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

Form SSA-3376-BK (01-2022) UF
Discontinue Prior Editions
Social Security Administration

Page 1 of 9
OMB No. 0960-0542

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 (01-2022) UF

Page 2 of 9

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 68FR 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 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 (01-2022) UF
Discontinue Prior Editions
Social Security Administration

Page 3 of 9
OMB No. 0960-0542

FUNCTION REPORT - CHILD
AGE 1 TO 3rd BIRTHDAY
SECTION 1 - IDENTIFYING INFORMATION
1. A. Print NAME OF CHILD:
MIDDLE

FIRST

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 (01-2022) UF

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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

Form SSA-3376-BK (01-2022) UF

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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.)

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

NO (Continue)
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:

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Form SSA-3376-BK (01-2022) 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 (01-2022) UF

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

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

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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:

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Form SSA-3376-BK (01-2022) 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)

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 (01-2022) UF

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SECTION 3 - REMARKS