Form SSA-3376 Function Report-Child Age 1 to 3rd Birthday

Function Report - Child Age 1 to 3rd 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.
x Print or type.
x Do not ask a doctor or hospital to complete this form.
x Be sure to explain your answer if an explanation is requested or needed.
x 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-3376-BK (5-2006) ef (07-2008)
Prior edition may be used until stock is exhausted

Continued on the Reverse

The Privacy
And Paperwork
Reduction Acts

See revised
Privacy Act
Statement below.

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.
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-3376-BK (5-2006) ef (07-2008)

Form Approved
OMB No. 0960-0542

SOCIAL SECURITY ADMINISTRATION

FUNCTION REPORT - CHILD
AGE 1 TO 3rd 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-3376-BK (5-2006) ef (07-2008)
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)

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-3376-BK (5-2006) ef (07-2008)

Page 2

2. C. Is the child totally
unable to talk?

Does the child have problems talking (for example, saying simple
words)?

Yes (answer questions below)

YES (Go to 2.D.)

No (continue to question 2.D.)

NO (Continue)

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

Says simple words like "he," "bottle," "doggy"
Uses two-word phrases, such as "mommy go" or "push toy"
Uses short sentences of 4 or more words, such as "Can I go out?"
Has a vocabulary of at least 50 words
For each of the two statements below, mark the block that best
describes the child, and then describe any other speech problems:
The child's speech can be understood by people who know the child
well:

Most of the time, or
Some of the time, or
Hardly ever.
The child's 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-3376-BK (5-2006) ef (07-2008)

Page 3

2.

D. Does the child have
difficulty understanding
and learning?

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

Yes

No

Waves "bye-bye"

Yes

No

Plays pat-a-cake

Yes

No

Uses one or more words (can be made-up words)
to ask for toys, food, or people

Yes

No

Follows most simple, one-step directions, such
as "come here" or "give it to me"

Yes

No

Knows and can point to parts of face or body such
as eye or hand when asked

Yes

No

Plays "pretend" with dolls or stuffed animals

Yes

No

Uses own name or "I" or "me" to refer to self

Yes

No

Listens at least 5 minutes to stories being read

Yes

No

Follows two-step directions, such as "find your shoe
and bring it to me"

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

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

Form SSA-3376-BK (5-2006) ef (07-2008)

Page 4

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 stand with help,
and can now stand without help, check "yes" for both.

2. E. Are the child's physical
abilities limited?

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

Yes

No

Crawl

Yes

No

Stand with help

Yes

No

Stand without help

Yes

No

Walk holding on to someone or something

Yes

No

Walk without holding on

Yes

No

Climb onto furniture

Yes

No

Throw a ball or other object

Yes

No

Dance or jump up and down

Yes

No

Walk up and down steps by self

Yes

No

Run, but may fall down sometimes

Yes

No

Run without falling

Yes

No

Stack small blocks 2 high

Yes

No

Stack small blocks 4 high

Yes

No

Stack small blocks 6 high

Yes

No

Push and pull small toys

Yes

No

Scribble with a crayon or pencil

Yes

No

Hold crayon or pencil with thumb and fingers, not
fist

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

Form SSA-3376-BK (5-2006) ef (07-2008)

Page 5

2. F. 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)

Yes

No

Is affectionate towards parents

Yes

No

Says "no" a lot

Yes

No

Plays next to other children but not with them

Yes

No

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

G. Is the child's ability to
help take care of his or
her personal needs
limited?

Plays "catch" or other simple games with other
children
If necessary, please explain. In addition, please tell us anything else
you think we should know about the child's behavior around 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)

Yes

No

Cooperates in getting dressed

Yes

No

Cooperates in brushing teeth

Yes

No

Drinks from a cup or glass without help

Yes

No

Feeds self with spoon

Yes

No

Can undress by self

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

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

H. Please tell us anything else about the child that you think we should know.

Form SSA-3376-BK (5-2006) ef (07-2008)

Page 6

SECTION 3 - REMARKS

Form SSA-3376-BK (5-2006) ef (07-2008)

Page 7

Privacy Act Statement
Collection and Use of Personal Information

Sections 205(a), 223(d), and 1631(e)(1), of the Social Security Act, as amended, authorize us to
collect this information. We will use the information you provide on behalf of the minor child to
determine his or her benefit eligibility.
Furnishing us the information is voluntary. However, failing to provide us with all or part of the
requested information may prevent us from making an accurate and timely decision on the claim.
We rarely use the information for any purpose other than for making a decision regarding
entitlements to benefits. However, we may use it for the administration and integrity of our
programs. We may also disclose the information to another person or to another agency in
accordance with approved routine uses, including but not limited to the following:
1. To enable a third party or an agency to assist us in establishing rights to our benefits and
coverage;
2. To comply with Federal laws requiring the release of information from our records (e.g.
to the Government Accountability Office and 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, and investigatory activities necessary to assure the
integrity and improvement of our programs (e.g., to the Bureau of the Census and to
private entities under contract with us).
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. We use the information from these programs to establish or verify a person’s
eligibility for federally funded and administered benefit programs and for repayment of incorrect
payment’s or delinquent debts under these programs.
A complete list of routine uses of this information is available in our Privacy Act System of
Records Notices entitled, Claims Folders Systems, 60-0089. Additional information about this
and other system of records notices and our programs are available on-line
at www.socialsecurity.gov or at your local Social Security office.