Ssa 3881 Bk Form PDF Details

The SSA-3881-BK form is a critical document for children applying for Supplemental Security Income (SSI) benefits. As a comprehensive questionnaire, it plays a vital role in assessing the unique needs and circumstances of each child. This eight-page form requires detailed information, including the child’s educational background, any special education or accommodations received, counseling or tutoring services, and involvement with social services or welfare agencies. It also probes into any special therapy or treatments the child may have undergone, including physical, speech, and occupational therapy, to better understand the child's current health and developmental status. Furthermore, the form seeks information on vocational rehabilitation services, if any, highlighting the Social Security Administration's thorough approach in evaluating claims. By covering aspects from basic personal information to detailed queries about the applicant’s school and health history, the SSA-3881-BK ensures a holistic review process. This meticulous documentation is essential for making informed decisions on SSI eligibility, directly impacting the well-being and support provided to children with disabilities or special needs.

QuestionAnswer
Form NameSsa 3881 Bk Form
Form Length8 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min
Other names3881 form ssa, children claiming ssi benefits, children claiming ssi, ssa 3881

Form Preview Example

Form SSA-3881-BK (06-2018) UF

 

Discontinue Prior Editions

Page 1 of 8

Social Security Administration

OMB No. 0960-0499

 

 

QUESTIONNAIRE FOR CHILDREN CLAIMING SSI BENEFITS

Please print, type, or write clearly and answer all items to the best of your ability. If you need help completing any part of this form, we will help you. If you are filing on behalf of someone else, enter his or her name and social security number in the space provided and answer all questions. If you do not know the answer, enter "unknown." If the question does not apply, enter "N/A." If you need more space to answer any of the questions, please use "REMARKS" and enter the number of the question next to your answer.

Child's Full Name

Social Security Number

Date (mm/dd/yyyy)

Informant's Name

Relationship to Child

Daytime Telephone Number (including Area Code)

1.Is (was) the child cared for by a baby sitter? Does (did) the child attend any type of preschool, daycare and/or after school program? If so, please specify. If more than one of the above, use the "REMARKS" section.

Name

Address (Number, Street, City, State, ZIP Code)

Telephone Number (including Area Code)

Dates Attended

2. a. Is (was) the child in school?

Yes

No

If "yes," and the school was not listed in Item 12A of the SSA-3820-F6, please show it here.

(If more than one, use the "REMARKS" section.)

Name

Address (Number, Street, City, State, ZIP Code)

 

 

Telephone Number (including Area Code)

Dates Attended

Grade Level Completed

Last Teacher's Name

Form SSA-3881-BK (06-2018) UF

 

 

Page 2 of 8

 

 

 

 

2.b. Is the child in a special education program?

Yes

No

Don't Know

 

 

 

 

c. Does the school make any special accommodations for the

 

 

 

child; e.g., adaptive furniture, wheelchair ramps, extra

Yes

No

Don't Know

assistance or attention?

 

 

 

 

 

If "yes" in 2.b. or 2.c., indicate type of program and/or

Specify number of hours per week the child is

accommodations:

in special education program:

 

d. Do you have a copy of the child's individual education plan

 

 

(IEP), the report in which the teacher outlines the child's

Yes

No

problems and lists the plans for correcting them?

 

 

If "yes," please provide a copy.

 

 

 

 

 

3. Does the child receive any special counseling or tutoring?

 

 

a. In school

Yes

No

b. Outside school

Yes

No

If "yes," in 3.a. or 3.b., please indicate: (If more than one, use the "REMARKS" section.)

Type of Counseling, Tutoring

Date Began and Ended (If completed)

Frequency of Visits

Counselor's or Tutor's Name

Telephone Number (including Area Code)

Address (Number, Street, City, State, ZIP Code)

4.Does the child or family have a child welfare, social services or early intervention caseworker?

Yes

No

If "yes," please provide the following information: (If more than one, use the "REMARKS" section.)

Caseworker's Name

Organization

Address (Number, Street, City, State, ZIP Code)

Telephone Number (including Area Code)

File or Record Number

Date First Saw/Last Saw Caseworker

Form SSA-3881-BK (06-2018) UF

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5.Has the child ever been tested or evaluated by any of the following agencies or organizations? If "yes," indicate in the space provided below the agency name, address, telephone number, record number, and the type and date of test or evaluation performed (e.g., vision, hearing, speech, physical).

a. Public/Community Health Department

b. Child Welfare/Social Services Agency

c. Developmental Evaluation Center

d. Mental Health/Intellectual Disability

e. Special Needs/Crippled Children Agency

f. Speech and Hearing Center

g. Women, Infants, and Children (WIC) Program

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

No

No

Use the letter designation (5a, 5b, etc.) to identify the agency.

If additional space is needed, use "REMARKS" section.

Form SSA-3881-BK (06-2018) UF

Page 4 of 8

6.Does (did) the child receive any special therapy (physical, speech and language, occupational), exercises, or any other services for his/her impairments?

Include information about any therapy or exercises the parent, guardian or caregiver provides the child.

Yes

No

If "yes," indicate below the therapist's name, the name of the person who PRESCRIBED AND/OR DESIGNED the therapy program, the type(s) and frequency of treatment, when treatment began and ended (if completed), and where treatment was received (e.g., home, hospital, therapist's office, clinic.)

