Function Report - Adult

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.

Latest Forms, Documents, and Supporting Material

Document Name
Form SSA-3373 Function Report - Adult Form and Instruction
Supporting Statement - 0681 (Final).docx Supporting Statement A
Addendum - 0681 (Final).docx Supplementary Document
Function Report - Adult Form and Instruction

All Historical Document Collections

202104-0960-006 Approved with change	Revision of a currently approved collection	2021-09-03
201804-0960-007 Approved without change	Revision of a currently approved collection	2018-07-30
201505-0960-011 Approved with change	Revision of a currently approved collection	2015-07-23
201311-0960-003 Approved without change	No material or nonsubstantive change to a currently approved collection	2013-11-12
201207-0960-005 Approved without change	Revision of a currently approved collection	2012-09-27
200905-0960-008 Approved without change	Revision of a currently approved collection	2009-07-31
200708-0960-018 Approved without change	Revision of a currently approved collection	2008-05-30
200608-0960-008 Approved without change	Revision of a currently approved collection	2006-08-21
200310-0960-012 Approved without change	New collection (Request for a new OMB Control Number)	2003-10-31