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Form SSA-3373-BK, Function Report - Adult (02-2024), page 1
Complex · 71/100Form Complexity Index

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What this form asks for

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Form SSA-3373-BK, Function Report - Adult, is an SSA questionnaire completed by an adult disability claimant (or someone assisting them) to describe functional limitations caused by illnesses, injuries, or conditions. It covers day-to-day activities, personal care, household tasks, mobility, social functioning, and physical/mental abilities. SSA uses these responses to evaluate how the claimant’s impairments impact work-related functioning and to help make an accurate and timely disability decision. Providing complete, specific examples and not leaving blanks is important because missing details can delay or negatively affect the determination.
Fillable fields189
Pages10
Sections76
Tables and lists1
Questions that depend on earlier answers33
Form Complexity IndexComplex, 71/100

The AI checks your answers before you download

16 checks built for this form, so a wrong date or a missing answer is caught before anyone else sees it.

Disabled Person Name Completeness and Character Validation

Validate that the disabled person’s name includes at least a first and last name, and that the middle initial (if provided) is a single alphabetic character. Reject or flag entries containing invalid characters (e.g., excessive punctuation, emojis, or control characters) and enforce reasonable length limits to prevent truncation or injection issues. If validation fails, require correction because the name is a primary identifier used to match the form to the correct claim file.

Social Security Number (SSN) Format and Disallowed Values Check

Ensure the SSN is exactly 9 digits (allowing optional hyphens in the pattern XXX-XX-XXXX) and contains only numeric characters after normalization. Block known invalid patterns such as all zeros in any group (e.g., 000-xx-xxxx, xxx-00-xxxx, xxx-xx-0000) and obvious placeholders (e.g., 123-45-6789) if your business rules disallow them. If validation fails, stop submission or route to manual review because SSN errors can misfile the report and delay adjudication.

Daytime Telephone Number Selection and Format Consistency

Require the user to indicate whether the provided number is 'Your Number', 'Message Number', or 'None', and ensure only one option is selected. If a phone number is provided, validate it as a 10-digit US number (with optional formatting characters) and require a valid 3-digit area code and 7-digit local number. If validation fails, prompt for correction because SSA may need to contact the respondent and inconsistent phone data reduces reachability.

Residence Type Single-Choice with 'Other' Specification

Validate that exactly one residence type is selected (House, Apartment, Boarding House, Nursing Home, Shelter, Group Home, Other). If 'Other' is selected, require the accompanying description field to be non-empty and meaningful (not 'N/A' or a single character). If validation fails, require correction because living situation affects functional context and may be used for follow-up or representative contact decisions.

Household Composition Selection with 'Other' Relationship Requirement

Ensure exactly one option is selected for 'With whom do you live?' (Alone, With Family, With Friends, Other). If 'Other' is selected, require a relationship description (e.g., roommate, caregiver, partner) and enforce reasonable length/character rules. If validation fails, prompt for completion because household support is relevant to daily activity limitations and consistency checks elsewhere in the form.

Work Limitation Narrative (Question 5) Non-Blank and Non-Placeholder

Require a substantive response describing how conditions limit ability to work, consistent with the form instruction not to leave answers blank (accepting 'none' or 'does not apply' only if logically appropriate). Detect and reject placeholder-only entries (e.g., 'N/A', '.', repeated characters) and enforce a minimum content threshold (e.g., at least a few words). If validation fails, require revision because this narrative is central to disability evaluation and missing content undermines the report’s usefulness.

And 10 more checks
  • Daily Routine Description (Question 6) Completeness Check
  • Conditional Detail Requirement for Yes/No Caregiving Questions (Q7–Q9)
  • Sleep Impact (Question 11) Conditional Explanation Validation
  • Personal Care Section Consistency (Question 12) Between 'No Problem' and Explanations
  • Meals Preparation Logic and Required Follow-Ups (Question 13a/13b)
  • House and Yard Work Completeness and Branching (Question 14)
  • Getting Around and Driving Consistency (Question 15)
  • Shopping Section Required Pairing of Mode and Details (Question 16)
  • Money Management 'No' Answers Must Be Explained (Question 17)
  • Signature Block Completeness and Date/Address Format Validation (Page 10)

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How to Fill Out SSA-3373 Online for Free in 2026

What the AI walks you through.

  1. Enter Section A general information: the disabled person’s name, Social Security number, contact phone number, and current living situation (where and with whom you live).
  2. In Section B, describe how your illnesses, injuries, or conditions limit your ability to work, using concrete examples and typical day-to-day impacts.
  3. Complete Section C daily activities by detailing your daily routine, caregiving responsibilities, sleep issues, personal care limitations, meal preparation, household/yard work, shopping, transportation, and money management.
  4. Fill out hobbies and social activities questions by listing interests, frequency of participation, changes since your condition began, and any issues getting along with others or needing reminders/accompaniment.
  5. In Section D, check affected abilities (e.g., lifting, walking, concentration, following instructions) and explain each limitation with measurable details (how far, how long, how much, how often), including stress/routine changes and any unusual behaviors or fears.
  6. Report assistive devices and medications, including whether aids were prescribed, when they were prescribed, when you use them, and any medication side effects (list only medicines that cause side effects).
  7. Use Section E (Remarks) to add any missing explanations, then provide the name and contact information of the person completing the form, date it, review for blanks, and submit it to the local SSA office as instructed.

