Form SSA-3881-BK at a glance
What it is: Form SSA-3881-BK is the Questionnaire for Children Claiming SSI Benefits from the Social Security Administration.
A filled-in Form SSA-3881-BK example: a parent fills in page 1 for a child in school
How to fill out Form SSA-3881-BK, box by box
Child's name, Social Security Number, date and informant
Enter the Child's Full Name, Social Security Number and Date (mm/dd/yyyy).
Enter the Informant's Name, Relationship to Child and Daytime Telephone Number (including Area Code).
1. baby sitter, preschool, daycare or after school program
If the child is (was) cared for by a baby sitter, or does (did) attend any type of preschool, daycare and/or after school program, specify it with Name, Address (Number, Street, City, State, ZIP Code), Telephone Number (including Area Code) and Dates Attended. If more than one, use the "REMARKS" section.
2.a. Is the child in school
For 2.a., mark Yes or No for "Is (was) the child in school?"
If "yes," and the school was not listed in the SSA-3820, show it here with Name, Address (Number, Street, City, State, ZIP Code), Telephone Number (including Area Code), Dates Attended, Grade Level Completed and Last Teacher's Name. If more than one, use the "REMARKS" section.
More rules for Form SSA-3881-BK
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.
Print, type, or write clearly and answer all items to the best of your ability.
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, use "REMARKS" and enter the number of the question next to your answer.
For 2.b., mark Yes, No or Don't Know for "Is the child in a special education program?"
For c., mark Yes, No or Don't Know for "Does the school make any special accommodations for the child; e.g., adaptive furniture, wheelchair ramps, extra assistance or attention?"
If "yes" in 2.b. or 2.c., indicate type of program and/or accommodations, and specify number of hours per week the child is in special education program.
For d., mark Yes or No for "Do you have a copy of the child's individual education plan (IEP), the report in which the teacher outlines the child's problems and lists the plans for correcting them?" If "yes," please provide a copy.
For 3., mark Yes or No for "Does the child receive any special counseling or tutoring?" and mark Yes or No for a. In school and b. Outside school. If "yes," in 3.a. or 3.b., indicate Type of Counseling, Tutoring, Date Began and Ended (If completed), Frequency of Visits, Counselor's or Tutor's Name, Telephone Number (including Area Code) and Address (Number, Street, City, State, ZIP Code). If more than one, use the "REMARKS" section.
For 4., mark Yes or No for "Does the child or family have a child welfare, social services or early intervention caseworker?" If "yes," provide the Caseworker's Name, Organization, Address (Number, Street, City, State, ZIP Code), Telephone Number (including Area Code), File or Record Number and Date First Saw/Last Saw Caseworker. If more than one, use the "REMARKS" section.
For 5., mark Yes or No for each of 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 and g. Women, Infants, and Children (WIC) Program. If "yes," indicate the agency name, address, telephone number, record number, and the type and date of test or evaluation performed (e.g., vision, hearing, speech, physical). Use the letter designation (5a, 5b, etc.) to identify the agency. If additional space is needed, use "REMARKS" section.
For 6., mark Yes or No for "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. If "yes," indicate 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.)
For 7., mark Yes or No for "Does (did) the child receive vocational rehabilitation services?" If "yes," describe services received. Include dates and record number.
Providing information about the child's involvement with the court system is optional. For 8., mark Yes or No for "Has the child ever been involved with the court system other than in custody proceedings?" If "yes," explain involvement, including testing and evaluation.
For 9., mark Yes or No for "Does (did) the child participate in any community or school activities, such as choir, Special Olympics, Boy's/Girl's Club, Scouts, or sports?" 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.
If the child takes any medication on an ongoing basis, indicate the MEDICATION, DOSAGE/ FREQUENCY, PRESCRIBED BY (NAME), REASON FOR MEDICATION and any SIDE EFFECTS. Then explain how well the medication(s) work.
For 11 a., if you are unable to give the information you need about the child, mark Yes or No for someone else who helps care for the child and, knows of the child's impairment who can help get the information you need and, if necessary, bring the child to a consultative examination.
For b., if "yes," provide the Name, Address (Number, Street, City, State, ZIP Code), Daytime telephone number (including Area Code) and Relationship (e.g., relative, neighbor, family friend) to the child of this person.
Furnishing this information is voluntary. However, failing to provide all or part of the information may delay the determination or continued eligibility for benefits.
It will take about 30 minutes to read the instructions, gather the facts, and answer the questions.
Sources
[1] Form SSA-3881-BK (01-2022), Questionnaire for Children Claiming SSI Benefits, Social Security Administration (the Official source link on this page).