Disability Report Form – Fill Out and Use This PDF

Disability Report Form – Fill Out and Use This PDF

Disability Report Form PDF Details

Form Preview Example

How to Edit Disability Report Form Online for Free

Disability Report Form isn’t the one you’re looking for?

Disability Report Form PDF Details

Form Preview Example

How to Edit Disability Report Form Online for Free

Disability Report Form isn’t the one you’re looking for?

Related Documents

Disability Report Form PDF Details

It is important for both parents and educators to be aware of the different types of disabilities that can impact a child's ability to learn. The disability report form is one way to provide information about a child's specific needs so that they can receive the appropriate support in school. This form can be helpful in identifying any early signs of a disability, and it can also help to track the progress of a child over time. It is important to fill out this form accurately and completely so that the right resources can be put in place for the child.

Question	Answer
Form Name	Disability Report Form
Form Length	14 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	3 min 30 sec
Other names	applying for child social security disability, form ssa 3820, child disability application form, filing disability for a child

Form Preview Example

Form SSA-3820-BK (05-2021) UF
Discontinue Prior Editions	Page 1 of 14
Social Security Administration	OMB No. 0960-0160

Disability Report - Child - SSA-3820-BK

Read All Of This Information Before You Begin Completing This Form

This Is Not An Application

If You Need Help

If you need help with this form, complete as much of it as you can, and your interviewer will help you finish it.

How To Complete This Form

•Fill out as much of this form as you can before your interview appointment. Print or write clearly.

•DO NOT LEAVE ANSWERS BLANK. If you do not know the answers, or the answer is "none" or "does not apply," write: "don't know," or " none," or "does not apply."

•IN SECTION 4, PUT INFORMATION ON ONLY ONE DOCTOR/HMO/THERAPIST/ OTHER/ HOSPITAL/CLINIC IN EACH SPACE.

•Each address should include a ZIP code. Each telephone number should include an area code.

•DO NOT ASK A DOCTOR OR HOSPITAL TO COMPLETE THE FORM. However, you can get help from other people, like a friend or family member.

•If your appointment is for an interview by telephone, have the form ready to discuss with us when we call you.

•If your appointment is for an interview in our office, bring the completed form with you or mail ahead of time, if you were told to do so.

•Be sure to explain an answer if the question asks for an explanation, or if you want to give additional information.

•If you need more space to answer any questions or want to tell us more about an answer, please use Section 10, "DATE AND REMARKS," on Pages 11 and 12, and show the number of the question being answered.

About The Child's Medical And Other Records

If you have any of the following records for the child at home, send them to our office with your completed forms or bring them with you to the interview. If you need the records back, tell us and we will photocopy them and return them to you.

•The child's medical records

•Copies of the child's prescriptions or medicine containers

•The child's Individualized Education Program

•The child's Individualized Family Service Plan

YOU DO NOT NEED TO ASK DOCTORS OR HOSPITALS FOR ANY MEDICAL RECORDS THAT

YOU DO NOT ALREADY HAVE. With your permission, we will do that for you. The information we ask for on this form tells us from whom to request medical and other records. If you cannot remember the names and addresses of any of the doctors or hospitals, or the dates of treatment, perhaps you can get this information from the telephone book, or from medical bills, prescriptions and medicine containers.

Form SSA-3820-BK (05-2021) UF

Page 2 of 14

Privacy Act Statement

Collection and Use of Personal Information

Sections 205(a), 1631(e)(1), and 223(d)(5)(A) of the Social Security Act, as amended, allow us to collect this information. Furnishing us this information is voluntary. However, failing to provide all or part of the information may affect the decision on the claim.

We will use the information to make a decision regarding if a child is eligible for benefit payments. We may also share your information for the following purposes, called routine uses:

1.To Federal, State, or local agencies that conduct business with the Social Security Administration (SSA) and the release of records is determined to be relevant and necessary; and disclosure is compatible to the reason why the records were collected;

2.To third party contacts when additional information about the child is needed or verification of eligibility for benefits; and

3.To workers who are performing work for SSA as authorized by law and who technically do not have the status of Federal employees; and other Federal agencies for assisting SSA in the efficient administration of its programs.

In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where authorized, we may use and disclose this information in computer matching programs, in which our records are compared with other records to establish or verify a person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent debts under these programs.

A list of additional routine uses is available in our Privacy Act System of Records Notice (SORN)

60-0089, entitled Claims Folders Systems. Additional information and a full listing of all our SORNs are available on our website at www.socialsecurity.gov/foia/bluebook.

