Function Report - Adult

OMB 0960-0681

OMB 0960-0681

SSA uses Form SSA-3373-BK to collect information about a disability applicant's or recipient's impairment-related limitations and ability to function. This information, together with medical evidence, forms the evidentiary basis upon which the initial disability process is founded. The respondents are Title II and Title XVI applicants(or current recipients undergoing redeterminations for) disability benefits.

The latest form for Function Report - Adult expires 2021-11-30 and can be found here.

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