SSA Form SSA-3380-BK, known as the “Function Report – Adult – Third Party,” is a form used by the Social Security Administration (SSA) to collect detailed information about an applicant’s daily activities and the impact of their disability. This form is typically filled out by someone who knows the applicant well, such as a family member, close friend, or caregiver, and provides a third-party perspective on the applicant’s physical and mental capabilities. The information gathered through this form is crucial for evaluating the severity of the disability and determining how it affects the applicant’s ability to work and perform daily tasks.
The purpose of SSA Form SSA-3380-BK is to give SSA additional context and a clearer understanding of the applicant’s condition from someone who observes them regularly. The form asks for insights into the applicant’s daily living practices, physical abilities, social functioning, and mental capabilities. It also includes sections for detailing any assistance the applicant requires with personal care, meal preparation, medication, and managing finances.
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It is worth mentioning that in the document itself, it is noted that none of the columns can be left blank. But this does not mean at all that you need to invent if you do not know what to answer. You can just write “I don’t know.” This answer will also count.
Provide Contact Information
Enter the name of the disabled person in item 1. Next, you should specify:
Insert Details About Your Relationship
Write how much time you know each other and how often you spend time together. It is worth pointing out that you are helping the disabled person, if so.
Check the Living Conditions
Check the box where the person lives and with whom.
Write About Existing Restrictions in Doing Work
If you are aware of the situation, write how a person’s disability interferes with the performance of the duties. You can indicate if colleagues or strangers have to help or assist them or how much effort has to be put into performing certain tasks.
Describe the Applicant’s Daily Routine
You can mention what difficulties arise during the day, whether a person is mobile or not, whether he/she leaves the house, whether can perform ordinary tasks. It should show what restrictions have appeared for the disabled person.
Describe the Applicant’s Attitude Towards People or Pets
If a disabled person cares about someone — their loved ones or about pets, you need to indicate this here, and it is highly desirable to provide explanations. Taking full care of the dog is not at all the same as opening the door for it once a day so that it runs out into the yard. The administration may make an unsatisfactory decision if it thinks that the applicant is quite capable of caring for himself and others.
Note the Differences Before and After Disability
It is a goodwill practice to show on certain examples how complicated a person’s life has become after disability and what restrictions have appeared in it.
The form also requires the applicant to describe sleeping problems (if there are any) in a separate section.
Testify On Personal Care and Meals
In these questions, you can specify in more detail the difficulties of a person in everyday life, if any.
First, they ask for your answers regarding personal care:
This one is a rather detailed point, and you may not know about all the moments, in which case it is better to write this way.
Next comes an extensive question regarding nutrition and personal independence in this matter.
List Difficulties Associated With Housework
The question is whether disability affects housework or gardening, and can it be done in principle.
Indicate if someone helps with the housework. For example, if an assistant comes to vacuum and generally clean the house (or another dwelling unit) because the person is not able to do it independently (and not because the claimer is lazy), you should indicate it in the application form.
Answer the Questions Related to Leisure
More detailed answers related to a person’s free time are required. You must show if they can do particular activities related to daily maintenance and routine on their own:
Carefully approach the filling of these points. They overlap with each other in many ways. You should not have a testimony that contradicts each other. For example, you cannot say that the applicant loves going to church on Sundays but does not leave home.
It is important to show how life and activities have changed after being sick or injured. Point out what was easy before, but not at all now.
Describe the Claimer’s Abilities
This broad clause deals directly with disability.
First of all, it is worth noting with a tick what human abilities the disease has affected.
And explain with examples how it is shown in the picture below.
Give detailed answers about how quickly a person gets tired, how long they can hold attention, whether they can follow instructions. Remember that all submitted answers must reflect what you wrote earlier.
There are questions about relationships with other people at work or government officials.
Mention the psychological state of a person:
You will also need to note which assistive devices the applicant is using, if so.
If you know about pills that a disabled person has to take, indicate it in the form as well. All medical prescriptions (and the effect they have) need to be documented.
Add Other Relevant Info
If you want to add something or run out of space in the paragraphs above, you can write it here. Add a reference in the paragraph and include anything you want in Section E.
Provide Your Details
At the end of the form, you must leave your details, including the address, and put the date of the document completion.
