Function Report – Adult – Third Party (Form SSA-3380-BK) Instructions

Check this box if the disabled person's illnesses, injuries, or conditions affect their ability to lift.

Check this box if the disabled person's illnesses, injuries, or conditions affect their ability to squat.

Check this box if the disabled person's illnesses, injuries, or conditions affect their ability to bend.

Check this box if the disabled person's illnesses, injuries, or conditions affect their ability to stand.

Check this box if the disabled person's illnesses, injuries, or conditions affect their ability to reach.

Check this box if the disabled person's illnesses, injuries, or conditions affect their ability to walk.

Check this box if the disabled person's illnesses, injuries, or conditions affect their ability to sit.

Check this box if the disabled person's illnesses, injuries, or conditions affect their ability to kneel.

Check this box if the disabled person's illnesses, injuries, or conditions affect their ability to talk.

Check this box if the disabled person's illnesses, injuries, or conditions affect their ability to hear.

Check this box if the disabled person's illnesses, injuries, or conditions affect their ability to climb stairs.

Check this box if the disabled person's illnesses, injuries, or conditions affect their ability to see.

Check this box if the disabled person's illnesses, injuries, or conditions affect their memory.

Check this box if the disabled person's illnesses, injuries, or conditions affect their ability to complete tasks.

Check this box if the disabled person's illnesses, injuries, or conditions affect their concentration.

Check this box if the disabled person's illnesses, injuries, or conditions affect their ability to understand.

Check this box if the disabled person's illnesses, injuries, or conditions affect their ability to follow instructions.

Check this box if the disabled person's illnesses, injuries, or conditions affect their ability to use their hands.

Check this box if the disabled person's illnesses, injuries, or conditions affect their ability to get along with others.

Provide a detailed explanation of how the disabled person's illnesses, injuries, or conditions affect each of the abilities checked in item 23a.

Provide a detailed explanation of how well the disabled person follows spoken instructions.

Enter how well the disabled person can follow written instructions.

Check this box if the person can go out alone.

Check this box if the person cannot go out alone.

Provide a detailed explanation of why the person cannot go out alone, assuming the answer to the previous question was 'No'.

Enter the street number and name of the person completing this form.

Enter the email address of the person completing this form.

Specify which of the aids were prescribed by a doctor.

Enter the date when the aids were prescribed.

Describe when the person needs to use these aids.

Select this checkbox if the disabled person uses crutches.

Select this checkbox if the disabled person uses a cane.

Select this checkbox if the disabled person uses a hearing aid.

Select this checkbox if the disabled person uses a walker.

Select this checkbox if the disabled person uses a brace or splint.

Check this box if the disabled person uses glasses or contact lenses.

Check this box if the disabled person uses a wheelchair.

Check this box if the disabled person uses an artificial limb.

Check this box if the disabled person uses an artificial voice box.

Check this box if the disabled person uses any other assistive devices not listed and provide an explanation.

Provide details about other aids used by the disabled person that are not listed above.

Provide the duration for which the disabled person can pay attention.

Check this box if the person takes care of anyone else.

Check this box if the person does not take care of anyone else.

If the disabled person cares for anyone else, describe for whom they care and what they do for them.

Check this box if the disabled person's ability to handle money has changed since their illnesses, injuries, or conditions began.

Check this box if the disabled person's ability to handle money has not changed since their illnesses, injuries, or conditions began.

Provide a detailed explanation of how the disabled person's ability to handle money has changed since the onset of their illnesses, injuries, or conditions.

Provide a detailed description of any changes in social activities that have occurred since the onset of the illnesses, injuries, or conditions.

Please enter the city of the person completing the form.

Please enter the state of the person completing the form.

Please enter the ZIP Code of the person completing the form.

Enter the current date.

Enter the area code for your daytime telephone number.

Check this box if the daytime telephone number provided is your direct number.

Check this box if the daytime telephone number provided is a message number where someone can take a message for you.

Check this box if you cannot provide a daytime telephone number.

Enter the three-digit prefix of your daytime telephone number.

Enter the four-digit line number of your daytime telephone number.

Describe the kinds of things the disabled person does with others in social activities.

State how often the disabled person participates in these social activities.

Provide a detailed description of the disabled person's daily activities from the time they wake up until they go to bed.

Provide a detailed explanation of how the person's illnesses, injuries, or conditions limit their ability to work.