Paperwork Reduction Act Statement - This information collection meets the requirements of

44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget (OMB) control number. We estimate that it will take about 90 minutes to read the instructions, gather the facts, and answer the questions. Send only comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401.

Form SSA-3820-BK (05-2021) UF
Discontinue Prior Editions	Page 3 of 14
Social Security Administration	OMB No. 0960-0160

Disability Report - Child

Section 1 - Information About the Child

A. Child's Name (First, Middle Initial, Last)

B. Child's Social Security Number

C. Your Name (If agency, provide name of agency and contact person)

Your Mailing Address (Number and Street, Apt. No. (if any), P.O. Box, or Rural Route)

City

State

ZIP Code

Your Email Address (Optional)

D. Your Daytime Phone Number	(If you do not have a phone number where we can reach you, give us a
	daytime number where we can leave a message for you.)

Area Code

Number

Your Number

Message Number

None

E. What is your relationship to the child?

F. Can you speak and understand English?

Yes

No If "No," what is your preferred language?

NOTE: If you cannot speak and understand English, we will provide you an interpreter, free of charge. If you cannot speak and understand English, is there someone we may contact who speaks and understands English and will give you messages?

Yes (Enter name, address, phone number, relationship)

Name:		Relationship to Child:

Address:

(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)

City

Can you read and understand English?

Yes

	Daytime
State ZIP	Phone
State ZIP	Phone	Area Code	Number
No

G. Does the child live with you?

Yes

No If "No," with whom does the child live?

Name:		Relationship to Child:

Address:

(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)

City	State ZIP
Can this person speak and understand English?	Yes

If "No," what is this person's preferred language?

Daytime
Phone	Area Code	Number
	Area Code	Number

Can this person read and understand English?

Yes

City

Daytime Phone Number:

Relationship to Child:

Can this person speak and understand English? If "No," what is this person's preferred language?

Can this person read and understand English?

Form SSA-3820-BK (05-2021) UF

Page 4 of 14

Section 1 - Information About the Child

H. Can the child speak and understand English?

Yes

If "No," what languages can the child speak?

If the child understands any other languages, list them here:

I. What is the child's height (without shoes)?

What is the child's weight (without shoes)?

J. Does the child have a medical assistance card?

Yes

If "Yes," show the number here:

Section 2 - Contact Information

A. Does the child have a legal guardian or custodian other than you?

Yes (Enter name, address, phone number, relationship)

Name:

Address:

(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)

City

State

ZIP

Daytime Phone Number

Area Code

Number

Relationship to Child:

Can this person speak and understand English?

Yes

If "No," what is this person's preferred language?

Can this person read and understand English?

Yes

B. Is there another adult who helps care for the child and can help us get information about the child if necessary?

Yes (Enter name, address, phone number, relationship)

Name of Contact:

Address:

(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)

State

ZIP

Area Code

Number

Yes

Form SSA-3820-BK (05-2021) UF	Page 5 of 14

Section 3 - The Child's Illnesses, Injuries or Conditions and How They Affect Him/Her

A. What are the child's disabling illnesses, injuries, or conditions?

B. When did the child become disabled?

MM/DD/YYYY

C. Do the child's illnesses, injuries or conditions cause pain or other symptoms?

Yes

Section 4 - Information About the Child's Medical Records

A. Has the child been seen by a doctor/hospital/clinic or anyone else for the illnesses, injuries or conditions?

Yes No

B. Has the child been seen by a doctor/hospital/clinic or anyone else for emotional or mental problems?

Yes No

Form SSA-3820-BK (05-2021) UF	Page 6 of 14

Section 4 - Information About the Child's Medical Records

Tell us who may have medical records or other information

about the child's illnesses, injuries or conditions.

C. List each Doctor/HMO/Therapist/Other. Include the child's next appointment.

1.Name

Street Address

City

Dates

First Visit

State	ZIP	Last Visit

Phone

Area Code

Number

Patient ID # (if known)

Next Appointment

Reasons for visits

What treatment was received?

2. Name

Dates

Street Address

First Visit

City

State

ZIP

Last Visit

Phone			Patient ID # (if known)

	Area Code	Number

Reasons for visits

Next Appointment

What treatment was received?

Form SSA-3820-BK (05-2021) UF	Page 7 of 14

Section 4 - Information About the Child's Medical Records

Doctor/HMO/Therapist/Other

3.Name

Dates

Street Address

First Visit

City

State

ZIP

Last Visit

Phone			Patient ID # (if known)	Next Appointment

	Area Code	Number

Reasons for visits

What treatment was received?

