Form SSA-3881 BK SSA-3881 BK Questionnaire for Children Claiming SSI Benefits

Form Approved
OMB No. 0960-0499

Social Security Administration

QUESTIONNAIRE FOR CHILDREN CLAIMING SSI BENEFITS

Please print, type, or write clearly and answer all items to the best of your ability. If you
need help completing any part of this form, we will help you. If you are filing on behalf
of someone else, enter his or her name and social security number in the space
provided and answer all questions. If you do not know the answer, enter "unknown." If
the question does not apply, enter "NIA." If you need more space to answer any of the
questions, please use "REMARKS" and enter the number of the question next to your
answer.

Child's Full Name

Social Security Number Date (month, day, year)

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Informant's Name

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I~elationshipto Child

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Daytime Telephone Number
(including Area Code)

Is (was) the child cared for by a baby sitter? Does (did) the child attend any type of preschool, daycare
and/or after school program? If so, please specify. If more than one of the above, use the "REMARKS"
section.

1.

Name

Address (Number, Street, City, State, Zip Code)

Telephone Number (including Area Code)

Dates Attended

a. Is (was) the child in school?

2.

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b

Yes

No

If "yes," and the school was not listed in Item 12A of the SSA-3820-F6, please show it here
(If more than one, use the "REMARKS" section.)
Vame

Address (Number. Street, City, State, Zip Code)

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Telephone Number (including Area Code)

Dates Attended

Grade Level Completed

Last Teacher's Name

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Form SSA-3881-BK

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b. Is the child in a special education program?

2.

q Yes q No q Don't Know

c. Does the school make any special accommodations for the
child; e.g., adaptive furniture, wheelchair ramps, extra
b
assistance or attention?
If "yes" in 2.b. or 2.c., indicate type of program and/or
accommodations:

q Yes q No q Don't Know
Specify number of hours per week the
child is in special education program:

d. Do you have a copy of the child's individual education plan
(IEP), the report in which the teacher outlines the child's
problems and lists the plans for correcting them?
-

q Yes q No

If "yes," please provide a copy.
Does the child receive any special counseling or tutoring?

3.

a. In school

b

OYes

b. Outside school

b

OYes

q No
q No

If "yes,"in 3.a. or 3.b., please indicate: (If more than one, use the "REMARKS" section.)
Type of Counseling, Tutoring

Date Began and Ended (If completed)

Frequency of Visits

Counselor's or Tutor's Name

Telephone Number (including Area Code)
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Address (Number and Street, City, State and Zip Code)

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Does the child or familv have a child welfare. social services or
early intervention caseworker?
b

4.

q Yes q No

If "yes,"please provide the following information: (If more than one, use the "REMARKS"section.)
Caseworker's Name

Organization

Address (Number and Street, City, State and Zip Code)

Telephone Number (including Area Code)

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File or Record Number
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Form SSA-3881-BK

Date First SawILast Saw Caseworker
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P a ~ 2e

5.

1

Has the child ever been tested or evaluated by any of the following agencies or organizations?

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If "yes," indicate in the space provided below the agency name, address, telephone number, record
number, and the type and date of test or evaluation performed (e.g., vision, hearing, speech, physical).

a. PubliclCommunity Health Department

#-

b. Child WelfareISocial Services Agency b c. Developmental Evaluation Center
d. Mental HealthIMental Retardation Center
e. Special Needslcrippled Children Agency
f. Speech and Hearing Center

q Yes q No
q Yes q No
b
a y e s q No
a y e s q No
r a y e s q No
b a y e s q No

g. Women, Infants and Children (WIC) Program

ayes

Use the letter designation (5a, 5b, etc.) to identify the agency.

If additional space is needed, use "REMARKS" section.
Form SSA-3881-BK

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No

6. Does (did) the child receive any special therapy (physical, speech and
language, occupational), exercises, or any other services for hislher
b
impairments?

