Pain Report - Child

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SSA-3371-BK Pain Report – Child
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Getting to the SSA-3371 within the Upload Documents Portal
1. In the Representative Payee portal for beneficiary: Form selection for the SSA-3371

2. “Next” selected:

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SSA-3371-BK Pain Report – Child
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Your Information

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3. “Next” selected:

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SSA-3371-BK Pain Report – Child
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a. “View Information” tab is selected:

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b. “Got it, continue”

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Identifying Information
4. If “Get Started” from the “Let’s work on this together/” Your Information page or “Next”
selected from Screen 3.b:

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5. “View Information” or “Next” selected will prompt to same screen:

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6. If “Yes” selected (it is noted that this should Yes is not likely an option to this question, as
the mySSA.gov account holder would be a rep/payee for the child applicant. However, the
agency language is on the SSA-3371:

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SSA-3371-BK Pain Report – Child
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a. Agency information to be completed:

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7. If “No” selected:
8.

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First Pain
9. Once “Next” selected from either Screenshot 6.a or 7:

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a. Once the above questions are answered additional questions are prompted:

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b. (additional questions on page 1 to be completed before selecting next)

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SSA-3371-BK Pain Report – Child
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c. Next selected – moves to page 2 of “First pain”

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d. Complete questions, if “No” selected to the question regarding medication, the screen
prompts the use to hit “Next” :

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e. If no medication, and selecting “next” prompts to page 3 of First Pain:

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f. If “yes” selected to the question regarding medication, prompted to answer additional
questions regarding pain:

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g. “Add Medicine” selected which prompts you to a pop-up with several questions to work
through when selecting “next” for each:

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SSA-3371-BK Pain Report – Child
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h. “Finish” selected takes back to page with med information provided. There is an option to
“Add Another Medicine” which will present the same prompts noted above in Screens 8.g:

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i. If “next” selected after selecting “Yes” to the medication question and adding the
medication information, page 3 prompted:

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j. If “yes” to side effects:

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k. If no to side effects:

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l. If the user answers (8.k) “yes” to having pain in more than one body part on page 3 of First
pain (also see 8.e), then the user will be prompted to answer all of the same questions
above in Section 8, but will be noted as a “Second pain”. If t

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i.

Once the user selects “Next” the Second Pain screen will appear

ii.

Likewise if the user “yes” to have additional pain afte the Second pain, then
then a Third Pain screen will appear.

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m. If the user answers (8.k) “no” to having pain in more than one body part on page 3 of First
pain (also see 8.e), then the user will be prompted to move to the “Remarks” page.

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Remarks
10. One the user has completed the First Pain or First/Second/Third Pain and “Next” selected,
they will be promted to the Remarks page:

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Review and Submit

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11. Remarks text is option. Once “Review” selected:

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a. The user has the option to click “Edit” where necessary. The user is to review and/or expand
the PDF in Document Preview, which pulls the information from the conversation form.
Example:

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Confirmation
b. Once “Submit” selected:

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