If you need more space, use Section 10.

D. List each Hospital/Clinic. Include the child's next appointment.

1.		Hospital/Clinic			Type of Visit	Dates

	Name			Inpatient Stays		Date In	Date Out
				(Stayed at least overnight)
				(Stayed at least overnight)

	Street Address
				Outpatient Visits
				(Sent home same day)

	City					Date First Visit	Date Last Visit
				Emergency Room Visits
	State		ZIP	Emergency Room Visits
	State		ZIP

	Phone					Dates of Visits

		Area Code	Number

	Next appointment				The child's hospital/clinic number

Reasons for visits

What treatment did the child receive?

What doctors does the child see at this hospital/clinic on a regular basis?

Form SSA-3820-BK (05-2021) UF								Page 8 of 14

		Section 4 - Information About the Child's Medical Records

				Hospital/Clinic

2.		Hospital/Clinic			Type of Visit		Dates

	Name			Inpatient Stays		Date In		Date Out
				Inpatient Stays
				(Stayed at least overnight)
				(Stayed at least overnight)

	Street Address
				Outpatient Visits
				(Sent home same day)

	City					Date First Visit		Date Last Visit
				Emergency Room Visits
	State		ZIP	Emergency Room Visits
	State		ZIP

	Phone					Dates of Visits

		Area Code	Number

	Next appointment				The child's hospital/clinic number

Reasons for visits

What treatment did the child receive?

What doctors does the child see at this hospital/clinic on a regular basis?

If you need more space, use Section 10.

E. Does anyone else have medical records or information about the child's illnesses, injuries or conditions (foster parents, social workers, counselors, tutors, school nurses, detention centers, attorneys, insurance companies, and/or Worker's Compensation), or is the child scheduled to see anyone else?

Yes (If "Yes," complete information below.)

Name

Dates

Address

First Visit

City

State

ZIP

Last Seen

Phone

Area Code

Number

Next Appointment

Claim Number (if any)

Reasons for Visits

If you need more space, use Section 10.

Form SSA-3820-BK (05-2021) UF	Page 9 of 14

Section 5 - Medications

Does the child currently take any medications for illnesses, injuries or conditions? If "Yes," tell us the following: (Look at the child's medicine container's, if necessary)

Yes

Name of Medicine

If Prescribed,

Give Name of Doctor

Reason for Medicine

Side Effects

The Child Has

If you need more space, use Section 10.

Section 6 - Tests

Has the child had, or will he/she have, any medical tests for illnesses, injuries, or conditions?

Yes	No If "Yes," tell us the following (give approximate dates, if necessary)

Kind of Test

EKG (Heart Test)

Treadmill (Exercise Test)

Cardiac Catheterization

Biopsy - Name of body part

Speech/Language

Hearing Test

Vision Test

IQ Testing

EEG (Brain Wave Test)

HIV Test

Blood Test (Not HIV)

Breathing Test

X-Ray - Name of body part

MRI/CAT Scan - Name of body part

When Was/Will Tests Be Done

(Month, Day, Year)

Where Done

(Name of Facility)

Who Sent The Child

For This Test

If the child has had other tests, list them in Section 10.

Form SSA-3820-BK (05-2021) UF		Page 10 of 14

Section 7 - Additional Information

A. Has the child been tested or examined by any of the following?
Headstart (Title V)	Yes	No
Public or Community Health Department	Yes	No
Child Welfare or Social Service Agency or WIC	Yes	No
Early Intervention Services	Yes	No
Program for Children with Special Health Care Needs	Yes	No
Mental Health/Developmental Disabilities Center	Yes	No

B. Has the child received Vocational Rehabilitation or other employment support services to help him or her go to work?

Yes

If you answered "Yes" to any of the above A. or B., please complete C. below:

C.1. Name of Agency

Address

(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)

City				State	ZIP
Phone Number
	Area Code	Number
Type of Test			When Done

Type of Test			When Done

File or Record Number

2.Name of Agency

Address

(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)

City				State	ZIP
Phone Number
	Area Code	Number
Type of Test			When Done

Type of Test			When Done

File or Record Number

If the child has had other tests, list them in Section 10.

Form SSA-3820-BK (05-2021) UF		Page 11 of 14

	Section 8 - Education

A. Is this child currently enrolled in any school?	Yes, grade:	No (too young)

	No, other reason (complete B)

B. Other reason the child is not enrolled in school:

C. List the name of the school the child is currently attending and give dates attended. If the child is no longer in school, list the name of the last school attended and give dates attended.

