Form SSA-3820-BK Disability Report - Child

DISABILITY REPORT - CHILD - Form SSA-3820-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 your interviewer will
help you finish it.

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.
Fill out this form hefore your interview appointment.
Print or w.hr;+2 I t t i
,
DO NOT LEAVE ANSWERS BLANK. If you do not know the answers, or the answer is
"none" or "does not apply," write: "don't know," or " none," or "does not apply."
E
IN SECTION 4, PUT INFORMATION ON ONLY ONE DOCTOR/IN EACH SPACE.
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5
Each address should include a ZIP code. Each telephone number should include an area co e.
DO NOT ASK A DOCTOR OR HOSPITAL TO COMPLETE THE FORM. However,
2
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you can get help from a friend or family member.
If your appointment is for an interview by telephone, have the form ready to discuss with us
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P
when we call you.
0
If your appointment is for an interview in our office, hring the completed form with you or
5
h
mail ahead of time, if you were told to do so.
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Be sure to explain an answer if the question asks for an explanation or if you want to give
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additional information.
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If you need more space to answer any questions or want to tell us more about an answer,
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V)
please use Section 10, "DATE AND REMARKS," on Pages I I and 12, and show the number
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of the question being answered.
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ABOUT THE CHILD'S MEDICAL AND OTHER RECORDS
If you have any of the following records for the child at home, send them to our office with your
completed forms or bring them with you to the interview. If you need the records back, tell us and
we will photocopy them and return them to you.
The child's medical records
Copies of the child's prescriptions
The child's Individualized Education Program
The child's Individualized Family Service Plan

YOU DO NOT NEED TO ASK DOCTORS OR HOSPITALS FOR ANY MEDICAL
RECORDS THAT YOU DO NOT ALREADY HAVE. With your permission, we will do that for
you. The information we ask for on this form tells us from whom to request medical and other
records. If you cannot remember the names and addresses of any of the doctors or hospitals, or the
dates of treatment, perhaps you can get this information from the telephone book, or from medical
bills, prescriptions and

b
X

The Privacy and Paperwork Reduction Acts
The Social Security Administration is authorized to collect the information on this form under
sections 205(a), 223(d) and 1631(e)(l) of the Social Security Act. The information on this form is
needed by Social Security to make a decision on the named claimant's claim. While giving us the
information on this form is voluntary, failure to provide all or part of the requested information could
prevent an accurate or timely decision on the named claimant's claim. Although the information you
furnish is almost never used for any purpose other than making a determination about the claimant's
disability, such information may be disclosed by the Social Security Administration as follows: (1) lo
enable a third party or agency to assist Social Security in establishing righls to Social Security
benefits andlor coverage; (2) to comply with Federal Laws requiring the release of information from
Social Security records (e.g., to the General Accounting Office and the Department of Veterans
Affairs); and (3) to facilitate statistical research and such activities necessary to assure the integrity
and improvement of the Social Security programs (e.g., to the Bureau of the Census and private
concerns under contract to Social Security).
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, Stale, or local government agencies.
Many agencies may use matching programs to find 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. Explanations
about these and other reasons why information you provide us may be used or given out are available
in Social Security offices.

PAPERWORK REDUCTION ACT: This information collection meets the requirements of 44
U.S.C. 9 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 60 minutes to read the instructions, gather the facts, and
answer the questions. SEND THE COMPLETED FORM TO YOUR LOCAL SOCIAL
SECURITY OFFICE. The off~ceis listed under U. S. Government agencies in your telephone
directory or you may call Social Security at 1-800-772-1213. You may send comments on our time
esrimare above to: SSA. 1338 Annex Building. Baltimore. MD 21235-0001. Send&o
relating lo our time estimate to this d r e s s , nol the completed form.

commenls

REMOVE THIS SHEET BEFORE RETURNING THE COMPLETED FORM.

Form Approved

SOCIAL SECURITY ADMINISTRATION

OM6 No 0960 0577

D I S A B I L I T Y REPORT

- CHILD

SECTION 1 -- INFORMATION ABOUT THE CHILD
A. CHILD'S NAME (First, Middle Initial, Last1

B. CHILD'S SOCIAL SECURITY NUMBER

C. YOUR NAME (If agency, provide name of agency and contact person1
YOUR MAILING ADDRESS (Number and Street, Apt. No. (if anyl, P.O.Box, or Rural Route]

1

CITY

l
I

STATE

ZIP CODE

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-

D. YOUR DAYTIME PHONE NUMBER (If v o ~ k a % numbef$/iii
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Sta'd"d;t12,*

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DI

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n u m h r where we can leave a message for you1
Area Code

Your Number

Number

Message Number

None

51

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E. What is your relationship t o the child?
F. Can you speak English?

