Function Report – Adult – Third Party (Form SSA-3380-BK) Completed Form Examples and Samples
View a detailed example of a completed Function Report – Adult – Third Party (Form SSA-3380-BK). Our sample helps you understand how to effectively fill out this crucial Social Security disability form to describe an applicant's daily limitations.
Function Report – Adult – Third Party (Form SSA-3380-BK) Example
How this form was filled:
This is an example of a Function Report – Adult – Third Party (Form SSA-3380-BK) filled out by an applicant's brother. It details the daily living, social, and physical limitations of an individual, Jane Smith, who suffers from Major Depressive Disorder and Fibromyalgia. The report provides specific, consistent answers about how her conditions affect her ability to function.
Information used to fill out the document:
- Applicant's Name: Jane Smith
- Applicant's Social Security Number: 987-65-4321
- Third Party's Name: Robert Smith
- Relationship to Applicant: Brother
- Date Form Completed: May 10, 2026
- Applicant's Conditions: Major Depressive Disorder, Fibromyalgia
- Onset of Limiting Conditions: June 2024
- Summary of Daily Activities: Spends most of the day resting in bed or on the couch; needs prompting for basic personal care.
- Meal Preparation: Unable to cook full meals; relies on microwaveable food or assistance from others.
- Household Chores: Cannot perform chores like cleaning, laundry, or yard work due to fatigue and pain.
- Mobility: Rarely leaves the house; needs assistance for all appointments. Can only walk about 50 feet before needing to rest.
- Social Functioning: Has withdrawn from friends and family; avoids phone calls and social gatherings.
- Cognitive Function: Experiences poor concentration and memory; has trouble following instructions and making decisions.
- Physical Abilities: Cannot lift more than 5 lbs, stand for more than 10 minutes, or sit for more than 30 minutes without severe pain.
What this filled form sample shows:
- Provides a clear example of how to describe the impact of co-occurring mental and physical conditions.
- Demonstrates how to give specific, concrete examples of functional limitations (e.g., 'can only walk 50 feet').
- Shows how a third party can provide consistent and credible information about the applicant's daily life.
- Highlights the importance of explaining changes in hobbies, interests, and social activities before and after the conditions began.
- Includes details on limitations in concentration, memory, and task completion, which are critical for many disability claims.
Form specifications and details:
| Form Name: | Function Report – Adult – Third Party |
| Form Number: | SSA-3380-BK |
| Agency: | Social Security Administration (SSA) |
| Use Case: | Report completed by a family member for an applicant with severe physical (Fibromyalgia) and mental (Depression) health conditions. |
Created: February 05, 2026 08:25 PM
