SSA Form SSA-3373-BK, known as the “Function Report – Adult,” is a comprehensive questionnaire used by the Social Security Administration (SSA) to assess the everyday functioning of individuals applying for disability benefits. This form is filled out by the disability applicant themselves and provides the SSA with detailed insights into how an applicant’s condition affects their ability to perform daily activities, manage personal care, and maintain social interactions. It is an essential part of the disability determination process, helping the SSA gauge the severity of the disability and its impact on the applicant’s life, particularly in relation to their capacity for work.
The form covers a wide range of topics, including the applicant’s ability to perform tasks such as cooking, cleaning, shopping, and managing money. It also delves into the individual’s ability to walk, sit, lift, and use public transportation, among other physical functions. Additionally, SSA Form SSA-3373-BK explores mental and emotional health by asking about memory, concentration, handling stress, and changes in social behavior.
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Should you wish to check out more SSA documents that you can edit and fill out online, listed here are a number of the more popular forms among our users. Moreover, do not forget that you may upload, fill out, and edit any PDF at FormsPal.
The form includes ten pages and consists of five sections. Fill out all the boxes and lines attentively, even if you do not know what to answer specifically, tell about it, and add further explanations, if necessary.
Write in Your Personal Information
This section is to indicate your name, the social security number, telephone for the daytime calls (if you can give it), your place of living, and any person living together with you. Fill in only one of the boxes on every line.
Describe Your Health Condition
Section B is to describe all your illnesses, injuries, or any other health conditions preventing you from regular work or making it complicated. Do your best to be as detailed and comprehensible as possible. It will certainly affect the final decision to grant you the disability pension or not.
Tell About Your Daily Routine, Activities, and Occupations
Primarily, describe all the activities you usually perform throughout the whole day. Just tell in a free form about everything you remember. If you take care of any other persons or pets, and someone helps you to carry out these home duties, write about it too.
Describe How Your Illnesses or Injuries Inflicted on Your Regular Abilities
Here you may cheer on the impossibility to perform any activities you were able to do before. Describe in what way these limitations are caused by your illnesses, injuries, or any other health problems. The same relates to problems with your personal care; fill out all the boxes in the list. If you do not find any problems with self-service, start with this answer.
Explain How You Manage to Cook and Perform Your Household Duties
Here you may concentrate on any details connected with your favorite food preparation.
Your ability to carry out any household chores may be of a certain interest, too, as well as any of your outdoor activities.
Answer Some Questions About Shopping and Getting Around
Indicate here if you are still able to go outside and travel anywhere. Clarify what places you prefer to visit, whether you can do it yourself and what means of transportation you usually prefer. Your ability to drive a car can add some useful information about your health condition too.
Pay Attention to Your Interests and Social Activities
Describe your hobbies and interests here, with a special emphasis on any changes in these activities caused by your current disability.
Explain the Changes in Your Abilities to Perform Any Movements or Tasks
This section is especially important for the understanding of your health status at present, what ordinary abilities you have lost, and to what extent. Do your best to explain how those changes are connected with your illnesses and to what degree. For example, the ability to keep the attention and complete any work from the beginning to the end is very important for the profound impression about your health.
Point Out What Mobility Aids You Have to Use
If you need any aids like the walker or the wheelchair, or maybe the hearing aid or an artificial voice box to move or communicate, be sure to indicate it here.
List the Medicines You Currently Take
Here you need to list the medicines you use to take now for the treatment of your disabilities only if they produce any side effects. In this case, you have to describe what exactly you feel and due to what concrete medicine this or that side effect appears.
Add Any Details You Missed Above and Complete This Form
In the last empty section of this document, you may add anything concerning the points you have filled out on the previous pages. When you cope with this task, pay special attention to the lower lines on the page.
Sign and date the questionnaire, put on your name, and indicate the place of living. Check the whole document attentively because you have an opportunity to use our form-building software again to be sure that everything is correct. Make a copy for yourself, and now it is possible to send your application to the service.