Name of School

Address

(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)

City		County
Phone Number

	Area Code	Number
Dates Attended

Teacher's Name

Has the child been tested for behavioral or learning problems?	Yes
If "Yes", complete the following:

StateZIP

Type of Test		When Done
Type of Test		When Done
Type of Test		When Done

Is the child in special education?

Yes

If "Yes", and different from above, give:

Name of Special Education Teacher

Is the child in speech/language therapy? If "Yes", and different from above, give:

Name of Speech/Language Therapist

Yes

Form SSA-3820-BK (05-2021) UF	Page 12 of 14

Section 8 - Education

D. List the names of all other schools attended in the last 12 months and give dates attended. Name of School

Address

(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)

Dates Attended

Teacher's Name

Was the child tested for behavioral or learning problems? If "Yes", complete the following:

Type of Test

Yes

When Done When Done

Was the child in special education?

Yes

If "Yes", and different from above, give: Name of Special Education Teacher

Was the child in speech/language therapy? If "Yes", and different from above, give: Name of Speech/Language Therapist

Yes

If the child has had other tests, list them in Section 10.

E. Is the child attending Daycare/Preschool? If "Yes", complete the following:

Name of Daycare/Preschool/Caregiver

Address

Yes

(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)

City		County	State	ZIP
Phone Number
	Area Code	Number

Dates Attended

Teacher's/Caregiver's Name

Form SSA-3820-BK (05-2021) UF	Page 13 of 14

Section 9 - Work History

A. Has the child ever worked (including sheltered work)?	Yes
If "Yes", complete the following:
Dates Worked
Name of Employer
Address

(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)

City		County	State	ZIP
Phone Number
	Area Code	Number

Name of Supervisor

B. List job title, and briefly describe the work and any problems the child may have had doing the job.

Section 10 - Date and Remarks

Please give the date you filled out this disability report.

Date (MM/DD/YYYY)

Use this section for any additional information about your child.

Form SSA-3820-BK (05-2021) UF	Page 14 of 14

Section 10 - Date and Remarks

How to Edit Disability Report Form Online for Free

Dealing with PDF forms online can be very easy using our PDF editor. Anyone can fill in social security form child here without trouble. To make our editor better and simpler to use, we constantly design new features, with our users' suggestions in mind. Should you be looking to get started, this is what you will need to do:

Step 1: Open the form inside our tool by clicking on the "Get Form Button" above on this page.

Step 2: The editor provides the ability to change PDF files in various ways. Modify it with any text, adjust existing content, and include a signature - all close at hand!

It is actually simple to complete the document using out detailed tutorial! This is what you should do:

1. The social security form child necessitates certain details to be entered. Make certain the following fields are filled out:

2. Once your current task is complete, take the next step – fill out all of these fields - speak and understand English is, Yes Enter name address phone, Name, Address, Relationship to Child, Number Street Apt No if any PO Box, City, State, ZIP, Daytime Phone, Area Code, Number, Can you read and understand English, Yes, and G Does the child live with you with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Relationship to Child, G Does the child live with you, and Daytime Phone of form ssa 3820

It's easy to make errors when filling out your Relationship to Child, thus be sure to take a second look before you finalize the form.

3. This next portion is all about If No what is this persons, Can this person read and, and Yes - complete all these blanks.

Part number 3 for submitting form ssa 3820

4. It is time to proceed to the next segment! In this case you've got all these Section Information About the, H Can the child speak and, Yes, If No what languages can the child, If the child understands any other, I What is the childs height, What is the childs weight without, J Does the child have a medical, Yes, If Yes show the number here, Section Contact Information, A Does the child have a legal, Yes Enter name address phone, Name, and Address blanks to fill in.

form ssa 3820 conclusion process described (step 4)

5. Now, this final segment is what you'll have to wrap up before using the document. The blanks in question include the following: Daytime Phone Number, Relationship to Child, Area Code, Number, Can this person speak and, Yes, If No what is this persons, Can this person read and, Yes, B Is there another adult who helps, Yes Enter name address phone, Name of Contact, Address, City, and Daytime Phone Number.

Step 3: After proofreading the fields, hit "Done" and you're all set! Join us now and immediately gain access to social security form child, available for download. Every single modification you make is handily kept , meaning you can change the file at a later stage anytime. At FormsPal.com, we do everything we can to make sure that all of your information is stored private.

Phone Number