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The SSA SSA-3380-BK form plays a critical role in the Social Security Administration's process for evaluating claims related to mental impairments. This form is designed to gather comprehensive information about an individual's daily activities, social functioning, and ability to maintain concentration and persistence in tasks. It serves as a tool for claimants to detail how their mental health conditions impact their lives, thereby assisting the SSA in making informed decisions regarding eligibility for disability benefits. The form prompts individuals to provide insights into their personal experiences, including challenges faced in social interactions, work environments, and self-care routines. Completing the SSA-3380-BK form accurately is essential, as it can significantly influence the outcome of a disability claim. By emphasizing the importance of this form, individuals can better understand its implications and the necessity of thorough documentation in the pursuit of support from the Social Security Administration.
SSA SSA-3380-BK Example
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FUNCTION REPORT - ADULT - THIRD PARTY Form
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
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
•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 you need more space to answer any questions, use the "REMARKS" section on Page 10, and show the number of the question being answered.
Function Report - Adult - Third Party Form
REMEMBER TO GIVE US THE NAME AND ADDRESS OF THE PERSON
COMPLETING THIS FORM ON PAGE 10
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Privacy Act and Paperwork Reduction Act Statements
Sections 205(a), 223(d), and 1631 of the Social Security Act (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)
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
PLEASE REMOVE THIS SHEET BEFORE RETURNING
THE COMPLETED FORM.
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FUNCTION REPORT- ADULT - THIRD PARTY
How the disabled person's illnesses, injuries, or conditions limit his/her 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, Last)
2.YOUR NAME (Person completing the form)
3.RELATIONSHIP (To disabled person)
4.DATE (MM/DD/YYYY)
5.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.)
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Your Number
Message Number
None
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.)
House |
Apartment |
Boarding House |
Shelter |
Group Home |
Other (What?) |
Nursing Home
b. With whom does he/she live? (Check one.)
Alone |
With Family |
Other (describe relationship)
With Friends
SECTION B - INFORMATION ABOUT ILLNESSES, INJURIES, OR CONDITIONS
8. How does this person's illnesses, injuries, or conditions limit his/her ability to work?
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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?
If "YES," for whom does he/she care, and what does he/she do for them?
Yes
No
11.Does he/she take care of pets or other animals? If "YES," what does he/she do for them?
12.Does anyone help this person care for other people or animals? If "YES," who helps, and what do they do to help?
Yes No
Yes No
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? |
Yes |
No |
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If "YES," how? |
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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
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b. Does he/she need any special reminders to take care of personal needs and grooming?
If "YES," what type of help or reminders are needed?
c. Does he/she need help or reminders taking medicine? If "YES," what kind of help does he/she need?
Yes No
Yes No
16. MEALS |
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a. Does the disabled person prepare his/her own meals? |
Yes |
If "Yes," 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?
b. If "No," explain why he/she cannot or does not prepare meals.
No
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? If "YES," what help is needed?
Yes
No
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d. If the disabled person doesn't do house or yard work, explain why not. |
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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.) |
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Walk |
Drive a car |
Ride in a car |
Ride a bicycle |
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Use public transportation |
Other (Explain) |
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c. When going out, can he/she go out alone? |
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Yes |
No |
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If "NO," explain why he/she can't go out alone. |
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d. Does the disabled person drive?
If he/she doesn't drive, explain why not.
Yes
No
19.SHOPPING
a. If the disabled person does any shopping, does he/she shop: (Check all that apply.)
In stores By phone By mail By 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: |
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Pay bills |
Yes |
Count change |
Yes |
Explain all "NO" answers. |
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No |
Handle a savings account |
No |
Use a checkbook/money orders |
Yes Yes
No No
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b. Has the disabled person's ability to handle money changed since |
Yes |
No |
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the illnesses, injuries, or conditions began? |
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If "YES," explain how the ability to handle money has changed. |
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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. How does the disabled person spend time with others? (Check all that apply.) |
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In person |
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Video Chat (for example Skype or Facetime) |
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Other (Explain) |
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b. Describe the kinds of things he/she does with others. |
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How often does he/she do these things?
c. 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?
How often does he/she go and how much does he/she take part?
Yes
No
Does he/she need someone to accompany him/her?