YES

--.-

NO

n

If "NO". what languages can you speak?
If you cannot speak English, is there someone we may contact who speaks English
and will give you messages?
NAME

2
V)
V)

RELATIONSHIP TO CHILD

?

ADDRESS
/Number. Sneel, Apt. No. Iif anyl, P O . Box, or Rural Route1

Dry

Srare

Can you read English?

G. Does the child live with you?

DAYTIME
PHONE

ZIP

YES

w
X
Area Code

Number

NO

YES

NO

If "NO", with whom does the child live?

NAME

RELATIONSHIP TO CHILD

ADDRESS
/Number, Sfreef, Apt. No. Iif anyl, P O . Box, or Rural Roofel

DAYTIME
City

Stare

Can this person speak English?

ZIP

YES

Areacode

Number

1
7 NO

If "NO", what languages can this person speak?
Can this person read English?
Form

SSA-3820-8K 17-20031

EF

YES

(07-20031 Prior editions may

be used

NO
PAGE 1

SECTION 1 - INFORMATION ABOUT THE CHILD

H. Can the child speak English?

YES

NO

If "NO." what languages can the child speak?

I. What is the child's height lwithout shoesl?
What is the child's weight (without shoesl?
J. Does the child have a medical assistance card? (for example Medicaid, Medi-Cal)
YES

NO

If "YES", show the number here:

SECTION 2 - CONTACT INFORMATION

A. Does the child have a legal guardian or custodian other than you?
YES (Enter name, address, phone number, relationship1

NO

NAME
ADDRESS
(Number, Street, Apt. No. /;f any], P O . Box, or Rural Route1

U ty

State

ZIP

DAYTIME PHONE NUMBER
Area Code

Number

RELATIONSHIP TO CHILD

B. Is there another adult who helps care for the child and can help us get information
about the child if necessary?
YES (Enter name, address, phone number, relationship1

NO

NAME OF CONTACT
ADDRESS
(Number, Street, Apt. No. (if anyl, P O . Box, or Rural Routel
C;ty

Slate

ZIP

DAYTIME PHONE NUMBER
Area Code

Number

RELATIONSHIP TO CHILD

Form SSA-3820-BK

(7.20031 EF 107-2003)

Prior editions may be used

PAGE 2

SECTION 3 - THE CHILD'S ILLNESSES, INJURIES OR
CONDITIONS AND HOW THEY AFFECT HIMIHER
A. What are the child's disabling illnesses, injuries, or conditions?
-

-

-

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B. How do the child's illnesses, injuries, or conditions limit hislher daily activities?

C. When did the child become disabled?

Monrh

D. Do the child's illnesses, injuries or conditions cause pain
or other symptoms?

Form SSA-3820-8K 17-2003)EF 107-2003) Prior editions may be used

Year

Day

YES

I

NO

PAGE 3

1

SECTION 4 - INFORMATION ABOUT THE CHILD'S MEDICAL RECORDS

A. Has the child been seen by a doctorlhospitallclinic or anyone else for the
illnesses, injuries or conditions?

n YES

NO

B. Has the child been seen by a doctorlhospitallclinic or anyone else for emotional or
mental problems?
NO

YES

Tell us who may have medical records or other
information about the child's illnesses, injuries or conditions.

C. List each DOCTORlHMOlTHERAPlSTIOTHER. Include the child's next appointment.
1. NAME

DATES

STREET ADDRESS

FIRST VISIT

CITY

STATE

ICHARTIHMO

PHONE
Area Code

LASTsEHd V b IY

ZIP

1

NEXT APPOINTMENT

# (If known)

Number

REASONS FOR VISITS

2.NAME

DATES

I

CITY

STATE

ZIP

WHAT TREATMENT WAS RECEIVED?

I

I
Form SSA-3820-BK 17-20031 EF 107-20031 Prior edirions may be used

PAGE 4

SECTION 4 - INFORMATION ABOUT THE CHILD'S MEDICAL RECORDS

3.

