ADDENDUM TO THE SUPPORTING STATEMENT FOR FORM SSA-3373-BK
OMB No. 0960-0681
EXPLANATIONS FOR REVISIONS TO FORM SSA-3373-BK (Function Report - Adult)
Background
Currently, there is no national adult “pain symptoms” form. As a result, there has been no uniformity in the format or the questions used to collect information about symptoms in adult disability claims since the SSA-3370-BK (Pain Report – Adult) was removed from circulation in 1997. (The SSA-3370-BK was formally made obsolete in August 2001.) Since 1997, when information about the functional effects of an adult claimant’s symptoms on his or her ability to work is needed, each disability determination services (DDS) uses its own forms and questions to collect this information. To correct the lack of national uniformity, we had promised OMB in 2004, in generic clearance package 0960-0555, that we would create a new national form to collect information about pain symptoms.
Rather than create an additional form, we are revising the SSA-3373-BK (Function Report – Adult) to collect information about the functional effects of a claimant’s physical or mental impairment-related symptom(s). This revision will provide a single form to collect and record information about the functional effects of a claimant’s illnesses, injuries, or conditions and related symptoms on his or her activities and abilities. The information collected by the revised
SSA-3373-BK, together with medical evidence, is part of the evidentiary basis upon which the initial disability process is founded. The revised SSA-3373-BK reduces the paperwork the claimant has to complete and the adjudicator has to review, and will reinstate national uniformity in the collection of information we need to assess disability for adult claimants under the title II and title XVI disability programs.
The revised form retains the number (SSA-3373-BK) and title (Function Report – Adult) as in the current form. However, in response to our adjudicator’s requests, we have reordered the sequence of subject headings to streamline review of the form. In addition, as part of SSA’s move to a paperless environment, wherever possible, for the revised form we adopted a question and answer format designed to translate easily into an electronic format when the time comes for this form to be converted to an electronic form. Thus, in the redesign, fewer questions require a narrative response. Because of this change, less information will need to be scanned, saving time and expense for the DDS and for SSA. In addition, the possible answers to each question have been numbered or lettered, as appropriate, for ease of data collection. We have also reworded the questions to eliminate “leading” the person completing the form. The revised form conforms to SSA’s plain language standard that makes it easier for the public to understand.
The SSA-3371 (Pain Report-Child), and the SSA-3375, SSA-3376, SSA-3377, SSA-3378, and SSA-3379 (Function Report-Child) (separate forms for each age group: Birth-1, 1-3, 3-6, 6-12, and 12-18) will continue to be used, when appropriate, in title XVI childhood disability claims.
Explanation of Proposed Revisions
Instruction cover sheet
The instruction cover sheet has been revised to make clear that we need information about the claimant’s injuries, illnesses, and conditions and any symptoms related to the injuries, illnesses, and conditions.
We made some changes to the first bulleted item on the cover sheet. We now ask the person completing the form to print of write clearly as our experience shows that the form is rarely, if ever, typed.
We also revised the cover sheet to include a specific instruction to consider any symptoms when answering questions about how the illnesses, injuries, or conditions affect activities or abilities and added an instruction that if the form is being completed by someone other than the claimant, we need an explanation in new Section D of why the claimant is not completing the form.
In answer to concern that the form does not allow enough space for claimant’s to answer some questions, we expanded the instruction in the last bullet to make clear that if more space is needed to answer any question, the person completing the form can use the “REMARKS” section or a blank sheet of paper.
The Privacy Act and Paperwork Reduction Act information has been duplicated from the current SSA-3373-BK, and updated, as necessary. We changed the estimate of how long it will take to read the instructions, gather the facts, and complete the form from 30 minutes to 60 minutes in response to public feedback that 30 minutes was insufficient.
Section A - General Information
We removed the “Date” from this section because it is redundant. The date the form is completed is captured at the end of new Section E (formerly Section D). The logical place for the date is with the information about who completed the form.
We amended the reminder on the cover sheet to show that the date the form is completed as well as the name and address of the person completing the form must be entered on the last page (now page 14).
We reworded the lead statements to questions 5.a. and 5.b. to clarify that we want to know about the claimant’s current living arrangements. There is no change in the number of possible answers in 5.a. and 5.b, but we renumbered the possible answers for ease of data collection and arranged them in a user-friendly layout.
Parts 5.c. and 5.d. are new. Part 5.c. was added to collect information about any changes in where the claimant lives or in the claimant’s living arrangements since the illnesses, injuries, or conditions began. Part 5.d. captures information about the reason for any change.
