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
THIS IS NOT AN APPLICATION

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

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 or medicine containers
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 medicine containers.

Disability Report - Child - Form SSA-3820-BK

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 as much of this form as you can before your interview appointment.
 Print or write clearly.
 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."
 IN SECTION 4, PUT INFORMATION ON ONLY ONE DOCTOR/HMO/THERAPIST/
OTHER/HOSPITAL/CLINIC IN EACH SPACE.
 Each address should include a ZIP code. Each telephone number should include an area code.
 DO NOT ASK A DOCTOR OR HOSPITAL TO COMPLETE THE FORM. However,
you can get help from other people, like a friend or family member.
 If your appointment is for an interview by telephone, have the form ready to discuss with us
when we call you.
 If your appointment is for an interview in our office, bring the completed form with you or
mail ahead of time, if you were told to do so.
 Be sure to explain an answer if the question asks for an explanation, or if you want to give
additional information.
 If you need more space to answer any questions or want to tell us more about an answer,
please use Section 10, "DATE AND REMARKS," on Pages 11 and 12, and show the number
of the question being answered.

The Privacy and Paperwork Reduction Acts
Sections 205(a), 223(d), and 1631 of the Social Security Act, as amended, authorizes us to
collect this information. The information you provide will allow the Social Security
Administration (SSA) to determine the child’s potential eligibility benefit payments and to help
us to decide if additional information is needed. Your response is voluntary. However, failure
to provide this requested information may prevent an accurate and timely decision on any
claim filed, or could result in loss of benefits.
We rarely use the information provided on this form for any purpose other than for the reasons
stated above. However, we may use it for 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
Medicare benefits 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 Department of Veterans Affairs);
3) To make determination 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 Medicare programs.
We may also use the information you provide in computer matching programs. Matching
programs compare our 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.
Explanations about these and other reasons why information you provide us may be used
or given out are available in Systems of Record Notice 60-0089 (Claims Folders Systems,
SSA, Office of General Counsel, Office of Privacy and Disclosure). The Notice, information
about this form, and any other information regarding our systems and programs, are available
on-line at www.socialsecurity.gov or at your 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 60 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.

REMOVE THIS SHEET BEFORE RETURNING THE COMPLETED FORM.

Form Approved
OMB No. 0960-0577

SOCIAL SECURITY ADMINISTRATION

DISABILITY REPORT - CHILD
SECTION 1 -- INFORMATION ABOUT THE CHILD
A. CHILD'S NAME (First, Middle Initial, Last)
B. CHILD'S SOCIAL SECURITY NUMBER
C. YOUR NAME (If agency, provide name of agency and contact person)
YOUR MAILING ADDRESS (Number and Street, Apt. No. (if any), P.O. Box, or Rural Route)
CITY

STATE

ZIP CODE

YOUR EMAIL ADDRESS (Optional)

Area Code

(If you do not have a phone number where we can reach
you, give us a daytime number where we can leave a
message for you.)

Your Number

Number

E. What is your relationship to the child?
F. Can you speak and understand English?
If "NO", what is your preferred language?

Message Number

YES

None

NO

NOTE: If you cannot speak and understand English, we will provide you an interpreter,
free of charge.
If you cannot speak and understand English, is there someone we may contact who
speaks and understands English and will give you messages?
YES
NAME

NO

(Enter name, address, phone number, relationship)

RELATIONSHIP TO CHILD

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

City

State

DAYTIME
PHONE

ZIP

Can you read and understand English?
G. Does the child live with you?

YES

YES

NO

NO

Area Code

Number

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

NAME

RELATIONSHIP TO CHILD

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

City

State

ZIP

DAYTIME
PHONE

Area Code

Can this person speak and understand English?

YES

NO

If "NO", what is this person's preferred language?
Can this person read and understand English?

YES

NO

Form SSA-3820-BK (XX-2010 DRAFT) EF (XX-2010) Prior editions may be used.

Number

PAGE 1

Disability Report - Child - Form SSA-3820-BK

D. YOUR DAYTIME PHONE NUMBER

SECTION 1 - INFORMATION ABOUT THE CHILD
YES

H. Can the child speak and understand English?

NO

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

If the child understands any other languages, list them here:
I.

What is the child's height (without shoes)?
What is the child's weight (without shoes)?

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, relationship)

NO

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

DAYTIME PHONE NUMBER

City
Area Code

State

ZIP

Number

RELATIONSHIP TO CHILD

Can this person speak and understand English?