I

NAME

DATES

FIRST VISIT

STREET ADDRESS
CITY

STATE

LAST SE€Nb'b/.f

ZIP

~CHARTIHMO # Ilf known)

PHONE

NEXT APPOINTMENT

1
If you need more space. use Section 10,

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D. List each HOSPITALICLINIC. Include the child's next appointment.
1.

HOSPlTALlCLlNlC
TYPE OF VISIT
NAME

DATE OUT

DATE IN

INPATIENT STAYS
(Stayed a1 leas1 overntghr,

STREET ADDRESS

DATE FIRST VlSlT DATE LAST VlSlT

OUTPATIENT VlSlTS

CITY

-

(Senr home same day)

ZIP

STATE -

DATES OF VlSlTS

EMERGENCY ROOM
VISITS

PHONE
*,,,,,i,,

4,ul c nil

number
The chlld's hosp~talicl~n~c

Next appointment
Reasons for vls~ts
---

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~

~

- -

..

~-

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What treatment did the child receive?

-

~-

..

~-

-~

~-

~

~

What doctors does the child see at this hospitallclinic on a regular basis?
.~
.-

-.

Form SSA-3820-BK (7.20031 EF 107-20031 Prior editions may be used

.

~

-

--

PAGE 5

SECTION 4 - INFORMATION ABOUT THE CHILD'S MEDICAL RECORDS
TYPE OF VISIT

HOSPITALICLINIC
NAME

DATES
DATE IN

INPATIENT STAYS

DATE OUT

(Stayed a1 least overn,ghN

STREET ADDRESS

OUTPATIENT VlSlTS

ClTY

(Sent home same day)

ZIP -

STATE -

Next

The child's hospitallclinic number

appointment

Reasons for

DATES OF VlSlTS

EMERGENCY ROOM
VISITS

PHONE

visits
--- - -

.
.

- - - --

~~.

What treatment did the child receive?
-- -~

.~

-

What doctors does the child see at this hospital/clinic on a

--

-

~

~

If you need more space, use Section 10,

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regular basis?

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E. Does anyone else have medical records or information about the child's illnesses,
injuries or conditions (Workers' Compensation, insurance companies, counselors,
detention centers, attorneys, and/or tutors), or is the child scheduled t o see anyone
else?
YES (If "YES,

"

complete information below.)

NO

NAME

DATES

ADDRESS

FIRST VISIT

CITY

STATE

L A S T ~ E ~ ~ ~ I T I ~

ZIP

NEXT APPOINTMENT

PHONE

CLAIM

NUMBER /If any)

REASONS FOR VlSlTS

p

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-

-

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1

If you need more space. use Section 10,
Fotm SSA-3820-BK 0-20031 EF (07-20031 Prior editions may be used

OiWr' Ilfll?/:gK!f?$?
PAGE 6

SECTION 5 - MEDICATIONS
Does the child currently take any medications for illnesses, injuries or conditions?
If "YES", tell Us the following: /Look at the child's medicine*,
if necessary.1
,-A*

NAME OF MEDICINE

I

PRESCRIBED BY
(Name of Doctor)

YES

NO

, *.a.

REASON FOR
MEDICINE

SIDE EFFECTS
THE CHILD HAS

If you need more space, use Section 10.
SECTION 6

- TESTS

Has the child had, or will helshe have, any medical tests for illnesses, injuries or
YES
NO
conditions?
If "YES", tell us the following (give approximate dates, if necessary).

KIND OF TEST

WHERE DONE
lNam of F a " )

X-RAY--Name of body part

MRIICAT SCAN - Name of body
part

If the child has had other tests, list them in Section 10, .fikTG flA/~ffpffk?S
Form SA-3820-8K

17-2003)EF (07-20031 Prior editions may be used

PAGE 7

SECTION 7 - ADDITIONAL INFORMATION
A. Has the child been tested or examined by any of the following?
Headstart (Title V)

YES

NO

Public or Community Health Department

YES

NO

Child Welfare or Social Service Agency

YES

NO

Women, Infant and Children (WIC) Program

YES

NO

YES

NO

Mental HealthIMental Retardation Center

YES

NO

Vocational Rehabilitation

YES

NO

YES

NO

Program for Children with Special Health
Care Needs

If "NO", and over age 15, do you want t o
be referred t o Vocational Rehabilitation?