Section B - INFORMATION ABOUT YOUR ABILITIES
On the revised form, this section corresponds to SECTION C - INFORMATION ABOUT ABILITIES –on the current form. We redesigned this section to neutralize the questions. The questions are designed to adapt to an electronic-ready format. We have reworded the heading from “INFORMATION ABOUT ABILITIES,” TO “INFORMATION ABOUT YOUR ABILITIES” to emphasize that we want information about the claimant’s abilities.
Question 6. – Question 6. on the revised form combines questions 20. and 21. from the current form:
Part 6.a. is a reordering of the list of functions in question 20.a. of the current form. We did this to mirror the sequence of functions on the SSA-4734-U8 (Physical Residual Functional Capacity Assessment) to coordinate the sequence of information on two forms that are used by our adjudicators in the course of evaluating and determining disability. We simplified the terms for some of the functions to make them more understandable to the claimant or other person completing the form on the claimant’s behalf. We removed some of the functions listed on the current form because we capture information about those functions through other questions on the revised form. For example, information about following memory or completing tasks will be collected in response to question 6.g. of the revised form. We moved some functions that are more correctly clustered with other questions in the revised form. For example, “Understanding” is more closely associated with the functions listed in question 6.g. of the revised form, where it is now placed. Part “a” is put into a “YES”/”NO” format to collect information on whether a function is affected by the illnesses, injuries, or conditions.
Part “b” of the revised form corresponds to the second part of question 20.a of the current form. In part “b” of the revised form, rather than ask for an explanation of how the illnesses, injuries, or conditions affect each of the listed functions, we now ask only for information about the functions to which the applicant responded “YES” in part “a”.
Part “c” is new. The question gives the claimant a simple format in which to describe his or her ability to do each of the listed functions.
Part “d” corresponds to question 21. of the current form. The new part “d” retains the list of assistive devices shown in the current question 21., but is reformatted to a “YES”/”NO” format.
Part “e” of the revised form corresponds to the fourth part of question 21. of the current form. For each “YES,” information is collected in part “e” on when the device is used and whether it does or does not help in performing daily activities. We removed “need” because many claimants use an assistive device, but don’t need to use the device.
New part “f” corresponds to the second and third questions of question 21. of the current form. This part collects information on when and by whom assistive devices that the claimant uses were prescribed. We removed question 20.b. of the current form (Are you right handed or left handed). The information is available through other sources, e.g., medical history, SSA employee observations.
The information collected by parts “g.1,” “g.3.,” “g.6.,” “g.7.,” “g.8.,” and “g.9.” of the revised form correspond respectively to the information collected in parts “d,” “e,” “f,” “g,” “k,” and “j” of question 20 of the current form put into a “YES”/”NO” format. We added “Read a newspaper, magazine, or book” (“g.4”) and “Watch a movie” (“g.5.”), to capture information about the ability to concentrate, and simplified the term and moved “Understanding” from question 20.a. of the current form to “Understand” in part “g.2.” of the revised form for the reasons noted above. We removed question 20.l. of the current form as we find that the claimant is often not aware of unusual behaviors and fears and that this information can best be obtained from medical, psychological, or third party sources.
Part “h” of the revised form collects information about how the illnesses, injuries, or conditions changed the ability to do any activity checked “YES” in part “g.” We removed question 20.c of the current form. Information about if and how the illnesses, injuries, or conditions affect the claimant’s ability to walk will be captured as part of new part “c”.
Question 7–
This question is new on the revised form. It collects information about any prescription and non-prescription medications, treatments, or other methods the claimant uses currently or has used in the past for his or her illnesses, injuries, conditions, or symptoms.
Part “a” collects information about any prescription or non-prescription medication and supplements information collected by Section 5. of form SSA-3368-BK (Disability Report – Adult).
Part “a.1.” collects information about the dosage and frequency the medication the claimant takes or has taken in the past.
Part “a.2”. corresponds to question 12.c. of the current form and collects information about whether the claimant needs help or reminders to take his or her medication.
Part “a.3.” collects information about any functional effects caused by medication.
Part “b” is new. This part collects information about any treatment other than medication (for example, acupuncture or physical therapy) or other method (for example, lying flat on the back or changing position) that the claimant uses currently or has used in the past for his or her illnesses, injuries, conditions, or symptoms.
Part “b.1” collects information about the type of treatment or other method the claimant uses or has used and the start and stop dates for the treatment or other method.
Part “b.2.” collects information about whether the treatment or other method was recommended by a doctor or other health care professional who treated or examined the claimant.
Parts “b.3.” and “b.4. collect the same information for treatments or other methods as do parts “a.2.” and “a.3. respectively for medications.