Check this box if the disabled person is right-handed.

Check this box if the disabled person is left-handed.

Check this box if the disabled person lives alone.

Check this box if the disabled person lives with family.

Check this box if the disabled person lives with friends.

Check this box if the disabled person lives with others not categorized as family or friends, and a description of the relationship is required.

Provide the relationship of the person with whom the disabled person lives if it is not one of the other specified options.

Check this box if the disabled person lives in a house.

Check this box if the disabled person lives in an apartment.

Check this box if the disabled person lives in a boarding house.

Check this box if the disabled person lives in a nursing home.

Check this box if the disabled person lives in a shelter.

Check this box if the disabled person lives in a group home.

Check this box if the disabled person lives in a residence type not listed, and provide details in the adjacent text field.

Provide the type of residence if none of the pre-defined options apply for where the disabled person lives.

Check this box if the disabled person drives.

Check this box if the disabled person does not drive.

Provide a detailed explanation of why the disabled person does not drive, if applicable.

Enter the total length of time you have known the disabled person.

Enter the name of the first medicine that causes side effects for the disabled person.

Describe the side effects of the first medicine for the disabled person.

Please provide any identifier or version number associated with the form title displayed in the right margin.

Describe the side effects caused by the fourth medicine the disabled person takes.

Enter the name of the fourth medicine the disabled person takes that causes side effects.

State how often the person goes outside.

Explain why the person does not go outside, if applicable.

Provide details on how well the disabled person gets along with authority figures such as police, bosses, landlords, or teachers.

Check this box if someone helps the disabled person care for other people or animals.

Check this box if no one helps the disabled person care for other people or animals.

Provide details about who helps the disabled person care for other people or animals, and describe what they do to help.

List the hobbies and interests of the disabled person (e.g., reading, watching TV, sewing, playing sports).

Describe how often and how well the disabled person engages in their hobbies and interests.

Describe any changes in the disabled person's hobbies and interests since the illnesses, injuries, or conditions began.

Provide a list of household chores, both indoors and outdoors, that the disabled person is able to do.

Indicate how much time the listed chores take and how often the disabled person does each of these things.

Check this box if the person needs help or encouragement doing house and yard work.

Check this box if the person does not need help or encouragement doing house and yard work.

Specify what type of help is needed if the disabled person requires assistance or encouragement doing household and yard work.

Provide a detailed explanation if the disabled person does not perform house or yard work.

Check this box if the disabled person has been fired or laid off from a job because of problems getting along with other people.

Check this box if the disabled person has never been fired or laid off from a job because of problems getting along with other people.

Provide a detailed explanation if the disabled person has been fired or laid off from a job due to problems getting along with other people.

Enter the name of the employer if the disabled person has been fired or laid off from a job.

Check this box if the disabled person prepares their own meals.

Check this box if the disabled person does not prepare their own meals.

Specify the kind of food the disabled person prepares, such as sandwiches, frozen dinners, or complete meals with several courses.

Indicate how often the disabled person prepares food or meals, for example, daily, weekly, or monthly.

State how long it takes the disabled person to prepare meals.

Describe any changes in the disabled person's cooking habits since the onset of the illness, injuries, or conditions.

Explain the reasons why the disabled person cannot or does not prepare meals if they answered 'No' to the previous question.

Check this box if the disabled person currently takes any medicines for their illnesses, injuries, or conditions.

Check this box if the disabled person does not currently take any medicines for their illnesses, injuries, or conditions.

Check this box if the individual needs help or reminders taking medicine.

Check this box if the individual does not need help or reminders taking medicine.

Enter the type of help or reminders needed for taking medicine.

Check this box if the person travels by walking when going out.

Check this box if the person travels by driving a car when going out.

Check this box if the person travels by riding in a car when going out.

Check this box if the person travels by riding a bicycle when going out.

Check this box if the person travels by using public transportation when going out.

Check this box if the person travels by a method other than those listed and provide an explanation.

Provide a detailed explanation of the other method of travel used when going out.

Check this box if the disabled person spends time with others in person.

Check this box if the disabled person spends time with others on the phone.

Check this box if the disabled person spends time with others via email.

Check this box if the disabled person spends time with others by texting.

Check this box if the disabled person spends time with others via mail.

Check this box if the disabled person spends time with others using a method not listed, and provide an explanation.

