Current 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.
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
RETURIG THE COMPLETED FORM.

Form SSA-3377-BK (5-2006) ef (01-2007)
Prior edition may be used until stock is exhausted

Continued on the Reverse

The Privacy
And Paperwork
Reduction Acts

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.
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. SED OR
BRIG 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-3377-BK (5-2006) ef (01-2007)

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:
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-3377-BK (5-2006) ef (01-2007)
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-3377-BK (5-2006) ef (01-2007)

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 (5-2006) ef (01-2007)

Page 3

2. D. Is the child's ability
to communicate 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

No

Asks a lot of what, why, and where questions

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

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 communicate:

Form SSA-3377-BK (5-2006) ef (01-2007)

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 (5-2006) ef (01-2007)

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)

Yes

No

Catch a large ball, like a beach ball

Yes

No

Yes

No

Ride a big wheel, tricycle, or bike with
training wheels
Wind up a toy

Yes

No

Print at least some letters

Yes

No

Copy first name

Yes

No

Use scissors fairly well

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

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
If "yes," or "not sure," please tell us what the child does or can do
impairment(s) affect his
by checking "yes" or "no" for each of the following:
or her behavior with other
Yes
No Enjoys being with other children the same
people?
Yes

No

age
Shows affection towards other children

Yes

No

Is affectionate towards parents

NO (Go to 2.H.)

Yes

No

Shares toys

NOT SURE
(Continue)

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)

YES (Continue)

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 (5-2006) ef (01-2007)

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

YES (Continue)

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

Yes

No

Dresses self without help (except tying
shoes)
Washes or bathes without help

Yes

No

Brushes teeth with help

Yes

No

Brushes teeth without help

Yes

No

Puts toys away

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 (5-2006) ef (01-2007)

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 (5-2006) ef (01-2007)

Page 8