Ssa 3379 Bk Form – Fill Out and Use This PDF

The Form SSA-3379-BK is designated for the Social Security Administration to gather necessary details on how a child's illnesses or disabilities affect their daily activities, specifically for children aged 12 to their 18th birthday. This form provides a comprehensive overview, requiring detailed input about the child’s capabilities and difficulties, ensuring a thorough evaluation for disability benefits. It's crucial for the guardian completing the form to provide as much information as possible and to utilize the additional space for remarks if needed. Click the button below to start filling out the form to assist in the accurate and timely determination of the child's benefit eligibility.

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Ssa 3379 Bk Form PDF Details

Under the oversight of the Social Security Administration, the Form SSA-3379-BK plays a crucial role in determining benefit eligibility for children aged 12 to their 18th birthday who are experiencing disabilities. This document, designated as the Function Report Child Age 12 to 18, serves as a primary tool for assessing how a child's illness or injury impacts their daily functions. Guardians or parents are urged to complete the form with detailed information regarding the child's capabilities, notably in seeing, hearing, speaking, and accomplishing other routine activities. Its structure encourages thoughtful responses, offering a blend of checkbox and open-ended questions to capture a comprehensive view of the child's condition. Moreover, the SSA underscores the voluntary nature of the information provided but also notes the potential implications of incomplete submissions on the decision-making process. Designated spaces for personal identifiers, detailed inquiries about functional abilities, and the insistence on clarification for certain responses emphasize the personal and situational specificity the SSA considers when making eligibility decisions. The document not only facilitates an understanding of the child’s physical limitations but also touches on potential communication barriers, thereby painting a full picture of the child's daily challenges. With the SSA promising assistance for those who encounter difficulties in filling out the form, it clearly positions itself as a supportive resource aiming for an accurate and swift determination process.

Question	Answer
Form Name	Ssa 3379 Bk Form
Form Length	11 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	2 min 45 sec
Other names	ssa 3379 bk form child, ssa form 3379, form ssa 3379 bk, ssa form 623

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Form SSA-3379-BK (10-2017) UF
Discontinue Prior Editions	Page 1 of 11
Social Security Administration	OMB No. 0960-0542

Function Report Child Age 12 to 18th Birthday

Filling Out The Function Report

IF YOU NEED HELP COMPLETING ANY PART OF THIS FORM, CONTACT YOUR SOCIAL SECURITY OFFICE. WE WILL HELP YOU.

The information that you give us on this form will be used by the office that makes the disability decision on the child's claim. You can help them by completing as much of the form as you can.

•Print or type.

•Do not ask a doctor or hospital to complete this form.

•Be sure to explain your answer if an explanation is requested or needed.

•If more space is needed to answer any of the questions, please use the "REMARKS" section and show the number of the question being answered.

The information we ask for on this form tells us how you think the child's illnesses or injuries affect the way he or she does many of his or her usual activities.

PLEASE REMOVE THIS SHEET BEFORE

RETURNING THE COMPLETED FORM.

Continued on the Reverse

Form SSA-3379-BK (10-2017) UF	Page 2 of 11

Privacy Act Statement

Collection and Use of Personal Information

Sections 205(a), 223(d), and 1631(e)(1), of the Social Security Act, as amended, authorize us to collect this information. We will use the information you provide on behalf of the minor child to determine his or her benefit eligibility.

Furnishing us the information is voluntary. However, failing to provide us with all or part of the requested information may prevent us from making an accurate and timely decision on the claim.

We rarely use the information for any purpose other than for making a decision regarding entitlements to benefits. However, we may use it for the administration and integrity of our programs. We may also disclose the information to another person or to another agency in accordance with approved routine uses, including but not limited to the following:

1.To enable a third party or an agency to assist us in establishing rights to our benefits and coverage;

2.To comply with Federal laws requiring the release of information from our records (e.g. to the Government Accountability Office and Department of Veterans Affairs);

3.To make determinations for eligibility in similar health and income maintenance programs at the Federal, State, and local level; and,

4.To facilitate statistical research, audit, and investigatory activities necessary to assure the integrity and improvement of our programs (e.g., to the Bureau of the Census and to private entities under contract with us).

We may also use the information you provide in computer matching programs. Matching programs compare our records with records kept by other Federal, State, or local government agencies. We use the information from these programs to establish or verify a person’s eligibility for federally funded and administered benefit programs and for repayment of incorrect payment’s or delinquent debts under these programs.

A complete list of routine uses of this information is available in our Privacy Act System of Records Notices entitled, Claims Folders Systems, 60-0089. Additional information about this and other system of records notices and our programs are available on-line at www.socialsecurity.gov or at your local Social Security office.

