SSA-3379-BK Function Report-Child Age 12 to 18th Birthday

Function Report Child Age 12 to 18th 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-3379-BK (05-2006) ef (03-2014)
Use (05-2006) ef (02-2007) edition until exhausted

Continued on the Reverse

u

Privacy Act Statement
Sections 1614 and 1631(e)(1), of the Social Security Act, as amended, and 20 CFR 416.924(a),
authorize us to collect this information. We will use the information you provide on behalf of the
child to determine his or her eligibility for Supplemental Security Income (SSI) payments based
on disability.
See Revised Privacy Act Statement Attached
Furnishing us the information is voluntary. However, failing to provide all or part of the
requested information may prevent our making an accurate and timely decision on the claim.
We rarely use the information you supply for any purpose other than to make a decision
regarding the child’s eligibility for SSI payments. 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 ensure 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 payments
or delinquent debts under these programs.
A complete list of routine uses of this information is available in our Privacy Act System of
Records Notice 60-0089, entitled, Claims Folders Systems. Additional information about this
and other system of records notices and our programs is 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 20 minutes to read the instructions, gather the facts, and
answer the questions. SEND 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.
Form SSA-3379-BK (05-2006) ef (03-2014)

Form Approved
OMB No. 0960-0542

SOCIAL SECURITY ADMINISTRATION

FUNCTION REPORT - CHILD
AGE 12 TO 18th 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
Form SSA-3379-BK (05-2006) ef (03-2014)
Use (05-2006) ef (02-2007) edition until exhausted

STATE
Page 1

ZIP CODE

SECTION 2 - FUNCTION DETAILS
2. A. Does the child have
problems seeing?
YES (Continue)

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:

u

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?
YES (Continue)

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

u

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

Child uses American Sign Language.
Child reads lips.
Form SSA-3379-BK (05-2006) ef (03-2014)

Page 2

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

Does the child have problems talking clearly?

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

Yes (answer questions below)
No (Continue to 2.D.)

u

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-3379-BK (05-2006) ef (03-2014)

Page 3

2. D. Are the child's daily
activities limited?
YES (Continue)

If "yes," or "not sure," please mark every statement below that
is true about the child:

u

NO (Go to 2.E.)

NOT SURE
(Continue)

u

Goes to school part-time

Works full-time

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

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:

u

NO (Go to 2.F.)

NOT SURE
(Continue)

Works part-time

Other. Describe:

E. Is the child's ability to
communicate limited?
YES (Continue)

Goes to school full-time

u

Yes

No Answer the telephone and make

Yes

No Deliver phone messages

Yes

No Repeat stories he or she has heard

Yes

No

Yes

No Explain why he or she did something

Yes

No Uses sentences with "because," "what if,"

telephone calls

Tell jokes or riddles accurately

Yes

or "should have been"
No Ask for what he or she needs

Yes

No Talks with family

Yes

No Talks with friends

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-3379-BK (05-2006) ef (03-2014)

Page 4

2. F. Is there any limitation in
the child's progress in
understanding and using
what he or she has
learned?
YES (Continue)

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:

u

NO (Go to 2.G.)

NOT SURE
(Continue)

Yes

No Read and understand sentences in comics

Yes

No Read and understand stories in books,

Yes

No Spell words of more than 4 letters

Yes

No Tell time

Yes

No Add and subtract numbers over 10

Yes

No Multiply and divide numbers over 10

Yes

No Understands money - can make correct

Yes

No Understand, carry out, and remember

and cartoons

magazines, or newspapers

u

change

simple instructions

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:

G. Are the child's physical
abilities limited?
YES (Continue)

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:

u

NO (Go to 2.H.)

NOT SURE
(Continue)

u

Yes

No Walk

Yes

No Ride a bike

Yes

No Run

Yes

No Throw a ball

Yes

No Dance

Yes

No Jump rope

Yes

No Swim

Yes

No Play sports

Yes
No Work video
games controls
car
If necessary, please explain. In addition, please tell us anything
else you think we should know about the child's physical
abilities:

Form SSA-3379-BK (05-2006) ef (03-2014)

Yes

No Drive a

Page 5

2. H. Does the child's
impairment(s) affect his
or her social activities or
behavior with other
people?
YES (Continue)

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:

u

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

u

Yes

No Has friends his or her own age

Yes

No Can make new friends

Yes

No Generally gets along with you or other

Yes

No Generally gets along all right with

Yes

No Generally gets along with school

Yes

No Plays team sports (for example, baseball,

adults

brothers and sisters
teachers

basketball, soccer)

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-3379-BK (05-2006) ef (03-2014)

Page 6

2. I. Is the child's ability to take If "yes," or "not sure," please tell us what the child does or can
care of his or her personal do by checking "yes" or "no" for each of the following:
needs and safety limited?
Yes
No Takes care of personal hygiene (keep
clean, brush teeth, comb hair, etc.)
YES (Continue)
u
Yes
No Washes and puts away his or her clothes
NO (Go to 2.J.)
NOT SURE
(Continue)

Yes

No Helps around the house (for example,

Yes

No Can cook a meal for self

Yes

No Gets to school on time

Yes

No Studies and does homework

Yes

No Takes needed medication

Yes

No Can use public transportation by himself/

washes or dries dishes, makes bed(s),
sweeps/vacuums floor, rakes or mows yard,
helps with laundry)

u

Yes

herself
No Accepts criticism or correction

Yes

No Keeps out of trouble

Yes

No Obeys rules

Yes

No Avoids accidents

Yes

No Asks for help when needed

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 and safety:

Form SSA-3379-BK (05-2006) ef (03-2014)

Page 7

2. J. Is the child's ability to pay If "yes," or "not sure," please tell us what the child does or can
attention and stick with a
do by checking "yes" or "no" for each of the following:
task limited?
Yes
No Works on arts and crafts projects (draws,
paints, knits, does woodwork)
YES (Continue)
u
Yes
No Keeps busy on his or her own
NO (Go to 2.K.)
NOT SURE
(Continue)

u

Yes

No Finishes things he or she starts

Yes

No Completes homework

Yes

No Completes homework on time

Yes

No Completes chores most of the time

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:

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

Form SSA-3379-BK (05-2006) ef (03-2014)

Page 8

SECTION 3 - REMARKS

Form SSA-3379-BK (05-2006) ef (03-2014)

Page 9