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
- AddressÂ