Yes
No
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d. Does this person have any problems getting along with family, friends, neighbors, or others?
If "YES," explain.
Yes
No
e. 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:
Lifting
Squatting
Bending
Standing
Reaching
Walking
Sitting
Kneeling
Talking
Hearing
Stair Climbing
Seeing
Memory
Completing Tasks
Concentration
Understanding Following Instructions Using Hands
Getting 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:
Right Handed?
Left 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, |
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chores, reading, watching a movie.) |
Yes |
No |
f. How well does the disabled person follow written instructions? (For example, a recipe.)
g. How well does the disabled person follow spoken instructions?
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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? Yes No If "YES," please explain.
If "YES," 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? |
Yes |
No |
If "YES," please explain.
24. Does the disabled person 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 |
Other (Explain) |
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Which of these were prescribed by a doctor?
When was it prescribed?
When does this person need to use these aids?
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25.Does the disabled person currently take any medicines for his/her illnesses, injuries, or conditions?
If " YES," do any of the medicines cause side effects?
Yes
Yes
No
No
If "YES," please explain. (Do not list all of the medicines that the disabled person takes. List only the medicines that cause side effects for the disabled person.)
NAME OF MEDICINE
SIDE EFFECTS PERSON HAS
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
File Breakdown
| Fact Name | Description |
|---|---|
| Purpose | The SSA-3380-BK form is used by the Social Security Administration to collect information about an individual's daily activities and limitations to assess their disability claim. |
| Target Audience | This form is primarily intended for individuals applying for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI). |
| Submission Process | Applicants must complete the form and submit it to the SSA, either online or by mail, as part of their disability application process. |
| Impact on Claims | The information provided on the SSA-3380-BK can significantly influence the outcome of a disability claim, as it helps the SSA evaluate the severity of the applicant's condition. |
| State-Specific Considerations | While the SSA-3380-BK is a federal form, applicants should be aware of state-specific laws and regulations that may affect their disability claims, such as state disability benefits laws. |
Guide to Using SSA SSA-3380-BK
Filling out the SSA-3380-BK form is an important step in your application process. Once you have completed the form, you will submit it to the Social Security Administration for review. This process will help determine your eligibility for benefits.
- Obtain the SSA-3380-BK form. You can download it from the Social Security Administration's website or request a paper copy.
- Read the instructions carefully. Familiarize yourself with the sections of the form to ensure accurate completion.
- Begin with your personal information. Fill in your name, Social Security number, and contact details in the designated fields.
- Provide information about your medical conditions. Describe your disabilities and how they affect your daily life.
- Detail your work history. List your past jobs, including the type of work you did and how long you were employed.
- Include information about your education. Specify the highest level of education you have completed.
- Answer the questions regarding your daily activities. Explain how your condition impacts your ability to perform routine tasks.
- Review your answers for accuracy. Ensure all information is complete and correct before submission.
- Sign and date the form. Your signature confirms that the information provided is true to the best of your knowledge.
- Submit the form. Send it to the appropriate Social Security office or follow the instructions for online submission.
Get Answers on SSA SSA-3380-BK
- Read the instructions carefully to understand what information is required.
- Answer each question honestly and to the best of your ability, providing specific examples when possible.
- Ensure that you describe how your condition affects your ability to perform daily tasks, interact with others, and manage responsibilities.
- Review your answers for accuracy and completeness before submission.
What is the SSA SSA-3380-BK form?
The SSA SSA-3380-BK form is a questionnaire used by the Social Security Administration (SSA) to gather information about an individual's mental functioning. This form is typically required when someone applies for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI) benefits due to mental health conditions. The information collected helps the SSA assess the severity of the applicant's mental impairments and how they impact daily activities.
Who needs to fill out the SSA SSA-3380-BK form?
Individuals who are applying for SSDI or SSI benefits based on mental health issues may be asked to complete this form. It is particularly relevant for those whose disabilities stem from conditions such as depression, anxiety disorders, schizophrenia, or other cognitive impairments. If mental health is a significant factor in the disability claim, the SSA will likely require this form to evaluate the case thoroughly.
How do I complete the SSA SSA-3380-BK form?
Completing the SSA SSA-3380-BK form involves providing detailed information about your mental health condition and its effects on your daily life. Here are some steps to follow:
Consider seeking assistance from a healthcare provider or a legal professional if you have questions about how to accurately represent your condition.
