Form SSA-3820-BK Disability Report - Child

Form SSA-3820-BK (XX-2018) UF
Discontinue Prior Editions
Social Security Administration

Page 1 of 14
OMB No. 0960-0160

Disability Report - Child - 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
• 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.
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.

Form SSA-3820-BK (XX-2018) UF

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Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 1631(e)(1), and 223(d)(5)(A) of the Social Security Act, as amended, allow us to
collect this information. Furnishing us this information is voluntary. However, failing to provide all or
part of the information may affect the decision on the claim.
We will use the information to make a decision regarding if a child is eligible for benefit payments. We
may also share your information for the following purposes, called routine uses:
1. To Federal, State, or local agencies that conduct business with the Social Security
Administration (SSA) and the release of records is determined to be relevant and necessary;
and disclosure is compatible to the reason why the records were collected;
2. To third party contacts when additional information about the child is needed or verification of
eligibility for benefits; and
3. To workers who are performing work for SSA as authorized by law and who technically do
not have the status of Federal employees; and other Federal agencies for assisting SSA in
the efficient administration of its programs.
In addition, we may share this information in accordance with the Privacy Act and other Federal laws.
For example, where authorized, we may use and disclose this information in computer matching
programs, in which our records are compared with other records to establish or verify a person’s
eligibility for Federal benefit programs and for repayment of incorrect or delinquent debts under these
programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice (SORN)
60-0089, entitled Claims Folders Systems. Additional information and a full listing of all our SORNs are
available on our website at www.socialsecurity.gov/foia/bluebook.

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 (OMB) control
number. We estimate that it will take about 90 minutes to read the instructions, gather the facts, and
answer the questions. Send only comments relating to our time estimate above to: SSA, 6401 Security
Blvd, Baltimore, MD 21235-6401.

Form SSA-3820-BK (XX-2018) UF
Discontinue Prior Editions
Social Security Administration

Page 3 of 14
OMB No. 0960-0160

Disability Report - Child
Section 1 - Information About the Child
B. Child's Social Security Number

A. Child's Name (First, Middle Initial, Last)

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)
(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.)

D. Your Daytime Phone Number
Area Code

Your Number

Number

Message Number

None

E. What is your relationship to the child?
F. Can you speak and understand English?

Yes

No

If "No," what is your
preferred language?

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 (Enter name, address, phone number, relationship)
Name:

No
Relationship to Child:

Address:

City

(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)
Daytime
Phone
State ZIP
Area Code

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

Yes

Yes

Number

No

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

Name:

Relationship to Child:

Address:

City

(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)
Daytime
Phone
State ZIP
Area Code

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?

Number

Form SSA-3820-BK (XX-2018) UF

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Section 1 - Information About the Child
H. Can the child speak and understand English?

Yes

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?

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)
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?

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

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?

ZIP

Form SSA-3820-BK (XX-2018) UF

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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

Day

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

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

No

Form SSA-3820-BK (XX-2018) UF

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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

Phone

Patient ID # (if known)
Area Code

ZIP

Last Visit

Next Appointment

Number

Reasons for visits

What treatment was received?

2. Name
Dates
Street Address

First Visit

City

State

Phone

Patient ID # (if known)
Area Code

Number

Reasons for visits

What treatment was received?

ZIP

Last Visit

Next Appointment

Form SSA-3820-BK (XX-2018) UF

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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

Phone

Patient ID # (if known)
Area Code

ZIP

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.
Hospital/Clinic

1.
Name

Type of Visit
Inpatient Stays
(Stayed at least overnight)

Dates
Date In

Date Out

Date First Visit

Date Last Visit

Street Address
Outpatient Visits
(Sent home same day)
City
Emergency Room Visits
State

ZIP
Dates of Visits

Phone
Area Code

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-2018) UF

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Section 4 - Information About the Child's Medical Records
Hospital/Clinic
Hospital/Clinic

2.

Type of Visit

Name

Dates

Inpatient Stays
(Stayed at least overnight)

Date In

Date Out

Date First Visit

Date Last Visit

Street Address
Outpatient Visits
(Sent home same day)
City
Emergency Room Visits
State

ZIP
Dates of Visits

Phone
Area Code

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?

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

ZIP

Next Appointment

Phone
Area Code
Claim Number (if any)

Last Seen

Number

Reasons for Visits

If you need more space, use Section 10.

Form SSA-3820-BK (XX-2018) UF

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Section 5 - Medications
Does the child currently take any medications for illnesses, injuries or conditions?

Yes

No

If "Yes," tell us the following: (Look at the child's medicine container's, if necessary)
Name of Medicine

If Prescribed,
Give Name of Doctor

Reason for Medicine

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?
Yes

No

If "Yes," tell us the following (give approximate dates, if necessary)

Kind of Test

When Was/Will Tests Be Done
(Month, Day, Year)

Where Done
(Name of Facility)

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.

Who Sent The Child
For This Test

Form SSA-3820-BK (XX-2018) UF

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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

Program for Children with Special Health Care Needs

Yes

No

Mental Health/Developmental Disabilities Center

Yes

No

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 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

Phone Number
Area Code

Number

Type of Test

When Done

Type of Test

When Done

File or Record Number
If the child has had other tests, list them in Section 10.

ZIP

Form SSA-3820-BK (XX-2018) UF

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Section 8 - Education
A. Is this 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

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:

Yes

No

Type of Test

When Done

Type of Test

When Done

Is the child in special education?

Yes

No

If "Yes", and different from above, give:
Name of Special Education Teacher

Is the child in speech/language therapy?
If "Yes", and different from above, give:
Name of Speech/Language Therapist

Yes

No

ZIP

Form SSA-3820-BK (XX-2018) UF

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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
Was the child tested for behavioral or learning problems?
If "Yes", complete the following:

Yes

No

Type of Test

When Done

Type of Test

When Done

Was the child in special education?

Yes

No

If "Yes", and different from above, give:
Name of Special Education Teacher

Was the child in speech/language therapy?

Yes

No

If "Yes", and different from above, give:
Name of Speech/Language Therapist
If the child has had other tests, list them in Section 10.
E. Is the child attending Daycare/Preschool?
If "Yes", complete the following:

Yes

No

Name of Daycare/Preschool/Caregiver
Address
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)

City

County

Phone Number
Area Code
Dates Attended
Teacher's/Caregiver's Name

Number

State

ZIP

Form SSA-3820-BK (XX-2018) UF

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Section 9 - Work History
A. Has the child ever worked (including sheltered work)?

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

County

State

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.

ZIP

Form SSA-3820-BK (XX-2018) UF

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Section 10 - Date and Remarks