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Function Report - Adult - Third Party (Form SSA-3380-BK), page 1
Complex · 71/100Form Complexity Index

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What this form asks for

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Form SSA-3380-BK, Function Report – Adult – Third Party, is completed by someone who knows the disabled person (such as a family member, friend, or caregiver) and can describe the person’s functioning. It asks about living situation, daily routines, personal care, household tasks, social activities, and physical/mental abilities affected by illnesses, injuries, or conditions. SSA uses these observations to assess how the claimant’s conditions limit work-related and everyday activities and to support a disability determination. Providing complete, specific examples helps SSA make a more accurate and timely decision.
Fillable fields197
Pages10
Sections68
Tables and lists1
Questions that depend on earlier answers40
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 (First/Middle/Last)

Validates that the disabled person’s name is provided and includes at least first and last name, with middle name/initial captured if present on the form. This is important to correctly associate the report with the correct claimant and avoid misfiling. If missing or clearly incomplete (e.g., only a first name), the submission should be flagged as incomplete and routed for follow-up.

Third-Party Filer Name Required (Person Completing the Form)

Ensures the name of the person completing the form is present in Section A and again in the signature block area on Page 10 (printed name). This is critical for accountability and for SSA to contact the reporter for clarification. If absent in either location, the form should fail validation because the source of the information cannot be verified.

Relationship to Disabled Person Must Be Provided and Plausible

Checks that the relationship field is not blank and is a meaningful descriptor (e.g., spouse, parent, friend, caregiver) rather than a non-answer. Relationship context affects credibility and interpretation of observations (e.g., daily caregiver vs. occasional acquaintance). If missing or nonsensical, the system should require correction or mark the record for manual review.

Form Date Format and Validity (MM/DD/YYYY)

Validates that the date fields (Section A Date and Page 10 Date) are present and match MM/DD/YYYY with a real calendar date. This matters for timeliness and for determining whether the information reflects the claimant’s current functioning. If the date is invalid, missing, or in the future beyond an allowed tolerance, the submission should be rejected or queued for correction.

Daytime Telephone Number Format and Contactability

Ensures a daytime phone number is provided and conforms to a valid NANP format (10 digits, allowing separators), including area code. The form explicitly requests a number where the reporter can be reached or where a message can be left, which is essential for follow-up. If the phone number is missing or malformed, validation should fail and prompt for a corrected contact number.

Living Arrangement Selection Consistency (Q7a/Q7b)

Checks that exactly one option is selected for where the disabled person lives (Q7a) and with whom they live (Q7b), and that any 'Other' selection includes a description. This prevents ambiguous housing context and supports downstream adjudication logic. If multiple selections are made where only one is intended, or 'Other' lacks details, the system should flag the response for correction.

And 10 more checks
  • Known Duration Field Validation (Q6a) and Unit Requirement
  • Mandatory Narrative Fields Not Left Blank (Use of 'None/Don't know/Does not apply')
  • Conditional Detail Required When Yes/No = YES (Care, Pets, Help, Sleep, Reminders, Medicine Help, etc.)
  • Conditional Detail Required When Yes/No = NO (Meals, Driving, Going Out Alone, etc.)
  • Money Management Matrix Completeness and 'NO' Explanations (Q20a)
  • Abilities Affected Checklist Requires Explanations for Checked Items (Q23a)
  • Quantitative Fields Must Be Interpretable (Walking Distance/Rest Time/Attention Duration)
  • Handedness Selection Must Be Single-Choice (Q23b)
  • Assistive Devices Section Consistency (Q24) with Prescription/Timing/Usage Details
  • Medication Side Effects Table Integrity (Q25)

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How to Fill Out SSA-3380-BK Online for Free in 2026

What the AI walks you through.

  1. Confirm you are the correct third-party respondent and gather key details about the disabled person (conditions, daily routine, limitations, assistive devices, medications/side effects, and changes over time).
  2. Complete Section A (General Information): enter the disabled person’s name, your name, relationship, date, contact phone number, and the disabled person’s living arrangement and household members.
  3. Complete Section B (Conditions and Work Limits): state how long you’ve known the person, how often you see them, and describe how their conditions limit their ability to work, using concrete examples.
  4. Complete Section C (Daily Activities): describe a typical day, caregiving responsibilities, pets, sleep issues, personal care needs, meal preparation, chores, getting around, shopping, and money handling—note any help needed and frequency/duration.
  5. Complete Section D (Abilities): check affected functional areas (e.g., lifting, walking, memory, concentration) and explain each with measurable details (how far, how long, how much); include stress/routine changes, authority interactions, and any unusual behaviors or fears.
  6. Complete Section D/24 and Section 25: list assistive devices used, whether prescribed and when, when they’re needed, and note any medication side effects (only those causing side effects).
  7. Use Section E (Remarks) for extra space, then sign off by printing your name, date, and address (and optional email), review for blanks (use “don’t know/none/does not apply” where appropriate), and submit as instructed.

