'Remarks' section. Leaving this section blank or not using it effectively to provide additional context might result in an incomplete picture of your disability. Utilize this space to offer any further explanations or clarifications that can help understand your condition better.
A not-so-obvious mistake is the failure to describe a typical day. This part of the form is crucial for giving the Social Security Administration (SSA) a frame of reference for your daily activities and limitations. Omitting details or providing a generic description won't reflect the true impact of your condition on your day-to-day life.
Forgetting to update contact information is another oversight. The SSA might need to contact you for further information or clarification. Making sure that your contact details are accurate and up to date ensures that the review process is not delayed unnecessarily.
Many also fall into the trap of embellishing their condition. While it might be tempting to exaggerate difficulties to ensure your application is successful, this strategy can backfire. Honesty is crucial when completing the SSA-3373-BK form; accuracy in portraying your condition establishes trust and credibility in your claim.
Relying on memory alone to complete the form can lead to inaccuracies or forgotten details. It's beneficial to consult your personal records, medical documents, or a diary where you note daily limitations and challenges. This preparation can help in providing precise and consistent answers.
Disregarding the instructions is a common error. Every section of the form comes with specific instructions that are easy to overlook if one is in a hurry. Not following these can lead to incorrectly filled-out sections, which might impact the assessment of your disability claim.
Last but certainly not least, not asking for help when needed can be detrimental. Whether it's consulting with a professional, such as a lawyer who specializes in Social Security Disability claims, or seeking assistance from friends or family, support can make a significant difference in the accuracy and completeness of your form.
When applying for Social Security disability benefits, the process involves more than just completing the SSA SSA-3373-BK form, which is also known as the Function Report - Adult. This critical form helps the Social Security Administration (SSA) evaluate the impact of an individual's health condition on their ability to perform daily activities and work. However, to build a comprehensive case, several other forms and documents are commonly submitted alongside the SSA SSA-3373-BK to provide a fuller picture of the applicant's situation.
Understanding and gathering these forms and documents is a vital step in the application process for Social Security disability benefits. Each plays a unique role in painting a detailed picture of the applicant's life, health, and work history for the SSA. A thorough and well-documented application increases the chances of a favorable outcome, contributing to a smoother process for obtaining the much-needed support and benefits.
The SSA-827 (Authorization to Disclose Information to the Social Security Administration) shares similarities with the SSA-3373-BK Function Report. Both forms are integral to the Social Security Administration's process for evaluating claims. The SSA-827 seeks permission from claimants to allow the SSA to obtain personal medical records and other pertinent information. This form is crucial for substantiating the details claimants provide in the SSA-3373-BK, particularly regarding their medical conditions and how these affect their functionality.
The RFC (Residual Functional Capacity) form is another document that has similarities with the SSA-3373-BK. This form is used by Disability Determination Services to capture a detailed understanding of a claimant's capabilities. The SSA-3373-BK provides subjective information from the claimant's perspective about their daily activities and limitations. In contrast, the RFC form consolidates objective medical evidence and professional observations to assess what the claimant can do despite their disability.
The SSA-3368 (Disability Report - Adult) also parallels the SSA-3373-BK in purpose and content. This form is typically the starting point for disability claims, collecting initial details about the claimant's medical condition, work history, and how their disability affects their life. While the SSA-3368 sets the stage for understanding the claimant's situation, the SSA-3373-BK delves deeper, seeking more granular insights into how the claimant's daily activities are impacted by their condition.
The Work History Report (SSA-3369-BK) bears resemblance to the SSA-3373-BK by collecting information pertinent to understanding a disability claimant's previous employment. The SSA-3369-BK focuses on the types of jobs the claimant has held over the past 15 years, the physical and mental demands of those jobs, and reasons for leaving. This information complements the SSA-3373-BK's detailed account of daily activities, offering a fuller picture of the claimant's ability to engage in substantial gainful activity.