SECTION C – INFORMATION ABOUT YOUR DAILY ACTIVITIES
On the revised form, this section corresponds to SECTION B – INFORMATION ABOUT DAILY ACTIVITIES – on the current form. This section has been redesigned to eliminate wording that is “leading” and to put the questions into an electronic-ready format. We changed the heading from “INFORMATION ABOUT DAILY ACTIVITIES,” to “INFORMATION ABOUT YOUR DAILY ACTIVITIES” to emphasize that we are asking about the daily activities of the person applying for disability.
Question 8. – PERSONAL CARE – On the revised form, this question consolidates under a single heading questions on the current form that collect information about personal care.
We removed the “NO PROBLEM” check box at the beginning of the question and reformatted the question into parts “a,” “b,” and “c.” Part “a” on the revised form corresponds to question 12.a. of the current form and calls for a “YES” or ”NO” answer to the same list of personal care activities as is on the current form, with two exceptions. “Shower or Bathe” has been substituted for “Bathe” because many people regularly shower rather than bathe as part of their regular personal care. “Care for teeth” has been added because is a regular part of personal care.
Part “b” requires a narrative description of any “YES” answer in part “a”. This is no different from the current form.
Part “c” is essentially a modification of question 12.c. on the current form, but specific to personal needs.
Question 9. - Question 9. on the revised form corresponds to question 11 on the current form.
Question 10. – This question on the revised form is a consolidation of the information requested by questions 6.-9. on the current form.
Part “a” collects information about other persons the claimant cares for.
Part “b” collects information about pets or other animals the claimant cares for. In addition to the “YES”/”NO” boxes, in parts “a” and “b” we have added a box, “NEVER DID THIS” to distinguish between a claimant who has never cared for another person, pet, or other animal, and a claimant who no longer cares for another person, pet, or other animal.
Part “c” is required only when the response to part “a” or part “b” is “YES.” Part “c” collects more detailed information on the nature and frequency of the care provided. Current Question 6. (Describe what you do from the time you wake up until going to bed) has been deleted. The current question requires a time-consuming narrative and the information requested can be collected more efficiently in a way that is less labor-intensive for the claimant and more readily assessed by the adjudicator through other questions on the form.
Question 11. - Question 11. on the revised form corresponds to question 10. on the current form. The question has been reworded to eliminate “leading” language in the current form.
Question 12. - GETTING AROUND on the revised form corresponds to Question 15. – GETTING AROUND – on the current form.
Part “a” of the revised form is a restructuring of questions 15.a. and c. of the current form. We have removed the first part of question 15.a. of the current form as the information is not necessary.
Part “b” on the revised form corresponds to question 15.b. of the current form, but is reworded.
Part “c” on the revised form collects information about how often and how far a claimant can drive and is triggered when part “b.2.” is checked.
Part “d” corresponds to question 15.d. of the current form. Part “d.1.” collects information about why a claimant who can drive does not. Part “d.2.” collects information about why a claimant cannot drive.
Part “e” is new and collects information about any changes in the way the claimant gets around outside the home since his or her illnesses, injuries, or conditions started.
Question 13. - MONEY – on the revised form corresponds to Question 17. – MONEY - on the current form. Both questions 17.a. and 17.b. of the current form have been restructured to follow the new format and much of the narrative portion of question 17.a. of the current form has been removed. “Pay bills” has been changed to “Use your money by yourself” to make clear that it is the claimant’s ability to manage money, not the claimant’s financial ability to pay bills that we are interested in. Parts “a” and “b” in the revised form correspond respectively to questions 17.a. and 17.b. of the current form.
Question 14. – MEALS – on the revised form corresponds to question 13. – MEALS – on the current form. The question has been reformatted in anticipation of a future electronic form and follows the “YES”/”NO” format used throughout the revised form. Rather than asking “the kinds of food” prepared, the questions now inquire about the complexity of the meals prepared.
Part “a” collects information on whether the claimant prepares his or her own meals. Substantively, part “a” is the equivalent of question 13.a. of the current form, but reformatted. In the revised form, a “NO” response to the question triggers a required narrative response to collect information as to why the claimant does not prepare meals. This information is collected in question 13.b. on the current form.
Part “b” collects information about what meals the claimant usually prepares. The reformatted question provides for checkboxes to indicate what meals (breakfast, lunch, dinner) the claimant usually prepares to replace the narrative format used in question 13.a of the current form.
Part “c” of the revised form collects information on the complexity of the meals prepared by the claimant and provides checkboxes (“c.1,” “c.2.,” or “c.3.”) to describe the level of complexity most often true.
Part “d” collects information about any change in the way the claimant prepares meals, the type of meals the claimant prepares, or how often the claimant prepares meals since the illnesses, injuries, or conditions began. A “YES,” triggers a request for a narrative description of the change(s). This request is equivalent to the fourth question under question 13.a. of the current form. We have removed the second and third questions under question 13.a. of the current form.
