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This version of the form is not currently in use and is provided for reference only. Download this version of
Form SSA-3380-BK
for the current year.
Form SSA-3380-BK Function Report - Adult - Third Party
What Is Form SSA-3380?
Form SSA-3380-BK, Function Report - Adult - Third Party , is a form that is used by disabled people who are applying to receive Social Security benefits. This form contains a function report for an adult and describes how the illnesses or injuries of this person affect and limit their activities. This form should be completed by a third party, such as a friend or a family member of the disabled person in question. A doctor treating this person is not allowed to complete this form.
Alternate Names:
- Form SSA-3380;
- Third-Party Adult Function Report.
This form was released by the U.S. Social Security Administration (SSA) and the latest version was issued on March 1, 2019 . An SSA-3380-BK fillable form is available for download below. The information provided in the Third-Party Adult Function Report is used by the Social Security Administration to determine the eligibility of the disabled person for disability benefits. The respondent must submit the completed form to a local Social Security office.
How to Fill Out Form SSA-3380-BK?
An SSA-3380-BK Form must be filled in as follows:
- Section A ("General Information") requires the respondent to provide the name of the disabled person, their own name, relationship to this person, and a daytime phone number.
- Section B ("Information About Illnesses, Injuries, or Conditions") requires the respondent to explain how the illnesses of the disabled person limit their ability to work.
- Describe the daily activities of the disabled person Section C ("Information About Daily Activities"). It is necessary to clarify whether the disabled person has family members or pets that they have to take care of. The respondent should explain how the illnesses of the disabled person affect their ability to dress, bathe, feed themselves, and use the toilet in "Personal Care." Provide information about special reminders needed for taking care or for taking medicine.
- The respondent must answer the questions about the ability of the disabled person to prepare meals in "Meals," clarify the kind of the prepared food, frequency of cooking, duration of the cooking process, and changes in cooking habits after the injury. Provide information about household indoors and outdoors work that the person can do, including its frequency and duration, in "House and Yard Work."
- Answer questions connected with the ability of the injured to go outside and describe their methods of movement in "Getting Around." The respondent should describe how the person does shopping in "Shopping." Provide information about the ability of this person to pay bills and handle a savings account in "Money."
- The respondent should describe the hobbies and interests of the person in "Hobbies and Interests." Provide information on how the injured person spends time with others in "Social Activities."
- Section D ("Information About Abilities") requires the respondent to answer questions regarding the abilities of the disabled person (following written or spoken instructions, handling stress, unusual behavior, etc.), provide information about their usage of the assistive devices, and list medicines that cause side effects for the disabled person.
- Section E ("Remarks") should be used for any additional information.
Download Form SSA-3380-BK Function Report - Adult - Third Party
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