Yes

No

Include information about any therapy or exercises the parent.
guardian or caregiver provides the child.
If "yes," indicate below the therapist's name, the name of the person who PRESCRIBED ANDIOR
DESIGNED the therapy program, the type@)and frequency of treatment, when treatment began and
ended (if completed), and where treatment was received (e.g., home, hospital, therapist's office, clinic.)
Therapist's Name

Telephone No. (including Area Code)
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Address (Number and Street, City, State and Zip Code)

Person Who PrescribedlDesigned Therapy

Information about Therapy:

Therapist's Name

Telephone No. (including Area Code)

I ~ d d r e s s(Number and Street. City. State and Zip Code)

Person Who PrescribedlDesigned Therapy

Information about Therapy:

Form SSA-3881-BK,

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Does (did) the child receive vocational rehabilitation services?

.

ye,

--)

NO

If "yes,"describe services received below the rehabilitation
counselor's information. Include dates and record number.
Rehabilitation Counselor's Name

Telephone No. (including Area Code)
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Address (Number and Street, City, State and Zip Code)

lservices received:

(If additional space is needed, use "REMARKS" section.)
"

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NOTE: PROVIDING INFORMATION ABOUT THE CHILD'S INVOLVEMENT
WITH THE COURT SYSTEM IS OPTIONAL
Has the child ever been involved with the court system other than in
b
custody proceedings?

O ~ e sq No

If "yes,"please explain involvement, including testing and evaluation.
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Youth Development Center's Name

Address (Number and Street. City, State and Zip Code)

Probation or Parole Officer's Name

Telephone No. (including Area Code)

Address (Number and Street, City, State and Zip Code)

Involvement including any testing and evaluation:

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>n
SSA-3881-BK

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Does (did) the child participate in any community or school activities,
such as choir, Special Olympics, Boy'slGirl's Club. Scouts, or sports?

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b

Yes

No

If "yes," describe involvement, amount of time spent in activity, and level of participation. Provide name,
address, and telephone number of individual who supervises the activity. Include dates of involvement.
If involvement ended, explain why.

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I.

If the child takes any medication on an ongoing basis, please indicate the following:
MEDICATION
PRESCRIBED
DOSACUFREQUENCY
BY (NAME)

REASON FOR
MEDICATION

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~rm
SSA-3881-BK

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DESCRIBE ANY
SIDE EFFECTS

11.

a. If you are unable to give us information we need about the child, is there someone else who
helps care for the child and, knows of the child's impairment who can help us get the
information we need, and, if necessary, bring the child to a consultative examination?
Yes

No

b. If "yes," please provide the following information about this person

Address (Number and Street, City, State and ZIP Code)

Daytime telephone number (including Area Code)

Relationship (e.g., relative, neighbor, family friend) to the child?
REMARKS:

Form SSA-3881-BK

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REMARKS (continued):

PRIVACY ACT: The information requested on this form is authorized by Section 223 and Section 1632 of the Social Security Act.
The information provided will he used in makmg a decision on your claim While complet~onof t h ~ form
s
is voluntary, failurc.to
provide all or part of the requested information could prevent an aicurak and tlmely deili~onon vow ilalm and could result in the
loss of benefits. Information you furnish on this form may he disclosed by the Social Security ~dministrationto another person or
governmental agency only with respect to Social Seeurity programs and to comply with Federal law requiring the exchange of
information between Social Security and another ageney.
We may also use the information you give us when we match records by computer. Matching programs compare our records with
those of other Federal. State, or local government agencies. Many agencies may use matchingprograms to f;nd or prove that a
person qualifies for benefits paid by the Federal government. The law allows us to do this even if you do not agree to it.
txplanat~onsahout these and other reasons why information you provide us may he used or glvcn out arc availahlc in Social
Seiuriiy offiies lfyou want to learn more about th~s,contact any Social Secuniy office.
PAPERWORK REDUCTION ACT: This information colIection meets the requirements of 44 U.S.C. 5 3507, as amended by
Section 2 of the Pavework 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 30 minutes to read the instmctions, gather the facts,
and answer the questions. SEND O R BRING THE COMPLETED FORM T O YOUR LOCAL SOCIAL SECURITY
OFFICE. To find the nearest ofice, call 1-800-772-1213. Send & comments on our time estimate above to: SSA,
6401 Security Blvd., Baltimore, MD 21235-6401.
Form SSA-3881-BK

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