B. Is the child participating in the Ticket Program or other program of vocational
rehabilitation services, employment services or other support services to help him
or her go to work?
YES

NO

If you answered "YES" t o any of the above in A, or B., please complete C, below:
C. 1 . NAME OF AGENCY
ADDRESS
INumber, Srreer, Apt. No. /if any), P. 0.Box, or Rural Route1

Ciry

Srare

ZIP

PHONE NUMBER
Area Code

Number

TYPE OF TEST
TYPE OF TEST

WHEN DONE

-

WHEN DONE

-.

FlLE OR RECORD NUMBER

--

2. NAME OF AGENCY
ADDRESS
INumber, Sfreef, Apr. No. lif any), P O . Box, or Rural Rourei

PHONE NUMBER
Area Code

Number

TYPEOFTEST
-

TYPE OF TEST
FlLE OR RECORD NUMBER

WHEN DONE
WHEN DONE

-~

~.

If there are any other agencies, show them in Section 10,
Farm SSA-3820-BK 17-20031 EF 107-20031 Prior editions may be used

Cafe b%'?p6&fh"$
PAGE 8

SECTION 8 - EDUCATION
A

W h a t if

t h m ohilrl'c r a s r r n n t n r a d m in fohnnl nr the hinha-t nradn

6.Is the child currently attending school

onrnnl~=t~=rl?

(other than summer school)?

YES

NO

If "NO", expla~nwhy the child is not attending school.

C. List the name of the school the child is currently attending and give dates attended.
If the child is no longer in school, list the name of the last school attended and give
dates attended.
N A M E OF SCHOOL
ADDRESS

... -.........

City

-.-

Counly

Stare

ZIP

Number

Area Code

DATES ATTENDED
TEACHER'S N A M E

nas me cnllo oeen resrea ror Denavloral or learnlng proolemsr

u re>

u

NU

If "YES", complete the following:
TYPE OF TEST

WHEN DONE

TYPE OF TEST

WHEN DONE

Is the child in special education?

YES

NO

If "YES", and different from above, give:
N A M E OF SPECIAL EDUCATION TEACHER

-

Is the chlld
I I YES
. - in soeech theranv7
-,
If "YES", and different from above, give:
~

~

~

~

I

I NO

N A M E OF SPEECH THERAPIST
Form SSA-3820-8K

17-20031 EF 107-20031 Prior editions may be used

PAGE 9

r

SECTION 8 - EDUCATION

D. List the names of all other schools attended in the last 12 months and give dates
attended.
NAME OF SCHOOL
ADDRESS
(Number, S m e r , Apr. No. (if any], P. 0.Box, or Rural Rourel

City

county

Slare

ZIP

PHONE NUMBER
Number

Area Code

DATES ATTENDED

.

TEACHER'S NAME

Was the child tested for behavioral or learning problems?

YES

NO

If "YES", complete the following:
TYPE OF TEST

WHEN DONE

TYPE OF TEST

WHEN DONE

YES

Was the child in special education?

NO

If "YES", and different from above, give:
NAME OF SPECIAL EDUCATION TEACHER
-

Was the child in speech therapy?

q

YES

q

NO

If "YES", and different from above, give:
NAME OF SPEECH THERAPIST

If there are other schools, show them in Section 10.
E. Is the child attending

U Y E S

O N 0

If "YES", complete the follow~ng:
NAME OF DAYCAREI
PRESCHOOLICAREGIVER
ADDRESS
(Number, S m e r , Apt. No. (if anyl, P.O. Box, or Rural Rourel

City

counry

State

ZIP

PHONE NUMBER
Number

Area Code

DATES ATTENDED
TEACHER'SICAREGIVER'S NAME
-

Form SSA-3820.81:

17-2003) EF 107-2003) Proor sdtroons may be used

- -

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PAGE 10

SECTION 9 - WORK HISTORY
A. Has the child ever worked (including sheltered

YES

NO

If "YES", complete the following:
DATES WORKED
NAME OF EMPLOYER
ADDRESS
(Number, Street, Apt. No. /if any), P O . Box, or Rural Route1

City

State

ZIP

PHONE NUMBER
Area Code

Number

NAME OF SUPERVISOR

B. List job title, and briefly describe the work and any problems the child may have had
doing the job.

SECTION 10 - DATE AND REMARKS
Please give the date you filled out this disability report.
Date (MMIDDIYYYY)

Use this section for any

/ /

information about your child.

Form SSA-3820-8K 17-20031 EF (07.2003) Prior editions may be used

PAGE 1 1

SECTION 10 - REMARKS

-

Farm SSA-3820-BK 17-20031 EF 107-20031 Prior editions may be used

PAGE 12