Form SSA-3373 Function Report - Adult

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.

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.
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•
•
•
•

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

HOW TO COMPLETE THIS FORM

Privacy Act Statements
Collection and Use of Personal Information
Sections 205(a), 223(d), and 1631 allow us to collect this information. Furnishing us this
information is voluntary. However, failing to provide all or part of the information may prevent
us from making a decision on your claim.
We will use the information you provide to determine eligibility for benefits. We may also share
your information for the following purposes, called routine uses:
• To contractors and other Federal agencies, as necessary, to assist us in efficiently
administering our programs; and
• To State audit agencies for auditing State supplementation payments and Medicaid
eligibility considerations.
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) 60-0058, entitled Master File of Social Security Number (SSN) Holders and SSN
Applications, as published in the Federal Register (FR) on December 29, 2010, at 75 FR
82121; 60-0089, entitled Claims Folders Systems, as published in the FR on April 1, 2003, at
68 FR 15784; and 60-0090, entitled Master Beneficiary Record, as published in the FR on
January 11, 2006, at 71 FR 1826. Additional information and a full listing of all our SORNs are
available on our website at https://www.ssa.gov/privacy. See Revised Privacy Act and
PRA Statements Attached
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 1800-772-1213 (TTY 1-800-325-0778). You may send comments on our time estimate above to:
SSA, 6401 Security Blvd, Baltimore, MD 21235-0001. 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
OMB No. 0960-0681

SOCIAL SECURITY ADMINISTRATION

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
Area Code

Message Number

None

Phone Number

4. a. Where do you live? (Check one.)
House

Apartment

Boarding House

Shelter

Group Home

Other (What?)

Nursing Home

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 (03-2016)
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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,
parents, friend, other?

Yes

No

Yes

No

Yes

No

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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Yes

No

b. Do you need any special reminders to take care of personal
needs and grooming?

Yes

No

Yes

No

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
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?
If "YES," what help is needed?

Form SSA-3373-BK (10-2015) UF (03-2016)

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Yes

No

d. If you don't do house or yard work, explain why not.

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

Use public transportation

Ride a bicycle

Other (Explain)

c. When going out, can you go out alone?

Yes

No

Yes

No

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.)
By phone

In stores

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

Yes

No

Handle a savings account

Yes

No

Count change

Yes

No

Use a checkbook/money orders

Yes

No

Explain all "NO" answers.

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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.

Yes

No

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 Do you spend time with others? (Check all that apply. In person, on the phone on the
computer, etc.)
Yes
No
__ in person
__ on the phone
__ email
__ texting
__ mail
__ video chat (for example: Skype or Facetime)
__ other: ______________________________
b. If "YES," dDescribe the kinds of things you do with others.
_______________________________________________________________________________
How often do you do these things?
c.b.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?

Yes

No

Yes

No

How often do you go and how much do you take part?

Do you need someone to accompany you?
If "YES," please explain.
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d.c.Do you have any problems getting along with family, friends, neighbors, or others?

Yes

If "YES," explain.

No

e.d.Describe any changes in social activities since the illnesses, injuries, or conditions
began.

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?

Form SSA-3373-BK (10-2015) UF (03-2016)

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Yes

No

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?

Yes

No

Yes

No

If "YES," please explain.

If "YES," please give name of employer.
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?
If "YES," please explain.
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

Other (Explain)
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?

Yes

No

Yes

No

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)

Date (month, day, year)

Address (Number and Street)

Email address (optional)

City

State

Form SSA-3373-BK (10-2015) UF (03-2016)

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ZIP Code

SSA will insert the following revised Privacy Act Statement into the form as soon
as possible:
Privacy Act Statement
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 to determine 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 the
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 68 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 of our SORNs, is available on our website at www.ssa.gov/privacy.

SSA will insert the following revised PRA Statement into the form as soon
as possible:
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 1800-325-0778). 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.