Lastly, the Adult Disability Starter Kit and the SSA-3373-BK Function Report share the goal of guiding individuals through the initial stages of filing for disability benefits. The starter kit provides checklists, factsheets, and a worksheet to help claimants gather the necessary information for their application. While the starter kit prepares claimants for the process, the SSA-3373-BK specifically collects in-depth personal accounts of how their disabilities affect functional capabilities, playing a crucial role in the evaluation process.
Filling out the SSA SSA-3373-BK form, also known as the Function Report - Adult, is a crucial step in applying for Social Security disability benefits. Let's break down what you should and shouldn't do to navigate this process smoothly.
Read the entire form before you start filling it out. Understanding the types of information requested will help you gather your thoughts and the necessary documents.
Be detailed in your explanations. Instead of just stating that you can't stand for long periods, specify how long you can stand before needing to sit down.
Use additional sheets of paper if you run out of space. Ensure each page is clearly labeled with your name and Social Security Number, along with indicating the question you are answering.
Be honest about your limitations and how your disability affects your daily life. This includes detailing any assistance you require with personal care, chores, and outside activities.
Discuss how your condition has changed over time. If certain tasks have become more difficult for you, make sure to include this information.
Review your answers before submitting the form to ensure all information is accurate and complete.
Rush through the form. Take your time to answer each question thoroughly to ensure no important details are missed.
Leave any questions unanswered. If a question does not apply to you, it's better to write "Not Applicable" or "N/A" than leaving it blank.
Exaggerate your abilities or limitations. Misrepresentation can affect the outcome of your application.
Use vague language. Avoid terms like "sometimes" or "a little bit" without providing specific examples to clarify.
Forget to sign and date the form. An unsigned or undated form can result in processing delays.
Submit the form without making a copy for your records. Keeping a copy will help you remember what information you provided and will be useful for future reference.
The Social Security Administration (SSA) Form SSA-3373-BK, often referred to as the Adult Disability Report, plays a crucial role in the determination process for Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) benefits. Despite its importance, there are several misconceptions surrounding this form. Clarifying these misunderstandings is essential for applicants to navigate the application process more effectively.
Completing the Form Guarantees Benefits: A common misconception is that simply filling out and submitting Form SSA-3373-BK guarantees approval for disability benefits. In reality, the Social Security Administration utilizes a comprehensive evaluation process. This form is a part of that process, providing detailed information about an applicant's condition and how it affects their ability to work. Approval depends on a combination of factors, including medical evidence, work history, and adherence to SSA’s definition of disability.
Only Physical Health Matters: Some applicants believe that the SSA-3373-BK form focuses solely on physical health conditions, neglecting mental health issues. However, the form is designed to collect information about both physical and mental health conditions that impact an individual's ability to work. Recognizing the importance of mental health, the SSA thoroughly considers these conditions during the disability determination process.
More Detailed Responses Lead to Quicker Approvals: While providing comprehensive and accurate information on the form is crucial, there is a misconception that more detailed responses will lead to quicker approval. The truth is, the complexity of an applicant's condition and the SSA’s workload at the time of application play a significant role in the timeline. Detailed responses can indeed help the SSA better understand an individual’s situation, but they do not necessarily expedite the processing time.
The Form is the Only Documentation Needed: Another misunderstanding is that the SSA-3373-BK form is the sole piece of documentation required for disability benefits approval. This is not the case. Applicants must also submit medical records, work history information, and other relevant documents. The form serves as a personal account of how one's disability affects daily activities and work, but it is the combination of this form with other evidence that aids the SSA in making a decision.
The SSA-3373-BK, also known as the Function Report - Adult, is a vital document used by the Social Security Administration (SSA) to evaluate an individual's eligibility for disability benefits. Understanding how to properly complete and use this document can significantly influence the outcome of a disability claim. Here are key takeaways to consider when dealing with the SSA-3373-BK form:
Properly filling out the SSA-3373-BK form is crucial for anyone applying for Social Security Disability benefits. Being thorough, accurate, and providing ample evidence of your condition are essential steps in utilizing the form effectively to support your claim. Remember, the goal is to give the SSA a comprehensive understanding of how your disability affects your life and your ability to work.
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