Form SSA-3375-BK Function Report Child - Child Birth to 1st Birthday

Form SSA-3375-BK (01-2022) UF
Discontinue Prior Editions
Social Security Administration

Page 1 of 7
OMB No. 0960-0542

Function Report - Child Birth to 1st 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-3375-BK (01-2022) UF

Page 2 of 7

Privacy Act Statement
Collection and Use of Personal Information
Sections 1614(a)(3) and 1631(e) 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 prevent an accurate and timely decision on any claim filed.
We will use the information to make a determination of eligibility for Supplemental Security Income
benefits. We may also share your information for the following purposes, called routine uses:
1. To Federal, State, or local agencies for administering cash or non-cash income
maintenance or health maintenance programs;
2. To appropriate State agencies, or other agencies providing services to disabled children,
to identify Title XVI eligible under the age of 16 for the consideration of rehabilitation
services; and
3. To specified business and other community members and Federal, State, and local
agencies for verification of eligibility for benefits.
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 Notices (SORNs)
60-0089, entitled Claims Folders Systems, as published in the Federal Register (FR), on April 1,
2003, at 68 FR 15784; 60-0103, entitled Supplemental Security Income Record and Special
Veterans Benefits, as published in the FR on January 11, 2006 at 71 FR 1830; and 60-0320,
entitled Electronic Disability (eDIB) Claim File, as published in the FR on December 22, 2003 at 68
FR 71210. Additional information, and a full listing of all of our SORNs, are available on our website
at www.ssa.gov/privacy/.
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-3375-BK (01-2022) UF
Discontinue Prior Editions
Social Security Administration

Page 3 of 7
OMB No. 0960-0542

FUNCTION REPORT - CHILD
BIRTH TO 1st 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

Page 4 of 7

Form SSA-3375-BK (01-2022) UF

SECTION 2 - FUNCTION DETAILS
2. A. Does the child have
problems seeing?
YES (Continue)
NO (Go to 2.B.)

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:

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)
NO (Go to 2.C.)

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:

Child cannot be fitted for hearing aid(s). Explain:

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

Form SSA-3375-BK (01-2022) UF

2. C. Are the child's activities
or abilities limited?

Page 5 of 7

If "yes," or "not sure," please tell us what the child does by
marking "yes" or "no" for each of the following:

YES (Continue)

Yes

No

Makes various cooing sounds, such as
"aaah" and "oooh"

NO (Go to 2.D.)

Yes

No

Makes various babbling sounds, such
as "babababa" or "mamamama"

NOT SURE
(Continue)

Yes

No

Says simple words other than "mama"
and "dada"

Child generally
Yes

No

Stops crying when picked up and held

Yes

No

Watches face of person talking to him or
her

Yes

No Pats, "talks to" or otherwise responds to

himself or herself in mirror
Yes

No Plays games, such as "peek-a-boo"

Yes

No Understands simple statements like "come

here" or "sit down"
Yes

No Points to something he or she wants that

is out of reach, such as a toy or food
Yes

No Understands names of favorite toys or

other things, such as a bottle
Yes

No Turns head in direction of familiar noises

or voices
Yes

No Turns head when his or her name is called

Yes

No Smiles at faces he or she knows

Yes

No Quiets or stops crying when sees parent

or other person he or she knows
Yes

No Cuddles in arms when held by parent or

caregiver
Yes

No Reaches out to be picked up

Form SSA-3375-BK (01-2022) UF

2. C. (Continued)

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Child can
Yes

No

Roll from stomach to back

Yes

No

Roll from back to stomach

Yes

No

Get to a sitting position without help

Yes

No

Rock back and forth on hands and knees

Yes

No

Crawl or creep

Yes

No

Pull self up to a standing position

Yes

No

Reach for toys, or other objects

Yes

No

Stand up without holding on to someone
or something

Yes

No

Walk holding on to someone or something

Yes

No

Eat foods, such as cereal, cookie, by self

Yes

No

Move toy or other object from hand-tohand

Yes

No

Hold small objects between fingers

Yes

No

Throw ball or other object

D. If necessary, please explain any of the items in Question 2.C. In addition, please tell us
anything else about the child that you think we should know:

Form SSA-3375-BK (01-2022) UF

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SECTION 3 - REMARKS