Question 15. – HOUSE AND YARD WORK – on the revised form corresponds to question 14. – HOUSE AND YARD WORK - on the current form.
Part “a” is reworded and reformatted. The new question provides for the option of a “YES” or “NO” answer. A “NO” requires a narrative explanation as to why the claimant does not do any house or yard work. This question corresponds to question 14.d. of the current form. A “YES” response collects information on house or yard work the claimant does and corresponds to the information collected by question 14.a. of the current form.
Part “b” of the revised form is new. This question collects information about any changes in the claimant’s functional abilities since his or her illnesses, injuries, or conditions started.
Part “c” of the revised form corresponds to question 14.c. of the current form. This question collects information on any help or encouragement the claimant needs to do house or yard work. The revised question also asks who provides any needed help or encouragement. We have deleted question 14.b. on the current form. In the revised form, the information requested by this question is collected through the claimant’s responses to other questions in this section and elsewhere on the form.
Question 16. – SHOPPING - on the revised form corresponds to Question 16. – SHOPPING – on the current form. The reformatting of the new question 16 reduces the required narrative.
Part “a” of the revised form is reworded, but corresponds to question 16.a. of the current form.
Parts “b.1.,” “b.2.,” and “b.3.” of the revised form correspond to question 15.b. and the first part of question 16.c. of the current form.
Questions 16.c. and 16.d. are new. Question 16.c. is a follow-up to part “a.” If the person applying for disability does not shop for him or herself or others, part “c” collects information about if this is a change since the illnesses, injuries, or conditions began.
Question 16.d. is a follow-up to part “b.” If the person applying for disability currently does shop, part “d” asks about change in shopping habits subsequent to the illnesses, injuries, or conditions. We removed the second part of question 16. c. of the current form as information about how long it takes the claimant to shop is not necessary.
Question 17. - SOCIAL ACTIVITIES - on the revised form corresponds to question 19.–SOCIAL ACTIVITIES - on the current form. The section has been restructured, reordered, and reworded.
Part “a” of the revised form corresponds to the first part of “a” of the current form.
Part “b” of the revised form corresponds to the second part of part “a” of the current form.
Part “c” of the revised form corresponds to the information requested in the first part of part “b” of the current form. We reworded the question to collect the information now collected by the second question in part “b” of the current form.
Part “d’ of the revised form corresponds to part “d” of the current form.
Part “e” of the revised form corresponds to part “c” of the current form.
Parts “f” and “g” of the revised form correspond to questions 20.h. and “I” of the current form. We moved these questions from the section on abilities to the section on activities because the functions belong with other questions about the claimant’s activities in social and work settings. We removed the first question in part “b” of the current form as information about the claimant’s ability to remember is collected in several other places in the form, and the third question in part “b” of the current form as the information is captured by the claimant’s response to question 12.a. of the revised form.
Question #18, HOBBIES AND INTERESTS – on the revised form corresponds to question 18. – HOBBIES AND INTERESTS - on the current form.
Part “a” of the revised form corresponds to part “a” and the first part of part “b” of the current form. The question is reworded and put in a “YES”/”NO”/”NEVER HAD ANY HOBBIES OR INTERESTS” format on the revised form. The “NEVER HAD ANY HOBBIES OR INTERESTS” box was added to distinguish between a claimant who has never had any hobbies or interests and a claimant who no longer pursues his or her hobbies or interests.
Part ‘b” of the revised form corresponds to part “c” of the current form. We removed the second part of part “b” of the current form. We no longer ask the claimant to assess how well he or she does any of the hobbies or interests listed.
SECTION D – OTHER INFORMATION
This section is new. We added this section in response to a DDS Chief Medical Consultant’s comments on the current SSA-3373-BK.
New question 19 is optional and collects information from the disabled person about anyone else who we can contact if further information is needed.
New question 20. is completed only if the form is completed by someone other than the disabled person.
Part “a” collects information about the relationship of the person completing the form to the disabled person.
Part “b” collects information about why this person completed the form for the disabled person. This information may provide additional information about a claimant’s abilities.
SECTION E – REMARKS
On the revised form, this section corresponds to SECTION D – REMARKS on the current form. In the revised form, in addition to the name and address of the person completing the form, we ask for their daytime telephone number. This information is needed if the adjudicator needs to re-contact the person about the information they have provided.
SSA-3373-BK addendum
| File Type | application/msword |
| File Title | REVISED FORM SSA-454-BK |
| Author | Tessa Albright, ext 57789 |
| Last Modified By | Faye |
| File Modified | 2006-08-17 |
| File Created | 2006-08-17 |