Form Ssa 3380 Bk

Form SSA-3380-BK is a form used by an individual seeking disability benefits from the Social Security Administration. This is a function report for an adult that is completed by a third-party. The third-party chosen to complete this extensive form cannot be a medical professional treating the applicant. It must be completed by someone such as a friend or family member. It's important to include as much information as possible in this form as it will be used along with other forms to determine whether the applicant qualifies for disability payments.

What is a SSA 3380 BK?

This form will be used by the Social Security Administration in order to process an individual’s application for benefits such as disability or SSI. The Form SSA 3380-BK is known as a Third Party Adult Function Report. This form will need to be filled out by a third party such as a friend or family member. It cannot be a medical professional. This person should be close to you, as this form asks very personal questions.
The third party will need to know information such as where you live, what your medical conditions are, and how you go through your daily life. This will include what your physical and mental limitations are. The Social Security Administration will need this information in order to determine whether or not you are eligible for benefits. Ensure that your third party is accurate and truthful on form.

How to complete an SSA 3380 BK (Step by Step)

To complete an SSA 3380-BK, you will need to provide the following information:

  • Section A - General Information
    • Name of disabled person
    • Name of person completing form
    • Relationship
    • Date
    • Daytime telephone number
    • Length of time you’ve known the person
    • Amount of time you spend with the disabled person
    • Location where the disabled person lives
    • With whom the disabled person lives
  • Section B - Information About Illnesses, Injuries, or Conditions
    • How person’s condition limits ability to work
  • Section C - Information About Daily Activities
    • Describe what the disabled person does from time he/she wakes up until going to bed
    • Indicate whether the person takes care of another person
    • Indicate whether the person cares for other people or animals
    • Explain what the disabled person was able to do before his/her condition that he/she can’t do now
    • Describe how the condition affects his or her sleep
    • Personal care
      • Explain how condition affects a person's ability to: dress: bathe, care for hair, shave, feed self, use the toilet, or other
      • Describe any special reminders he/she needs to take care of personal needs and grooming
      • Describe any help or reminders he/she needs to take medicine
    • Meals
      • Whether disabled person prepares his/her own meals
      • What kind of food is prepared
      • How often he/she prepares food or meals
      • How long does it take him/her
      • Describe any changes in cooking habits since the condition began
      • Explain if he/she cannot or does not prepare meals
    • House and yard work
      • List household chores disabled person is able to do
      • Explain how much time the chores take and how often he or she does each of these things
      • Explain whether he or she needs help or encouragement to do these things
      • Explain if the person does not or cannot do house or yard work
    • Getting around
      • Explain how often the person goes outside or why they do not go outside
      • Explain disabled person’s form of transportation
      • Whether disabled person can go out alone or explanation why not
      • Whether disabled person drive or explanation why not
    • Shopping
      • Whether the disabled person does any shopping: in stores, by phone, by mail, by computer
      • Describe what person shops for
      • Describe how other he/she shops and how long it takes
    • Money
      • Whether he/she is able to: pay bills, count change, handle a savings account, use a checkbook/money orders or explanation why not
      • Whether disabled person’s ability to handle money has changed since condition began and explanation how
    • Hobbies and Interests
      • Describe his/her hobbies and interests
      • Describe how often and well he/she does these things
      • Describe any changes in these activities since condition began
    • Social activities
      • Indicate whether a person spends time with others and explain types of things he/she does with them and how often he/she does them
      • List the places he/she goes on a regular basis
      • Explain whether he/she needs to be reminded to go to places
      • Explain how often he/she goes and how much he/she takes part
      • Explain whether he/she needs someone to accompany him/her
      • Explain any problems he/she has been getting along with family, friends, neighbors, or others
      • Describe any changes in social activities since his/her condition began
  • Section D - Information About Abilities
    • Indicate any of the items that disabled person’s conditions affect: lifting, squatting, bending, standing, reaching, walking, sitting, kneeling, talking, hearing, stair climbing, seeing, memory, completing tasks, concentration, understanding, following instructions, using hands, getting along with others
    • Explain how his/her condition affects those activities
    • Indicate his/her dominant hand
    • Indicate how far he/she can walk before needing to stop and rest and, if he/she has to rest, how long before he/she can resume walking
    • Indicate how long he/she can pay attention
    • Indicate whether he/she finishes what he/she starts
    • Indicate how well he/she follows written directions
    • Indicate how well he/she follows spoken instructions
    • Indicate how well he/she gets along with authority figures
    • Indicate whether he/she has ever been fired or laid off from a job because of problems getting along with people
    • Indicate how well he/she handles stress
    • Indicate how well he/she handles changes in routine
    • Indicate whether you’ve noticed any unusual behavior or fears in the disabled person
    • Indicate whether he/she uses any of the following: crutches, walker, wheelchair, cane, brace/splint, artificial limb, hearing aid, glasses/contact lenses, artificial voice box
      • Indicate any of the items that were prescribed, when they were prescribed, and why disabled person needs them
    • Explain any medicines that he/she take for illnesses, injuries, or conditions and any side effects that they cause
  • Section E - Remarks
    • Any information that was not indicated earlier in the form
  • Name of person completing the form
  • Date
  • Address 

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