Function Report - Adult - Third Party (Form SSA-3380-BK) Completed Form Examples and Samples
View detailed examples and samples of a completed Function Report - Adult - Third Party (Form SSA-3380-BK). Our guide helps you understand how to accurately fill out the form to describe a claimant's daily activities, limitations, and care needs for their Social Security disability application.
Function Report - Adult - Third Party (Form SSA-3380-BK) Example
How this form was filled:
This example shows Form SSA-3380-BK completed by a brother for his sister who suffers from severe rheumatoid arthritis and major depressive disorder. It details how her conditions severely limit her daily activities, personal care, ability to leave the house, and social interactions, providing a comprehensive picture of her functional limitations for the SSA.
Information used to fill out the document:
- Claimant's Name: Jane Smith
- Person Completing Form: Robert Smith
- Relationship to Claimant: Brother
- Claimant's Conditions: Severe Rheumatoid Arthritis, Major Depressive Disorder
- Date Form Completed: 05/10/2026
- Summary of Daily Routine: Spends most of the day in a recliner due to pain and fatigue. Has great difficulty with morning personal care. Can only make simple microwave meals. Watches TV but has trouble following plots.
- Personal Care Limitations: Needs help fastening buttons and zippers. Cannot wash her own hair or get in/out of the tub without assistance. Sometimes forgets to take medication.
- Household Chore Limitations: Unable to do any significant chores like vacuuming, laundry, or yard work. Robert helps with cleaning and errands weekly.
- Mobility: Uses a walker inside the house. Rarely leaves home except for doctor appointments, and requires Robert's assistance and vehicle.
- Cognitive & Social Limitations: Has trouble concentrating and making decisions. Has withdrawn from friends and avoids family gatherings due to anxiety and lack of energy.
What this filled form sample shows:
- Provides a clear example from a third-party perspective (a brother reporting for his sister).
- Details the functional impact of both physical (arthritis) and mental (depression) impairments.
- Includes specific, concrete examples for questions about daily activities and limitations.
- Demonstrates how to describe difficulties with personal care, concentration, and social interaction.
Form specifications and details:
| Use Case: | Adult claimant with combined physical and mental health impairments. |
| Form Name: | Function Report - Adult - Third Party |
| Form Number: | SSA-3380-BK |
| Submitted By: | Family Member (Brother) |
Created: January 29, 2026 06:22 PM