Provide a description of the other method through which the disabled person spends time with others.

Check this box if the disabled person spends time with others using video chat (e.g., Skype or Facetime).

Check this box if the disabled person is able to pay bills.

Check this box if the disabled person is not able to pay bills.

Check this box if the disabled person is able to handle a savings account.

Check this box if the disabled person is not able to handle a savings account.

Check this box if the disabled person is able to count change.

Check this box if the disabled person is not able to count change.

Check this box if the disabled person is able to use a checkbook or money orders.

Check this box if the disabled person is not able to use a checkbook or money orders.

Provide a detailed explanation for all 'No' responses regarding the individual's money management abilities.

Provide the full name of the person completing this form.

Enter the date the form is being completed.

Provide the full name of the disabled person, including their first, middle, and last names.

Check this box if the disabled person needs someone to accompany him/her.

Check this box if the disabled person does not need someone to accompany him/her.

Check this box if the person has no problems with personal care despite their illnesses, injuries, or conditions.

Explain how illnesses, injuries, or conditions affect the person's ability to dress.

Explain how illnesses, injuries, or conditions affect the person's ability to bathe.

Explain how illnesses, injuries, or conditions affect the person's ability to care for their hair.

Explain how illnesses, injuries, or conditions affect the person's ability to shave.

Explain how illnesses, injuries, or conditions affect the person's ability to feed themselves.

Explain how illnesses, injuries, or conditions affect the person's ability to use the toilet.

Explain how illnesses, injuries, or conditions affect the person's ability to perform other personal care activities not listed.

Check this box if the person needs any special reminders to take care of personal needs and grooming.

Check this box if the person does not need any special reminders to take care of personal needs and grooming.

Provide a description of the type of help or reminders needed for personal needs and grooming.

Check this box if the person takes care of pets or other animals.

Check this box if the person does not take care of pets or other animals.

Enter what the disabled person does to care for their pets or other animals.

Provide a list of places the disabled person visits on a regular basis, such as a church, community center, sports events, or social groups.

Provide a detailed description of the disabled person's abilities before the onset of their illnesses, injuries, or conditions.

Check this box if the person has problems getting along with family, friends, neighbors, or others.

Check this box if the person does not have problems getting along with family, friends, neighbors, or others.

Provide a detailed explanation if the person has any problems getting along with family, friends, neighbors, or others.

Enter your relationship to the disabled person.

Provide any added information not shown in earlier parts of this form.

Check this box if the person needs to be reminded to go places.

Check this box if the person does not need to be reminded to go places.

Provide details on how often the person goes to places and how much they participate.

Provide a description of how well the disabled person handles changes in routine.

Describe the side effects the disabled person experiences from the second medicine.

Enter the name of the second medicine the disabled person takes that causes side effects.

Check this box if the disabled person shops in stores.

Check this box if the disabled person shops by phone.

Check this box if the disabled person shops by mail.

Check this box if the disabled person shops by computer.

Describe the items or categories the disabled person shops for.

Provide details on how often the disabled person shops and the typical duration of their shopping trips.

Check this box if any of the medicines cause side effects.

Check this box if none of the medicines cause side effects.

Check this box if the illnesses, injuries, or conditions affect the disabled person's sleep.

Check this box if the illnesses, injuries, or conditions do not affect the disabled person's sleep.

Describe how the illnesses, injuries, or conditions affect the person's sleep.

Provide a detailed explanation of how well the disabled person handles stress.

Check this box if the disabled person finishes what he/she starts.

Check this box if the disabled person does not finish what he/she starts.

Describe the side effects the disabled person experiences from the third medicine listed.

Enter the name of the third medicine the disabled person takes that causes side effects.

Provide details on how much time you spend with the disabled person and what activities you do together.

This section contains important legal and privacy information regarding the collection and use of the information you provide. It explains the legal basis for the information request, the voluntary nature of providing the information, and the potential consequences of not providing it. It also details how the information may be shared and used by the Social Security Administration and other federal agencies.

Check this box if you have noticed any unusual behavior or fears in the disabled person.

Check this box if you have not noticed any unusual behavior or fears in the disabled person.

Provide a detailed explanation of any unusual behavior or fears observed in the disabled person.

Enter how far the disabled person can walk before needing to stop and rest.

Enter the duration of rest needed before the disabled person can resume walking.

Enter the name of the person completing this form.