Common Mistakes in Completing SSA-3373

The ones the AI is built to catch.

Leaving blanks instead of writing “none” or “does not apply”
People often skip questions they think don’t apply or that they can’t answer quickly, leaving empty lines or unchecked boxes. On SSA-3373, blanks can look like missing information and may delay a decision or trigger follow-up calls/letters. If you truly have nothing to report, write “none,” “does not apply,” or “don’t know” exactly as the instructions say, and still answer every Yes/No item.
Providing vague limitations without specific examples (Question 5 and Section D)
Many applicants write general statements like “I can’t work” or “I’m in pain,” but the form asks how conditions limit work and specific functional abilities. Vague answers make it hard for SSA to translate your statements into work-related limitations, which can weaken the evidence in your file. Use concrete details (e.g., “can stand 10 minutes,” “can lift 5 lbs,” “need to lie down twice daily”) and tie each limitation to symptoms.
Contradicting yourself across daily activities, chores, and ability sections
It’s common to report high activity in Section C (cooking, shopping, socializing) but later claim severe limits in Section D without explaining the difference. Inconsistencies can raise credibility questions and lead to additional development or unfavorable interpretation. If you can do an activity only with breaks, help, pain afterward, or only rarely, state that clearly and consistently in every relevant section.
Not explaining “Yes” answers about caregiving (Questions 7–9) and what help is actually provided
Applicants often check “Yes” for caring for others or pets but don’t describe the tasks, frequency, or whether someone else does the heavy parts. SSA may assume a higher functional level if caregiving sounds independent and demanding. Specify exactly what you do (e.g., “feed pet only,” “supervise child but cannot lift/bathe”), how long it takes, and who assists with physical or complex tasks.
Checking “NO PROBLEM with personal care” while describing major difficulties elsewhere
Some people check the “NO PROBLEM” box in Question 12 out of habit or embarrassment, even though they later describe trouble standing, using hands, bending, or concentrating. This can create a direct conflict in the record and may understate the impact of symptoms. If you have any difficulty dressing, bathing, toileting, grooming, or need reminders/help, do not check the box—describe what is hard, why, and what assistance or adaptations you use.
Incomplete meal preparation details (Question 13) and missing “before vs. after” changes
People frequently answer “Yes, I cook” but omit what they cook, how often, how long it takes, and what changed since the condition began. Without those details, SSA may assume you can plan, stand, use your hands, and sustain activity at a normal level. Include the type of meals (microwave vs. full meals), time on your feet, need for breaks, safety issues, and how your cooking habits changed.
Listing chores without frequency, duration, and assistance (Question 14)
Applicants often provide a simple list like “laundry, dishes” but don’t state how long each takes, how often they do it, or whether they need help/encouragement. SSA uses these specifics to gauge stamina, physical capacity, and consistency over time. For each chore, add frequency (e.g., weekly), time spent, what you cannot do, and whether you need help, reminders, or rest breaks.
Misreporting “getting around” and driving details (Question 15)
Some people check that they go out, walk, or drive but don’t explain limitations (short distances, only good days, only with someone, panic attacks, medication side effects). This can make it appear you can travel independently and reliably, which affects vocational conclusions. If you don’t drive, explain why; if you do drive, clarify how often, how far, and any restrictions (daylight only, avoid highways, need accompaniment).
Not explaining “NO” answers in money management (Question 17)
Question 17 explicitly says to explain all “NO” answers, but many people forget and just check boxes. Missing explanations can lead SSA to assume the issue is minor or unrelated to your conditions. If you answer “No,” describe the reason (memory, concentration, math errors, anxiety, impulsivity), give examples (missed payments, overdrafts), and note who helps and how.
Under-describing social activity changes and support needs (Questions 18–19)
Applicants often list hobbies or social contacts but don’t describe how participation changed, how often they actually engage, or whether they need reminders/accompaniment. SSA may interpret a hobby list as active functioning unless you clarify reduced frequency, shorter duration, or inability to sustain the activity. State what you used to do, what you do now, how long you can tolerate it, and whether you avoid people/places due to symptoms.
Failing to quantify walking, attention, and instruction-following limits (Question 20c–g)
People commonly answer with non-measurable phrases like “not far,” “not long,” or “depends,” which are hard to evaluate. SSA needs functional measurements to compare against work demands and to assess consistency with medical evidence. Provide best estimates (distance in feet/blocks, minutes of attention, rest time needed) and include what happens when you exceed limits (pain flare, shortness of breath, confusion).
Incomplete assistive device and medication side-effect reporting (Questions 21–22 and Page 10)
Applicants often check devices (cane, brace, walker) but omit whether a doctor prescribed them, when, and how often they’re needed; similarly, they may list all medications instead of only those causing side effects, or forget to describe the side effects. Missing prescription/timing details can reduce the weight of the device information, and unclear side-effect reporting can hide important functional impacts (drowsiness, dizziness, GI issues). For each device, state who prescribed it and when, and for medications list only those with side effects and describe the specific side effects and how they affect daily functioning.