YES

NO

YES

NO

If "NO", what is this person's preferred language?
Can this person read and understand English?

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, relationship)

NO

NAME OF CONTACT
ADDRESS
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)
City

State

ZIP

DAYTIME PHONE NUMBER
Area Code

Number

RELATIONSHIP TO CHILD

Can this person speak and understand English?

YES

NO

YES

NO

If "NO", what is this person's preferred language?
Can this person read and understand English?
Form SSA-3820-BK (XX-2010 DRAFT) EF (XX-2010)

PAGE 2

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

B. When did the child become disabled?

Month

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

Day

Year

YES

NO

SECTION 4 - INFORMATION ABOUT THE CHILD'S MEDICAL RECORDS
A. Has the child been seen by a doctor/hospital/clinic or anyone else for the
illnesses, injuries or conditions?
YES

NO

B. Has the child been seen by a doctor/hospital/clinic or anyone else for emotional or
mental problems?
YES

Form SSA-3820-BK (XX-2010 DRAFT) EF (XX-2010)

NO

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SECTION 4 - INFORMATION ABOUT THE CHILD'S MEDICAL RECORDS
Tell us who may have medical records or other
information about the child's illnesses, injuries or conditions.
C. List each DOCTOR/HMO/THERAPIST/OTHER. Include the child's next appointment.
1. NAME

DATES

STREET ADDRESS

FIRST VISIT

CITY

STATE

ZIP

Patient ID # (If known)

PHONE
Area Code

LAST VISIT
NEXT APPOINTMENT

Number

REASONS FOR VISITS

WHAT TREATMENT WAS RECEIVED?

2. NAME

DATES

STREET ADDRESS

FIRST VISIT

CITY

STATE

ZIP
Patient ID # (If known)

PHONE
Area Code

LAST SEEN
NEXT APPOINTMENT

Number

REASONS FOR VISITS

WHAT TREATMENT WAS RECEIVED?

Form SSA-3820-BK (XX-2010 DRAFT) EF (XX-2010)

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SECTION 4 - INFORMATION ABOUT THE CHILD'S MEDICAL RECORDS
DOCTOR/HMO/THERAPIST/OTHER
3. NAME

DATES

STREET ADDRESS

FIRST VISIT

CITY

STATE

ZIP

Patient ID # (If known)

PHONE
Area Code

LAST VISIT
NEXT APPOINTMENT

Number

REASONS FOR VISITS

WHAT TREATMENT WAS RECEIVED?

If you need more space, use Section 10.
D. List each HOSPITAL/CLINIC. Include the child's next appointment.
1.

HOSPITAL/CLINIC

DATES

TYPE OF VISIT

NAME

DATE IN

INPATIENT STAYS

DATE OUT

(Stayed at least overnight)

STREET ADDRESS

CITY
STATE

DATE FIRST VISIT DATE LAST VISIT

EMERGENCY ROOM
VISITS

DATES OF VISITS

(Sent home same day)

ZIP

PHONE
Area Code

OUTPATIENT VISITS

Number

Next appointment

The child's hospital/clinic number

Reasons for visits

What treatment did the child receive?

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

Form SSA-3820-BK (XX-2010 DRAFT) EF (XX-2010)

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SECTION 4 - INFORMATION ABOUT THE CHILD'S MEDICAL RECORDS
HOSPITAL/CLINIC
2.

HOSPITAL/CLINIC

TYPE OF VISIT

NAME

DATES
DATE IN

INPATIENT STAYS

DATE OUT

(Stayed at least overnight)

STREET ADDRESS

OUTPATIENT VISITS

CITY

DATE FIRST VISIT DATE LAST VISIT

(Sent home same day)

STATE

ZIP

Area Code

DATES OF VISITS

EMERGENCY ROOM
VISITS

PHONE
Number

The child's hospital/clinic number

Next appointment
Reasons for visits

What treatment did the child receive?

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

If you need more space, use Section 10.
E.
Does anyone else have medical records or information about the child's
illnesses, injuries or conditions (foster parents, social workers, counselors, tutors,
school nurses, detention centers, attorneys, insurance companies, and/or Worker's
Compensation), or is the child scheduled to see anyone else?
YES (If "YES," complete information below.)