Where do I submit the completed SSA SSA-3380-BK form?
Once you have completed the SSA SSA-3380-BK form, it should be submitted to the Social Security Administration. You can send it by mail to the address provided in the instructions that accompany the form. If you are filing your disability claim online, you may be able to upload the form directly through the SSA's online portal. Always keep a copy for your records.
What happens after I submit the SSA SSA-3380-BK form?
After submitting the SSA SSA-3380-BK form, the Social Security Administration will review the information provided along with other documentation related to your disability claim. This process may take several weeks. The SSA may contact you for additional information or clarification if needed. Once a decision is made regarding your claim, you will receive a notice in the mail detailing the outcome and any next steps.
Common mistakes
Filling out the SSA-3380-BK form can be a daunting task for many individuals seeking Social Security benefits. One common mistake is not providing complete information. Each section of the form is important, and omitting details can lead to delays or denials. It is essential to ensure that every question is answered thoroughly.
Another frequent error is misunderstanding the questions. Some individuals may misinterpret what is being asked, leading to inaccurate responses. Taking the time to read each question carefully can prevent this issue. If clarification is needed, seeking assistance from a knowledgeable source is advisable.
People often forget to include supporting documentation. The SSA-3380-BK form may require additional evidence to substantiate claims. Failing to attach necessary documents can hinder the review process. Always check the requirements and ensure that all relevant paperwork is included.
Inconsistent information is another pitfall. When individuals provide conflicting answers on different parts of the form, it raises red flags. Consistency is key. Review all responses to ensure they align with one another and accurately reflect the individual's situation.
Many applicants neglect to sign and date the form. This simple oversight can result in the form being considered incomplete. A signature is not just a formality; it confirms that the information provided is accurate to the best of the individual's knowledge.
Some individuals rush through the process. Filling out the form in haste often leads to careless mistakes. Taking the time to thoughtfully complete each section can make a significant difference in the outcome of the application.
Another common error is failing to keep a copy of the submitted form. Without a record, individuals may find it challenging to track their application status or respond to any requests for additional information. Always retain a copy for personal records.
People sometimes underestimate the importance of providing detailed descriptions of their impairments. Vague or overly general responses can fail to convey the severity of the condition. Providing specific examples and elaborating on how the impairment affects daily life can strengthen the application.
Additionally, some applicants may ignore the instructions provided with the form. These guidelines are there for a reason. Following them closely can help avoid unnecessary complications and ensure that the form is filled out correctly.
Lastly, individuals may overlook deadlines. Submitting the form late can have serious consequences for benefit eligibility. It is crucial to be aware of any time constraints and to plan accordingly to ensure timely submission.
Documents used along the form
The SSA SSA-3380-BK form is an essential document used by the Social Security Administration to assess an individual's ability to work due to mental impairments. However, there are several other forms and documents that often accompany this form to provide a comprehensive view of an applicant's situation. Understanding these documents can help streamline the application process and improve the chances of a favorable outcome.
- SSA-3368-BK: This form, known as the "Disability Report - Adult," collects information about the applicant's medical conditions, treatments, and work history. It provides a broader context for the mental health issues outlined in the SSA-3380-BK.
- SSA-827: The "Authorization to Disclose Information to the Social Security Administration" form allows the SSA to obtain medical records and other relevant information from healthcare providers. This is crucial for verifying claims made in the SSA-3380-BK.
- SSA-3441: This is the "Supplemental Disability Report," which provides updates on an applicant's condition and any new treatments or medications. It is particularly important for individuals whose conditions may have changed since their initial application.
- SSA-8000: The "Application for Supplemental Security Income" form is used to apply for SSI benefits. It helps the SSA assess financial eligibility alongside the mental health evaluation.
- Form SSA-4506: This is a "Request for Social Security Administration (SSA) Information." It is sometimes used to request a copy of a claimant's file, which can be beneficial for tracking the status of an application.
- Medical Records: Detailed medical records from healthcare providers, including diagnoses, treatment plans, and progress notes, are vital. They substantiate the claims made in the SSA-3380-BK and demonstrate the severity of the mental impairment.
- Personal Statements: These are written accounts from the applicant or family members detailing how the mental impairment affects daily life and functioning. They provide a personal perspective that complements the clinical data.