Therapist's Name

Telephone No. (including Area Code)

Address (Number, Street, City, State, ZIP Code)

Person Who Prescribed/Designed Therapy

Information about Therapy:

Therapist's Name

Telephone No. (including Area Code)

Address (Number, Street, City, State, ZIP Code)

Person Who Prescribed/Designed Therapy

Information about Therapy:

Form SSA-3881-BK (06-2018) UF

Page 5 of 8

7.Does (did) the child receive vocational rehabilitation services?

If "yes," describe services received below the rehabilitation counselor's information. Include dates and record number.

Rehabilitation Counselor's Name

Yes No

Telephone No. (including Area Code)

Address (Number, Street, City, State, ZIP Code)

Services received:

(If additional space is needed, use "REMARKS" section.)

NOTE: PROVIDING INFORMATION ABOUT THE CHILD'S

INVOLVEMENT WITH THE COURT SYSTEM IS OPTIONAL

8.Has the child ever been involved with the court system other than in custody proceedings?

Yes

No

If "yes," please explain involvement, including testing and evaluation.

Youth Development Center's Name

Address (Number, Street, City, State, ZIP Code)

Probation or Parole Officer's Name

Telephone No. (including Area Code)

Address (Number, Street, City, State, ZIP Code)

Involvement including any testing and evaluation:

Form SSA-3881-BK (06-2018) UF

Page 6 of 8

9.Does (did) the child participate in any community or school activities, such as choir, Special Olympics, Boy's/Girl's Club, Scouts, or sports?

Yes

No

If "yes," describe involvement, amount of time spent in activity, and level of participation. Provide name, address, and telephone number of individual who supervises the activity. Include dates of involvement. If involvement ended, explain why.

10. If the child takes any medication on an ongoing basis, please indicate the following:

MEDICATION DOSAGE/

PRESCRIBED BY

FREQUENCY

(NAME)

 

 

REASON FOR MEDICATION

DESCRIBE ANY SIDE EFFECTS

How well does the medication(s) work? Please explain:

Form SSA-3881-BK (06-2018) UF

Page 7 of 8

 

 

11 a. If you are unable to give us information we need about the child, is there someone else who helps care for the child and, knows of the child's impairment who can help us get the information we need, and, if necessary, bring the child to a consultative examination?

Yes

No

b. If "yes," please provide the following information about this person

Name

Address (Number, Street, City, State, ZIP Code)

Daytime telephone number (including Area Code)

Relationship (e.g., relative, neighbor, family friend) to the child?

REMARKS:

Form SSA-3881-BK (06-2018) UF

Page 8 of 8

 

 

REMARKS (continued):

Privacy Act Statement

Collection and Use of Personal Information

Sections 223(b), 1614, and 1631(e)(1) 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 delay the determination or continued eligibility for benefits.

We will use the information to make a decision on your claim. We may also share your information for the following purposes, called routine uses:

1.To specified business and other community members and Federal, State, and local agencies for verification of eligibility for benefits under section 1631(e) of the Act;

2.To the appropriate State agencies (or other agencies providing services to disabled children) to identify Title XVI eligibles under the age of 16 for the consideration of rehabilitation services in accordance with section 1615 of the Act, 42 U.S.C. 1382d; and

3.To third party contacts where necessary to establish or verify information provided by representative payees or payee applicants.

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 System; 60-0103, entitled Supplemental Security Income Record and Special Veterans Benefits; and 60-0320, entitled Electronic Disability (eDIB) Claim File. 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 control number. We estimate that it will take about 30 minutes to read the instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your local Social Security office through SSA's website at www.socialsecurity.gov. Offices are also 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, 6401 Security Blvd, Baltimore, MD 21235-6401.

Send only comments relating to our time estimate to this address, not the completed form.

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When it comes to blanks of this particular PDF, here is what you should do:

1. Fill out the form 3881 x with a number of major blanks. Collect all the important information and be sure not a single thing omitted!

Filling out part 1 in 3881 form

2. After filling out this part, go on to the next step and complete the necessary details in all these blanks - Name, Address Number Street City State, Telephone Number including Area, Dates Attended, Grade Level Completed, and Last Teachers Name.

Part number 2 of filling out 3881 form

3. This 3rd step should also be pretty uncomplicated, b Is the child in a special, Yes, Dont Know, c Does the school make any special, Yes, Dont Know, If yes in b or c indicate type of, Specify number of hours per week, d Do you have a copy of the childs, Yes, If yes please provide a copy, Does the child receive any, a In school, b Outside school, and Yes - these blanks will have to be filled out here.

Step number 3 in filling in 3881 form

4. This next section requires some additional information. Ensure you complete all the necessary fields - Type of Counseling Tutoring, Date Began and Ended If completed, Frequency of Visits, Counselors or Tutors Name, Telephone Number including Area, Address Number Street City State, Does the child or family have a, Yes, If yes please provide the, Caseworkers Name, Organization, Address Number Street City State, and Telephone Number including Area - to proceed further in your process!

Ways to fill out 3881 form portion 4

As for Address Number Street City State and Organization, ensure you review things here. These could be the most important ones in the PDF.

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Writing section 5 of 3881 form

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