SSA-3377 Function Report-Child Age 3 to 6th 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.
When we ask for certain numbers, such as dates and telephone numbers,
we provide blocks to fill in. In these places, please print only one
number in each block. For numbers under 10, put a zero in the first block
for the month and/or day, as appropriate. Make entries like this:
Month

Day

Year

0 5

2 7

9 4

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.
ANYONE MAKING A FALSE STATEMENT OR REPRESENTATION OF A MATERIAL
FACT FOR USE IN DETERMINING A RIGHT TO PAYMENT UNDER THE SOCIAL
SECURITY ACT COMMITS A CRIME PUNISHABLE UNDER FEDERAL LAW.

PLEASE REMOVE THIS SHEET BEFORE
RETURNING THE COMPLETED FORM.

Form SSA-3377-BK (5-1995) EF (12-2002)

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 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, 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 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. You may send
comments on our time estimate above to: SSA, 1338 Annex
Building, Baltimore, MD 21235-0001. Send only comments
relating to our time estimate to this address, not the completed
form.

Form SSA-3377-BK (5-1995) EF (12-2002)

Form Approved
OMB No. 0960-0542

SOCIAL SECURITY ADMINISTRATION

FUNCTION REPORT - CHILD
AGE 3 TO 6th BIRTHDAY
SECTION 1 - IDENTIFYING INFORMATION

1. A. Print NAME OF CHILD:
MIDDLE
INITIAL

FIRST

LAST

B. Child's SOCIAL SECURITY NUMBER:

C. Child's DATE OF BIRTH:
Month

Day

Year

Month

Day

Year

D. PERSON COMPLETING FORM
NAME:
RELATIONSHIP TO CHILD:
DATE FORM COMPLETED:

DAYTIME TELEPHONE NUMBER:
Area Code

Number

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

CITY

Form SSA-3377-BK (5-1995) EF (12-2002)

STATE

ZIP CODE

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)

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:

NO (Go to 2.C.)

Child cannot be fitted for hearing aid(s).
Child has other hearing problems. If so, please describe:

Child uses American Sign Language.
Child reads lips.
Form SSA-3377-BK (5-1995) EF (12-2002)

Page 2

2. C. Is the child totally

Does the child have problems talking clearly?

unable to talk?

Yes (answer questions below)

YES (Go to 2.D.)
No (continue to question 2.D.)

NO (Continue)

If "yes," please mark the block that best describes the child in
each of the two statements below, and then describe any other
speech problems:
Speech can be understood by people who know the child well:
Most of the time, or
Some of the time, or
Hardly ever.
Speech can be understood by people who don't know the child
well:
Most of the time, or
Some of the time, or
Hardly ever.
If the child has other problems talking, please explain:

Form SSA-3377-BK (5-1995) EF (12-2002)

Page 3

If "yes," or "not sure," please tell us what the child does or can
to communicate limited? do by checking "yes" or "no" for each of the following:

2. D. Is the child's ability

No

Yes

No

Uses complete sentences of more than 4
words most of the time

Yes

No

Talks about what he or she is doing

Yes

No

Takes part in conversations with other
children

Yes

No

Asks for what he or she wants

Yes

No

Tells about things and activities that
happened in the past

Yes

No

Can tell a made up or familiar short story

Yes

No

Can answer questions about a short
read-aloud children's story or TV story like
"Little Red Ridinghood"

Yes

No

Can deliver simple messages such as
telephone messages

NO (Go to 2.E.)
NOT SURE
(Continue)

Asks a lot of what, why, and where
questions

Yes

YES (Continue)

If necessary, please explain. In addition, please tell us anything
else you think we should know about the child's ability to
communicate:

Form SSA-3377-BK (5-1995) EF (12-2002)

Page 4

2. E. Does the child's

impairment(s) limit his
or her progress in
understanding and
using what he or she
has learned?