- Work History Report: This document outlines the applicant's past employment, job duties, and reasons for leaving jobs. It helps the SSA understand how the mental impairment has impacted work performance.
- Third-Party Questionnaires: Sometimes, family members or friends may be asked to fill out questionnaires about the applicant's daily activities and limitations. Their insights can offer additional context to the SSA-3380-BK.
- Functional Capacity Evaluation (FCE): An FCE assesses an individual's physical and mental capabilities in relation to work tasks. This evaluation can provide a clear picture of how the impairment affects the ability to perform job-related activities.
Each of these documents plays a crucial role in the overall assessment process. They collectively provide a clearer picture of an applicant's mental health and its impact on their ability to work. Ensuring that all relevant forms and supporting documents are completed accurately and submitted in a timely manner can significantly enhance the chances of a successful outcome.
Similar forms
The SSA-3380-BK form is used by the Social Security Administration (SSA) to gather information about an individual's daily functioning and limitations. Several other forms serve similar purposes in assessing disability and functional capacity. Below are five documents that share similarities with the SSA-3380-BK form:
- SSA-3368-BK: This form is used to collect information about an individual's work history and medical conditions. Like the SSA-3380-BK, it aims to evaluate the impact of these factors on daily life and functioning.
- SSA-827: This form authorizes the release of medical information. It complements the SSA-3380-BK by ensuring that the SSA has access to necessary medical records to assess an individual's disability claim.
- SSA-3373-BK: This document focuses on the individual's ability to perform daily activities and is similar to the SSA-3380-BK in that it seeks to understand how a person's impairments affect their daily life.
- Form SSA-451: This form is used for a continuing disability review. It assesses whether an individual's condition has changed since the last evaluation, paralleling the SSA-3380-BK's purpose of evaluating ongoing functional limitations.
- Form SSA-4000: This form is utilized for reporting work activity. It is relevant to the SSA-3380-BK as it helps determine how work affects an individual's disability status and daily functioning.
Dos and Don'ts
When filling out the SSA SSA-3380-BK form, attention to detail is crucial. Here are five important guidelines to consider:
- Do read the instructions carefully before starting. Understanding what information is required can prevent mistakes.
- Do provide accurate and complete information. Inaccuracies can lead to delays in processing your application.
- Do use clear and legible handwriting if filling out the form by hand. This ensures that your responses are easily understood.
- Don't leave any required fields blank. Omitting information can result in your application being returned or denied.
- Don't rush through the form. Take your time to ensure that all information is correct and thorough.
Misconceptions
The SSA-3380-BK form is an important document used by the Social Security Administration (SSA) to assess a person's ability to work due to mental impairments. However, several misconceptions exist regarding this form. Here are four common misunderstandings:
- Misconception 1: The SSA-3380-BK form is only for individuals with severe mental illnesses.
- Misconception 2: Completing the SSA-3380-BK form guarantees approval for disability benefits.
- Misconception 3: The SSA-3380-BK form is the only document needed for a disability claim.
- Misconception 4: You can fill out the SSA-3380-BK form without any assistance.
This is not true. The form is designed for anyone experiencing mental health issues that may affect their ability to work, regardless of the severity of their condition.
Filling out the form does not ensure that benefits will be granted. The SSA uses the information provided to evaluate the overall case, and approval depends on various factors, including medical evidence.
This is misleading. While the SSA-3380-BK form is an important part of the application, other documents, such as medical records and work history, are also required for a complete evaluation.
While individuals can complete the form on their own, seeking help from professionals or advocates can provide clarity and improve the accuracy of the information submitted.
Key takeaways
The SSA SSA-3380-BK form is an important document used for assessing the functioning of individuals with disabilities. Here are key takeaways regarding its completion and usage:
- The form is specifically designed to gather information about an individual's daily activities and limitations.
- It is crucial to provide detailed and accurate responses to ensure a comprehensive evaluation.
- Individuals should take their time when filling out the form to reflect their true capabilities and challenges.
- Supporting documentation, such as medical records, can enhance the validity of the information provided.
- After submission, applicants may receive follow-up questions or requests for clarification from the Social Security Administration.
- Understanding the implications of the information provided can help in the overall assessment process.