SSA-3375 Function Report-Child Birth to 1st Birthday

Function Report - Child Birth to 1st Birthday
Filling Out The Function Report
IF YOU NEED HELP COMPLETING ANY PART OF THIS FORM, CONTACT YOUR
SOCIAL SECURITY OFFICE. WE WILL HELP YOU.
The information that you give us on this form will be used by the office that makes the disability
decision on the child's claim. You can help them by completing as much of the form as you
can.
Print or type.
Do not ask a doctor or hospital to complete this form.
Be sure to explain your answer if an explanation is requested or needed.
If more space is needed to answer any of the questions, please use the
"REMARKS" section and show the number of the question being answered.

The information we ask for on this form tells us how you think the child's illnesses or injuries
affect the way he or she does many of his or her usual activities.

PLEASE REMOVE THIS SHEET BEFORE
RETURNING THE COMPLETED FORM.

Form SSA-3375-BK (5-2006) ef (12-2006)
Prior edition may be used until stock is exhausted

Continued on the Reverse

The Privacy
And Paperwork
Reduction Acts
See Revised
Privacy Act
Statement Attached

The Social Security Administration is authorized to collect the
information on this form under sections 205(a), 223(d) and 1631(e)(1) 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) 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); 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, State, 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. If
you want to learn more about this, contact any Social Security office.

See Revised PRA
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 20 minutes to read the instructions, gather the facts, and
answer the questions. SEND OR BRING THE COMPLETED
FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE.
The office is listed under U. S. Government agencies in your
telephone directory or 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 Boulevard,
Baltimore, MD 21235-6401. Send only comments relating to our
time estimate to this address, not the completed form.

Form SSA-3375-BK (5-2006) ef (12-2006)

Form Approved
OMB No. 0960-0542

SOCIAL SECURITY ADMINISTRATION

FUNCTION REPORT - CHILD
BIRTH TO 1st BIRTHDAY

SECTION 1 - IDENTIFYING INFORMATION
1. A. Print NAME OF CHILD:
FIRST

MIDDLE

LAST

B. Child's SOCIAL SECURITY NUMBER:

-

-

C. Child's DATE OF BIRTH:
Month/Day/Year

D. PERSON COMPLETING FORM
NAME:
RELATIONSHIP TO CHILD:
DATE FORM COMPLETED:
Month/Day/Year

DAYTIME TELEPHONE NUMBER (including Area Code):

MAILING ADDRESS (Number and Street, Apt. No. (if any), P.O. Box, or Rural Route):

CITY

STATE

ZIP CODE
-

Form SSA-3375-BK (5-2006) ef (12-2006)
Prior edition may be used until stock is exhausted

Page 1

SECTION 2 - FUNCTION DETAILS
2. A. Does the child have
problems seeing?

If "yes," please mark every statement below that is generally
true about the child:
Child uses glasses or contact lenses. If the child has problems
seeing even with glasses or contact lenses, please explain:

YES (Continue)
NO (Go to 2.B.)

Child cannot be fitted for glasses or contact lenses. Explain:

Child has other seeing problems. If so, please describe:

B. Does the child have
problems hearing?

If "yes," please mark every statement below that is generally true
about the child:

YES (Continue)
NO (Go to 2.C.)

Child uses hearing aid(s). If the child has problems hearing
even with a hearing aid(s) OR has trouble using a hearing
aid, please explain:

Child cannot be fitted for hearing aid(s). Explain:

Child has other hearing problems. If so, please describe:

Form SSA-3375-BK (5-2006) ef (12-2006)

Page 2

2. C. Are the child's activities
or abilities limited?

If "yes," or "not sure," please tell us what the child does by
marking "yes" or "no" for each of the following:

YES (Continue)

Yes

No

Makes various cooing sounds, such as "aaah"
and "oooh"

NO (Go to 2.D.)

Yes

No

Makes various babbling sounds, such as
"babababa" or "mamamama"

NOT SURE
(Continue)

Yes

No

Says simple words other than "mama" and
"dada"

Child generally

Form SSA-3375-BK (5-2006) ef (12-2006)

Yes

No

Stops crying when picked up and held

Yes

No

Watches face of person talking to him or her

Yes

No

Pats, "talks to" or otherwise responds to
himself or herself in mirror

Yes

No

Plays games, such as "peek-a-boo"

Yes

No

Understands simple statements like
"come here" or "sit down"

Yes

No

Points to something he or she wants that is
out of reach, such as a toy or food

Yes

No

Understands names of favorite toys or other
things, such as a bottle

Yes

No

Turns head in direction of familiar noises or
voices

Yes

No

Turns head when his or her name is called

Yes

No

Smiles at faces he or she knows

Yes

No

Quiets or stops crying when sees parent or
other person he or she knows

Yes

No

Cuddles in arms when held by parent or
caregiver

Yes

No

Reaches out to be picked up

Page 3

2. C. (Continued)

Child can

Yes

No

Roll from stomach to back

Yes

No

Roll from back to stomach

Yes

No

Get to a sitting position without help

Yes

No

Yes

No Crawl or creep

Yes

No Pull self up to a standing position

Yes

No Reach for toys, or other objects

Yes

No Stand up without holding on to someone or
something

Yes

No Walk holding on to someone or something

Yes

No Eat foods, such as cereal, cookie, by self

Yes

No Move toy or other object from hand-to-hand

Yes

No Hold small objects between fingers

Yes

No Throw ball or other object

Rock back and forth on hands and knees

D. If necessary, please explain any of the items in Question 2.C. In addition, please tell us
anything else about the child that you think we should know:

Form SSA-3375-BK (5-2006) ef (12-2006)

Page 4

SECTION 3 - REMARKS

Form SSA-3375-BK (5-2006) ef (12-2006)

Page 5

SSA will insert the following revised Privacy Act and PRA Statements into the form
at its next scheduled reprinting:
Function - Child Birth to 1st Birthday, Form SSA-3375-BK
Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 223(d), and 1631(e)(1) [42 U.S.C. 405(a), 423(d), and 1383 (e)(1)]
of the Social Security Act authorize us to collect this information. We will use the
information you provide on this report to assist us in making a decision on the named
claimant’s claim. The information you provide on this form is voluntary. However,
failure to provide all or part of the requested information could prevent us from
making an accurate and timely decision on the named claimant’s claim.
We rarely use the information you provide on this form for any purpose other than for
the reasons explained above. 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 an 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, General
Services Administration, National Archives Records Administration, 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.
A complete list of routine uses for this information is available in our System of
Records Notice entitled, Claims Folder System, 60-0089. This notice, additional
information regarding this form, and information regarding our programs and
systems, are available on-line at www.socialsecurity.gov or at any 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 20 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 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.