If "yes," or "not sure," please tell us what the child does or can
do by checking "yes" or "no" for each of the following.
Yes

No

Recite numbers to 3

Yes

No

Count three objects (like blocks, cars or
dolls)

Yes

No

Recite numbers to 10

Yes

No

Identify most colors, such as purple, and
shapes, such as a star

Yes

No

Knows his or her age

Yes

No

Asks what words mean

Yes

No

Knows his or her birthday

Yes

No

Knows his or her telephone number

Yes

No

Can define common words

Yes

No

Can read capital letters of the alphabet

Yes

No

Understands a joke

YES (Continue)
NO (Go to 2.F.)
NOT SURE
(Continue)

If necessary, please explain. In addition, please tell us anything
else you think we should know about the child's progress in
understanding and using what he or she has learned:

Form SSA-3377-BK (5-1995) EF (12-2002)

Page 5

2. F. Are the child's

physical abilities
limited?

If "yes," or "not sure," please tell us what the child does or
can do by checking "yes" or "no" for each of the following.

YES (Continue)
NO (Go to 2.G.)
NOT SURE
(Continue)

Yes

No

Catch a large ball, like a beach ball

Yes

No

Ride a big wheel, tricycle, or bike with
training wheels

Yes

No

Wind up a toy

Yes

No

Print at least some letters

Yes

No

Copy first name

Yes

No

Use scissors fairly well

If necessary, please explain. In addition, please tell us anything
else you think we should know about the child's physical
abilities:

G. Does the child's
impairment(s) affect
his or her behavior
with other people?

If "yes," or "not sure," please tell us what the child does or
can do by checking "yes" or "no" for each of the following.

YES (Continue)
NO (Go to 2.H.)
NOT SURE
(Continue)

Yes

No

Enjoys being with other children the
same age

Yes

No

Shows affection towards other children

Yes

No

Is affectionate towards parents

Yes

No

Shares toys

Yes

No

Takes turns

Yes

No

Plays "pretend" with other children

Yes

No

Plays games like tag, hide-and-seek

Yes

No

Plays board games (like checkers or
Candyland)

If necessary, please explain. In addition, please tell us anything
else you think we should know about the child's behavior
around other people:

Form SSA-3377-BK (5-1995) EF (12-2002)

Page 6

2. H. Does the child's

impairment(s) affect his
or her habits and ability
to take care of personal
needs?

If "yes," or "not sure," please tell us what the child does or can
do by checking "yes" or "no" for each of the following. Check
"yes" if it is something the child used to do but doesn't do any
more just because he or she is older. For example, if the child
used to dress with help but now dresses without help, check
"yes" for both.
Yes

No

Usually controls bowels and bladder
during the day

Yes

No

Eats using a fork and spoon by self

NO (Go to 2.I.)

Yes

No

Dresses self with help

NOT SURE
(Continue)

Yes

No

Dresses self without help (except tying
shoes)

Yes

No

Washes or bathes without help

Yes

No

Brushes teeth with help

Yes

No

Brushes teeth without help

Yes

No

Puts toys away

YES (Continue)

If necessary, please explain. In addition, please tell us anything
else you think we should know about the child's habits and
ability to take care of personal needs:

I. Is the child's ability to
pay attention and stick
with a task limited?
YES (Continue)
NO (Go to 2.J.)

If "yes," or "not sure," how long can the child pay attention to
TV, music, reading aloud or games?
15 minutes

30 minutes

If necessary, please explain. In addition, please tell us anything
else you think we should know about the child's ability to pay
attention and stick with a task:

NOT SURE
(Continue)

Form SSA-3377-BK (5-1995) EF (12-2002)

Page 7

2. J. Please tell us anything else about the child that you think we should know:

SECTION 3 - REMARKS

Form SSA-3377-BK (5-1995) EF (12-2002)

Page 8

SSA will insert the following revised Privacy Act and PRA Statements into the form
at its next scheduled reprinting:
Function - Child Age 3 to 6th Birthday, Form SSA-3377-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.