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

Form SSA-3376-BK (10-2016) UF
Discontinue Prior Editions
Social Security Administration

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.
• 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.

Continued on the Reverse

Form SSA-3376-BK (10-2016) UF

Privacy Act Statement

See Revised Privacy Act
Statement Attached

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.
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 (10-2016) UF
Discontinue Prior Editions
Social Security Administration

Page 1 of 7
OMB No. 0960-0542

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 (10-2016) UF

Page 2 of 7

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:

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:
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

Page 3 of 7

Form SSA-3376-BK (10-2016) UF

2. C. Is the child totally unable Does the child have problems talking
to talk?
(for example, saying simple words)?
YES (Go to 2.D.)
NO (Continue)

Yes (answer questions below)
No (continue to question 2.D.)
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:

Page 4 of 7

Form SSA-3376-BK (10-2016) UF

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 (10-2016) UF

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

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

Page 5 of 7

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.
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 (10-2016) UF

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

Page 6 of 7

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 Is affectionate towards parents

Yes

No Says "no" a lot

Yes

No Plays next to other children but not with them

Yes

No 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

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 (10-2016) UF

Page 7 of 7

SECTION 3 - REMARKS