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 control number. We estimate that it will take about 20 minutes to read the instructions, gather the facts, and answer the questions. SEND THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY

OFFICE. The office is listed under U. S. Government agencies in your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). You may send comments on our time estimate above to: SSA, 1338 Annex Building, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.

Form SSA-3379-BK (10-2017) UF
Discontinue Prior Editions	Page 3 of 11
Social Security Administration	OMB No. 0960-0542

FUNCTION REPORT - CHILD

AGE 12 TO 18th BIRTHDAY

SECTION 1 - IDENTIFYING INFORMATION

A. Print NAME OF CHILD:
FIRST	MIDDLE	LAST

B. Child's SOCIAL SECURITY NUMBER:

C. Child's DATE OF BIRTH:

Month/Day/Year

D. PERSON COMPLETING FORM

NAME:

RELATIONSHIP TO CHILD:

DATE FORM COMPLETED:

Month/Day/Year

DAYTIME TELEPHONE NUMBER (including Area Code):

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

CITY

STATE

ZIP CODE

Form SSA-3379-BK (10-2017) UF

Page 4 of 11

SECTION 2 - FUNCTION DETAILS

A. Does the child have	If "yes," please mark every statement below that is generally true
problems seeing?	about the child:
YES (Continue)
		Child uses glasses or contact lenses. If the child has
NO (Go to 2.B.)		problems seeing even with glasses or contact lenses,
		please explain:

Child cannot be fitted for glasses or contact lenses. Explain:

Child has other seeing problems. If so, please describe:

B. Does the child have	If "yes," please mark every statement below that is generally true
problems hearing?	about the child:
YES (Continue)		Child uses hearing aid(s). If the child has problems hearing
		even with a hearing aid(s) OR has trouble using a hearing
NO (Go to 2.C.)		aid, please explain:

Child cannot be fitted for hearing aid(s).

Child has other hearing problems. If so, please describe:

Child uses American Sign Language.

Child reads lips.

Form SSA-3379-BK (10-2017) UF

Page 5 of 11

C. Is the child totally unable to talk?

YES (Go to 2.D.)

NO (Continue)

Does the child have problems talking clearly?

Yes (answer questions below)

No (Continue to 2.D.)

If "yes," please mark the block that best describes the child in each of the two statements below, and then describe any other speech problems:

Speech can be understood by people who know the child well:

Most of the time, or

Some of the time, or

Hardly ever.

Speech can be understood by people who don't know the child well:

Most of the time, or

Some of the time, or

Hardly ever.

If the child has other problems talking, please explain:

Form SSA-3379-BK (10-2017) UF

Page 6 of 11

D. Are the child's daily	If "yes," or "not sure," please mark every statement below that
activities limited?	is true about the child:
YES (Continue)		Goes to school full-time	Works part-time
NO (Go to 2.E.)		Goes to school part-time	Works full-time
NOT SURE		Other. Describe:
		Other. Describe:
(Continue)


	If necessary, please explain. In addition, please tell us anything
	else you think we should know about the child's daily activities:

E. Is the child's ability to	If "yes," or "not sure," please tell us what the child does or can
communicate limited?	do by checking "yes" or "no" for each of the following:
YES (Continue)		Yes	No	Answer the telephone and make
NO (Go to 2.F.)				telephone calls
NO (Go to 2.F.)
NOT SURE		Yes	No	Deliver phone messages
NOT SURE
(Continue)		Yes	No	Repeat stories he or she has heard
		Yes	No	Repeat stories he or she has heard
		Yes	No	Tell jokes or riddles accurately
		Yes	No	Explain why he or she did something
		Yes	No	Uses sentences with "because," "what if,"
				or "should have been"
		Yes	No	Ask for what he or she needs
		Yes	No	Talks with family
		Yes	No	Talks with friends
	If necessary, please explain. In addition, please tell us anything
	else you think we should know about the child's ability to
	communicate:

Form SSA-3379-BK (10-2017) UF

Page 7 of 11

F. Is there any limitation in the child's progress in understanding and using what he or she has learned?

YES (Continue)

NO (Go to 2.G.)

NOT SURE (Continue)

If "yes," or "not sure," please tell us what the child does or can do by checking "yes" or "no" for each of the following:

Yes	No	Read and understand sentences in comics
		and cartoons
Yes	No Read and understand stories in books,
		magazines, or newspapers
Yes	No Spell words of more than 4 letters
Yes	No	Tell time
Yes	No Add and subtract numbers over 10
Yes	No Multiply and divide numbers over 10
Yes	No Understands money - can make correct
		change
Yes	No	Understand, carry out, and remember
		simple instructions

If necessary, please explain. In addition, please tell us anything else you think we should know about the child's progress in understanding and using what he or she has learned:

G. Are the child's physical abilities limited?

If "yes," or "not sure," please tell us what the child does or can do by checking "yes" or "no" for each of the following:

YES (Continue)

NO (Go to 2.H.)