Common Mistakes in Completing SSA-3380-BK

The ones the AI is built to catch.

Leaving blanks instead of writing “don’t know/none/does not apply”
People often skip questions they can’t answer or think are irrelevant, leaving empty fields. On this SSA form, blanks can look like missing information and may delay processing or trigger follow-up requests. To avoid this, write “don’t know,” “none,” or “does not apply” exactly as instructed whenever you cannot provide an answer.
Asking the disabled person for answers (defeats the “third-party” purpose)
Because the form is long and detailed, third parties sometimes ask the disabled person to tell them what to write. The form explicitly instructs you not to do this, and answers that read like self-reports can reduce the value of the third-party perspective. Use your own observations and experiences; if you truly don’t know something, state “don’t know” and explain what you have personally seen.
Providing vague daily-activity descriptions without a full day timeline
In Question 9, many people write general statements like “watches TV” or “doesn’t do much,” without describing a typical day from waking to bedtime. Vague answers make it hard for SSA to understand functional limitations and consistency across activities. Give a time-ordered routine (morning/afternoon/evening), including rest periods, assistance needed, and what changes on “bad days.”
Not specifying frequency, duration, and effort for chores, cooking, shopping, and going out
Questions 16–19 ask how often activities happen, how long they take, and what is done; people often answer only “yes/no” or list an activity without details. Missing frequency and duration prevents SSA from gauging stamina, persistence, and real-world functioning. Include specifics such as “2x/week for 10 minutes,” “needs breaks every 5 minutes,” or “takes 1 hour due to pain and rests afterward.”
Failing to identify help from others (or minimizing supervision/encouragement)
Respondents frequently say the person “does” an activity but omit that someone prompts, supervises, drives, prepares items, or finishes tasks (Questions 12, 15b–c, 17c, 18c). This can unintentionally overstate independence and understate limitations. Clearly state who helps, what they do (reminders, physical assistance, transportation, safety monitoring), and whether help is occasional or required every time.
Checking limitations in Section D without explaining measurable limits
In Question 23a, people often check many boxes (lifting, walking, concentration, etc.) but do not provide the requested explanations like pounds, distance, time, or examples. Without measurable limits, SSA may not be able to translate the report into functional capacity. Add concrete details (e.g., “can lift 5 lbs,” “walks 1 block then rests 10 minutes,” “can focus 5–10 minutes”) and real examples of what happens when limits are exceeded.
Contradictory answers across sections (e.g., “can’t go out” but “shops weekly”)
Because similar topics appear in multiple places (going out, shopping, social activities, driving), people sometimes give inconsistent responses. Contradictions can reduce credibility and lead to clarification requests. Before submitting, cross-check related answers and add context in Remarks (e.g., “shops only online,” “goes out only for medical appointments with someone driving”).
Misunderstanding “personal care” and skipping the explanation when there are issues
Question 15 includes a checkbox for “NO PROBLEM,” and some respondents check it even when the person needs reminders, uses adaptive methods, or has difficulty due to pain, fatigue, or mental symptoms. This can underreport important limitations in dressing, bathing, toileting, and grooming. Only check “NO PROBLEM” if there truly are no issues; otherwise describe what is hard, how long it takes, safety concerns, and what assistance or reminders are needed.
Listing all medications instead of only those causing side effects (or omitting side effects entirely)
Question 25 specifically says not to list all medicines—only those that cause side effects—yet many people either list everything or provide no side-effect details. This can clutter the response or miss key functional impacts like drowsiness, dizziness, nausea, or cognitive slowing. List only the medication(s) that cause side effects and describe the side effects and how they affect daily functioning (e.g., “sleepy for 4–6 hours after dose”).
Not clarifying assistive devices: prescribed vs. self-obtained, when used, and why
In Question 24, people often check devices (cane, brace, glasses, walker) but don’t state whether a doctor prescribed them, when they were prescribed, or under what circumstances they are needed. Missing details can weaken the connection between the condition and the functional need for the device. Specify prescription status (or “don’t know”), approximate date, and usage pattern (e.g., “uses cane every time outside due to balance,” “walker on bad days only”).
Forgetting to complete Page 10 identity/contact fields for the person completing the form
The form repeatedly reminds respondents to provide the name and address of the person completing the form on Page 10, but many stop after the questions and leave the signature/contact block incomplete. This can prevent SSA from verifying the source or contacting you for clarification, causing delays. Always complete the printed name, date, full address, and a reliable phone number; add email only if you check it regularly.