Frequently Asked Questions About SSA-3373

 

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How does the AI fill out SSA-3373?
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What happens to my information?
It is encrypted in transit and at rest, and it is never used to train AI.
How complex is SSA-3373 to fill out?
SSA-3373 has a Form Complexity Index of 71 out of 100, in the complex tier: 189 fillable fields across 10 pages. Instafill.ai's AI fills it in under a minute, with every field there for you to review before you download.
What is Form SSA-3373 (Function Report – Adult) used for?
SSA uses this form to understand how your illnesses, injuries, or conditions affect your daily activities and ability to work. The information helps the disability decision office evaluate your disability claim.
Who should fill out this form—the disabled person or someone else?
Ideally, the disabled person completes it. If someone else helps or completes it, that person must list their name and address on Page 10 where the form asks for the “Name of person completing this form.”
Do I have to answer every question even if it doesn’t apply to me?
Yes—do not leave answers blank. If something doesn’t apply or you don’t know, write “does not apply,” “none,” or “don’t know,” as the instructions state.
What phone number should I put if I don’t have a phone?
In Section A, provide a daytime number where SSA can leave a message for you (for example, a trusted family member, friend, or caseworker). If you truly have no number, indicate “None” as the form allows.
How should I answer Section B, Question 5 about how my conditions limit my ability to work?
Describe specific work-related limitations (for example, how long you can stand, how much you can lift, how pain or symptoms affect focus, attendance, pace, or interacting with others). Concrete examples are more helpful than general statements.
What should I write for Question 6 (daily routine from waking to bedtime)?
Give a typical day timeline and include what you can and cannot do, how long tasks take, and any breaks, naps, or help you need. Mention symptom flare-ups, fatigue, or pain that changes your routine.
If I take care of children, adults, or pets, should I include that even if I need help?
Yes. For Questions 7–9, list who/what you care for, what you do, and clearly state any help you receive and what others do for you.
How do I complete the Personal Care section if I can do things but it takes longer or hurts?
Explain the difficulty even if you can still do the task (for example, needing extra time, needing to sit, needing reminders, pain, dizziness, or needing help with buttons, bathing, or toileting). If you have no issues, you can check the “NO PROBLEM” box.
What details should I include about meals and cooking (Question 13)?
State whether you prepare meals, what kinds of meals, how often, how long it takes, and what changed since your condition began. If you don’t cook, explain why (for example, can’t stand, can’t concentrate, safety concerns, or limited hand use).
What if I don’t do house or yard work anymore?
In Question 14(d), explain why you don’t do it (for example, pain, shortness of breath, fatigue, balance issues, or mental health symptoms). If someone else does it, note who helps and what they do.
How should I answer questions about going outside, driving, and shopping (Questions 15–16)?
Describe how often you go out, how you travel, whether you can go alone, and why not if you can’t. For shopping, include where/how you shop, what you buy, how long it takes, and any limitations (needing help, using mobility aids, anxiety, or needing rest).
What does SSA want to know about handling money (Question 17)?
SSA is asking whether you can pay bills, count change, use a checkbook/money orders, or manage accounts, and whether your ability changed after your conditions began. If you answer “No,” explain what prevents you from doing it (memory, concentration, math, anxiety, etc.).
How do I fill out the Abilities section (Question 20) about lifting, walking, sitting, concentration, and instructions?
Check all affected items and then explain each one with specific limits (for example, “can lift 10 lbs,” “can walk 1 block,” “can sit 20 minutes,” “can focus 10 minutes,” or “need instructions repeated”). Include rest time needed and real-life examples when possible.
Do I list assistive devices like glasses, a cane, or a walker even if they weren’t prescribed?
Yes—Question 21 asks what you use and also asks which were prescribed by a doctor, when prescribed, and when you need them. If it wasn’t prescribed, you can still list it and clarify that it is not doctor-prescribed.
Where do I list medication side effects, and do I need to list every medication?
On Page 10 (Question 22), you only list medicines that cause side effects and describe the side effects. The form specifically says not to list all medicines—only those causing side effects.
What is the “Remarks” section for, and how do I use it correctly?
Use Section E (Remarks) to add details that didn’t fit elsewhere or to continue an answer. Always include the question number you’re adding information for.
Can my doctor or hospital fill out this form for me?
No—the instructions say not to ask a doctor or hospital to complete this form. You can use medical records separately, but this form is meant to capture your own (or a helper’s) description of daily functioning.
How do I submit the completed SSA-3373, and where do I send it?
The form instructs you to send or bring the completed form to your local Social Security office. If you need the correct office address or contact information, call SSA at 1-800-772-1213 (TTY 1-800-325-0778) or use the contact details on the letter that came with the form.
How long does SSA estimate it takes to complete this form?
SSA estimates about 61 minutes to read the instructions, gather facts, and answer the questions. Your time may vary depending on how many conditions and limitations you need to describe.
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