NOT SURE (Continue)

Yes

No Walk

No Run

No Dance

No Swim

No Drive a car

Yes

No Ride a bike

No Throw a ball

No Jump rope

No Play sports

No Work video games controls

If necessary, please explain. In addition, please tell us anything else you think we should know about the child's physical abilities:

Form SSA-3379-BK (10-2017) UF

Page 8 of 11

H. Does the child's impairment(s) affect his or her social activities or behavior with other people?

YES (Continue)

NO (Go to 2.I.)

NOT SURE (Continue)

If "yes," or "not sure," please tell us what the child does or can do by checking "yes" or "no" for each of the following:

Yes	No Has friends his or her own age
Yes	No Can make new friends
Yes	No Generally gets along with you or other
	adults
Yes	No Generally gets along all right with
	brothers and sisters
Yes	No Generally gets along with school
	teachers
Yes	No Plays team sports (for example, baseball,
	basketball, soccer)

If necessary, please explain, In addition, please tell us anything else you think we should know about the child's behavior around other people:

Form SSA-3379-BK (10-2017) UF

Page 9 of 11

I. Is the child's ability to take care of his or her personal needs and safety limited?

YES (Continue)

NO (Go to 2.J.)

NOT SURE (Continue)

If "yes," or "not sure," please tell us what the child does or can do by checking "yes" or "no" for each of the following:

Yes	No	Takes care of personal hygiene (keep
		clean, brush teeth, comb hair, etc.)
Yes	No Washes and puts away his or her clothes
Yes	No Helps around the house (for example,
		washes or dries dishes, makes bed(s),
		sweeps/vacuums floor, rakes or mows yard,
		helps with laundry)
Yes	No Can cook a meal for self
Yes	No	Gets to school on time
Yes	No Studies and does homework
Yes	No	Takes needed medication
Yes	No Can use public transportation by himself/
		herself
Yes	No Accepts criticism or correction
Yes	No Keeps out of trouble
Yes	No	Obeys rules
Yes	No	Avoids accidents
Yes	No Asks for help when needed

If necessary, please explain. In addition, please tell us anything else you think we should know about the child's ability to take care of his or her personal needs and safety:

Form SSA-3379-BK (10-2017) UF

Page 10 of 11

J. Is the child's ability to pay attention and stick with a task limited?

YES (Continue)

NO (Go to 2.K.)

NOT SURE (Continue)

If "yes," or "not sure," please tell us what the child does or can do by checking "yes" or "no" for each of the following:

Yes	No Works on arts and crafts projects (draws,
	paints, knits, does woodwork)
Yes	No Keeps busy on his or her own
Yes	No Finishes things he or she starts
Yes	No Completes homework
Yes	No Completes homework on time
Yes	No Completes chores most of the time

If necessary, please explain. In addition, please tell us anything else you think we should know about the child's ability to pay attention and stick with a task:

K. Please tell us anything else about the child that you think we should know.

Form SSA-3379-BK (10-2017) UF

Page 11 of 11

SECTION 3 - REMARKS

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ssa form 623 conclusion process outlined (portion 1)

2. After the previous section is completed, you have to add the needed details in MonthDayYear, DAYTIME TELEPHONE NUMBER including, MAILING ADDRESS Number and Street, CITY, STATE, and ZIP CODE so that you can go to the 3rd part.

3. This step is usually easy - complete every one of the form fields in problems seeing, If yes please mark every statement, YES Continue, NO Go to B, Child uses glasses or contact, Child cannot be fitted for glasses, and Child has other seeing problems If to conclude this segment.

4. This next section requires some additional information. Ensure you complete all the necessary fields - problems hearing, If yes please mark every statement, YES Continue, NO Go to C, Child uses hearing aids If the, Child cannot be fitted for hearing, Child has other hearing problems, Child uses American Sign Language, and Child reads lips - to proceed further in your process!

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5. While you draw near to the conclusion of your form, you will find a couple extra requirements that have to be satisfied. Notably, to talk, YES Go to D, Yes answer questions below, NO Continue, No Continue to D, If yes please mark the block that, Speech can be understood by people, Most of the time or, Some of the time or, Hardly ever, Speech can be understood by people, and Most of the time or must be done.

No Continue to D, Speech can be understood by people, and If yes please mark the block that inside ssa form 623

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