Frequently Asked Questions About SSA-3380-BK

 

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How does the AI fill out SSA-3380-BK?
You answer a few questions in plain words, or upload a document you already have. The AI reads what you give it and puts each answer into the right field of SSA-3380-BK, on every page, in seconds. It checks the answers against the form's own rules, and you review and change anything before you download, print or sign.
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-3380-BK to fill out?
SSA-3380-BK has a Form Complexity Index of 71 out of 100, in the complex tier: 197 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-3380-BK (Function Report – Adult – Third Party) used for?
SSA uses this form to understand how the disabled person’s medical conditions affect daily activities and ability to work. Your answers help SSA make a decision on the person’s disability claim.
Who should complete this form?
A third party who knows the disabled person well (such as a family member, friend, neighbor, or caregiver) should complete it. SSA wants information from someone who has observed the person’s functioning.
Should I ask the disabled person how to answer the questions?
No. The form specifically instructs you not to ask the disabled person to give you answers; SSA wants your independent observations.
Can a doctor or hospital fill out this form instead of me?
No. The instructions say not to ask a doctor or hospital to complete this form; it is meant to capture day-to-day functioning from a non-medical third party.
What if I don’t know the answer to a question or it doesn’t apply?
Do not leave blanks. Write “don’t know,” “none,” or “does not apply,” as appropriate.
What information do I need before I start?
Be ready to provide the disabled person’s living situation, your relationship to them, how long you’ve known them, and detailed examples of their daily activities and limitations. You should also know whether they use assistive devices and whether medications cause side effects.
How do I answer the question about what the disabled person does from waking up to bedtime (Question 9)?
Describe a typical day in order, including personal care, meals, chores, going out, rest periods, and any help they need. Concrete details (how long, how often, what they can’t do) are more helpful than general statements.
How should I report help the disabled person gets from others?
Whenever an activity is done with help, say who helps and what they do (for example, reminders, physical assistance, transportation, or supervision). The form asks about help in multiple sections, including personal care, chores, and going out.
What should I include in the Personal Care section (Question 15)?
Explain how the conditions affect dressing, bathing, hair care, shaving, feeding, and using the toilet, and whether reminders are needed. If there is no problem with personal care, you can indicate that, but don’t leave the section blank.
How do I complete the sections about meals and house/yard work (Questions 16–17)?
State whether the person prepares meals and what kind, how often, and how long it takes, and describe any changes since the condition began. For chores, list what they can do, how often, how long it takes, and whether they need help or encouragement—or explain why they do none.
What does SSA mean by “getting around” and “shopping” (Questions 18–19)?
These questions ask how often the person goes outside, how they travel (walking, driving, riding, public transportation), and whether they can go out alone. For shopping, describe where/how they shop, what they buy, and how often and how long it takes.
How should I answer the abilities checklist (Question 23) about lifting, walking, memory, concentration, etc.?
Check all areas affected and then explain each one with specific limits (for example, how many pounds they can lift, how far they can walk, how long they can pay attention). If you can, include examples of what happens when they try to do the activity.
What if the disabled person uses a cane, walker, glasses, or other aids (Question 24)?
Check the aids used, note which were prescribed by a doctor (or write “don’t know”), when they were prescribed (or “don’t know”), and when the person needs to use them. Include any “other” devices and explain.
Do I need to list all medications the disabled person takes (Question 25)?
No. The form says not to list all medicines—list only the medicines that cause side effects for the disabled person and describe the side effects.
What is the “Remarks” section for, and what must I complete on the last page?
Use Remarks (Section E) for extra space and reference the question number you’re adding to. On page 10, you must provide the name and address of the person completing the form (and the date); email is optional.
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