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.

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.
It is important that you tell us about your activities and abilities.
 Print or type.
 DO NOT LEAVE ANSWERS BLANK. If you do not know the answer or the answer
is "none" or the answer is "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

Privacy Act and Paperwork Reduction Act Statements
Sections 205(a), 1631(d)(1) and 1631(e)(1) of the Social Security Act, as amended, authorize us
to collect this information. 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. We generally use the information you supply for
the purpose of making decisions regarding claims. However, we may use it for the
administration and integrity of Social Security programs. We may also disclose information to
another person or to another agency in accordance with approved routine uses, which include but
are not limited to the following: (1) to enable a third party or agency to assist Social Security in
establishing rights to Social Security benefits and/or coverage; (2) to comply with Federal laws
requiring the release of information from Social Security records (e.g., to the Government
Accountability Office and the Department of Veterans Affairs); (3) to make determinations for
eligibility in similar health and income maintenance programs at the Federal, State and local
level; and (4) to facilitate statistical research, audit, or investigative activities necessary to assure
the integrity of Social Security programs.
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, State, or local government
agencies. Information from these matching programs can be used to establish or verify a
person’s eligibility for Federally-funded or administered benefit programs and for repayment of
payments or delinquent debts under these programs.
Additional information regarding this form, routine uses of information, and our programs and
systems, is available on-line at www.socialsecurity.gov or at any local Social Security office.
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 THE OFFICE THAT REQUESTED
IT. If you do not have that address, you may call Social Security at 1-800-772-1213 (TTY
1-800-325-0778). You may send comments on our time estimate above to: SSA, 6401 Security
Blvd., Baltimore, MD 21235-6401. 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

SOCIAL SECURITY ADMINISTRATION

OMB No. 0960-0681

FUNCTION REPORT – ADULT
How your illnesses, injuries, or conditions limit your activities
For SSA Use Only
Do not write in this box
Related SSN _________-____-____________
Number Holder _________________________

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.)
(_______)
Area Code

_________-______________

□ Your number □ Message number □ None

Phone Number

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

□ House
□ Shelter

□ Apartment
□ Boarding House
□ Nursing Home
□ Group Home □ Other (What?) ________________________________________

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 other conditions limit your ability to work? ______________________
_

________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
FORM SSA-3373-BK (9-2005) ef(09-2005)

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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,
Yes
No
parents, friend, other?
If "YES," for whom do you care, and what do you do for them? _________________________________
___________________________________________________________________________________

8. Do you take care of pets or other animals?

□ Yes □ No

If "YES," what do you do for them? _______________________________________________________
___________________________________________________________________________________

9. Does anyone help you care for other people or animals?

□ Yes □ No

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?

□ Yes □ No

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___________________________________________________________________________
FORM SSA-3373-BK (9-2005) ef(09-2005)

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Care for hair_____________________________________________________________________
Shave__________________________________________________________________________
Feed self________________________________________________________________________
Use the toilet_____________________________________________________________________
Other___________________________________________________________________________

□

□

b. Do you need any special reminders to take care of personal needs and
Yes
No
grooming?
If "YES," what type of help or reminders are needed? ________________________________________
___________________________________________________________________________________
c. Do you need help or reminders taking medicine?

□ Yes □ No

If "YES," what kind of help do you need? __________________________________________________
___________________________________________________________________________________
13. MEALS
a. Do you prepare your own meals?

□ Yes □ No

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?
________________________________________________________________________________
FORM SSA-3373-BK (9-2005) ef(09-2005)

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c. Do you need help or encouragement doing these things?

□ Yes □ No

If "Yes," what help is needed? ________________________________________________________
d. If you do not 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
□ Use public transportation

□ Ride in a car
□ Ride a bicycle
□ Other (Explain)___________________________________
c. When going out, can you go out alone?
□ Yes □ No
If "NO," explain why you can't go out alone? _______________________________________________
__________________________________________________________________________________

□ Yes □ No

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.)

□ In stores

□ By phone

□ 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
Count change

□ Yes □ No
□ Yes □ No

Handle a savings account
Use a checkbook/money orders

□ Yes □ No
□ Yes □ No

Explain all "NO" answers.____________________________________________________________
________________________________________________________________________________
FORM SSA-3373-BK (9-2005) ef(09-2005)

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□

□

b. Has your ability to handle money changed since the illnesses,
Yes
No
injuries, or conditions began?
If "YES," explain how the ability to handle money has changed. _____________________________
________________________________________________________________________________
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. Do you spend time with others? (In person, on the phone, on the computer, etc.)?

□ Yes □ No

If "YES," describe the kinds of things you do with others. __________________________________
________________________________________________________________________________
How often do you do these things? ____________________________________________________
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

How often and how much do you take part? ____________________________________________
________________________________________________________________________________
Do you need someone to accompany you?
c. Do you have any problems getting along with family, friends, neighbors,
or others?

□ Yes □ No
□ Yes □ No

If "YES," explain. _________________________________________________________________
________________________________________________________________________________

FORM SSA-3373-BK (9-2005) ef(09-2005)

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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
□ 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 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)

□ Yes □ No

f. How well do you follow written instructions? (For example, a recipe) _________________________
________________________________________________________________________________
g. How well do you follow spoken instructions? ____________________________________________
________________________________________________________________________________
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?
FORM SSA-3373-BK (9-2005) ef(09-2005)

□ Yes □ No
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If "YES," please explain. ____________________________________________________________
________________________________________________________________________________
If "YES," please give the name of the employer___________________________________________
j. How well do you handle stress? ______________________________________________________
________________________________________________________________________________
k. How well do you handle changes in routine? _____________ ______________________________
________________________________________________________________________________

□ Yes □ No

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 use these aids? _________________________________________________________
__________________________________________________________________________________
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

FORM SSA-3373-BK (9-2005) ef(09-2005)

Side Effects You Have

Page 7

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

Zip Code
-

FORM SSA-3373-BK (9-2005) ef(09-2005)

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