NO

NAME

DATES

ADDRESS

FIRST VISIT

CITY

STATE

PHONE

ZIP

LAST SEEN
NEXT APPOINTMENT

Area Code

Number

CLAIM NUMBER (If any)
REASONS FOR VISITS

If you need more space, use Section 10.
Form SSA-3820-BK (XX-2010 DRAFT) EF (XX-2010)

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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 containers, if necessary.)
NAME OF MEDICINE

IF PRESCRIBED,
GIVE NAME OF DOCTOR

REASON FOR
MEDICINE

YES
NO

SIDE EFFECTS
THE CHILD HAS

If you need more space, use Section 10.
SECTION 6 - TESTS
Has the child had, or will he/she have, any medical tests for illnesses, injuries or
conditions?
If "YES", tell us the following (give approximate dates, if necessary).
YES
NO

KIND OF TEST

WHEN WAS/WILL
TESTS BE DONE?
(Month, day, year)

WHERE DONE
(Name of Facility)

WHO SENT THE
CHILD FOR
THIS TEST

EKG (HEART TEST)
TREADMILL (EXERCISE TEST)
CARDIAC CATHETERIZATION
BIOPSY--Name of body part
SPEECH/LANGUAGE
HEARING TEST
VISION TEST
IQ TESTING
EEG (BRAIN WAVE TEST)
HIV TEST
BLOOD TEST (NOT HIV)
BREATHING TEST
X-RAY--Name of body part
MRI/CAT SCAN - Name of body
part

If the child has had other tests, list them in Section 10.
Form SSA-3820-BK (XX-2010 DRAFT) EF (XX-2010)

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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 or WIC

YES

NO

Early Intervention Services

YES

NO

YES

NO

YES

NO

Program for Children with Special Health
Care Needs
Mental Health/Mental Retardation Center

B. Has the child received Vocational Rehabilitation or other employment support services
to help him or her go to work?
YES

NO

If you answered "YES" to any of the above in A. or B., please complete C. below:

C. 1. NAME OF AGENCY
ADDRESS
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)

City

State

ZIP

PHONE NUMBER
Area Code

Number

TYPE OF TEST

WHEN DONE

TYPE OF TEST

WHEN DONE

FILE OR RECORD NUMBER
2. NAME OF AGENCY
ADDRESS
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)

City

State

ZIP

PHONE NUMBER
Area Code

Number

TYPE OF TEST

WHEN DONE

TYPE OF TEST

WHEN DONE

FILE OR RECORD NUMBER

If there are any other agencies, show them in Section 10.
Form SSA-3820-BK (XX-2010) DRAFT EF (XX-2010)

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SECTION 8 - EDUCATION
A. Is the child currently enrolled in any school?

YES, grade: _________

NO, too young

NO, other reason (complete B)

B. Other reason the child is not enrolled in 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.
NAME OF SCHOOL
ADDRESS
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)

City

County

State

ZIP

PHONE NUMBER
Area Code

Number

DATES ATTENDED
TEACHER'S NAME
Has the child been tested for behavioral or learning problems?
If "YES", complete the following:
TYPE OF TEST

NO

WHEN DONE

TYPE OF TEST
Is the child in special education?

YES

WHEN DONE
YES

NO

If "YES", and different from above, give:
NAME OF SPECIAL EDUCATION TEACHER
Is the child in speech/language therapy?

YES

NO

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

Form SSA-3820-BK (XX-2010 DRAFT) EF (XX-2010)

PAGE 9

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, Street, Apt. No. (if any), P.O. Box, or Rural Route)

City

County

State

ZIP

PHONE NUMBER
Area Code

Number

DATES ATTENDED
TEACHER'S NAME

YES

Was the child tested for behavioral or learning problems?

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
YES

Was the child in speech therapy?

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 Daycare/Preschool?

YES

NO

If "YES", complete the following:
NAME OF DAYCARE/
PRESCHOOL/CAREGIVE
R
ADDRESS
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)

City

County

State

ZIP

PHONE NUMBER
Area Code

Number

DATES ATTENDED
TEACHER'S/CAREGIVER'S NAME
Form SSA-3820-BK (XX-2010 DRAFT) EF (XX-2010)

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 Route)

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 (MM/DD/YYYY)

Use this section for any additional information about your child.

Form SSA-3820-BK (XX-2010 DRAFT) EF (XX-2010)

PAGE 11

SECTION 10 - REMARKS

Form SSA-3820-BK (XX-2010 DRAFT) EF (XX-2010)

PAGE 12