Form SSA-3373, Function Report - Adult Instructions
This form contains 197 fields organized into 1 section. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Form SSA-3373 (02-2024) U F Discontinue Prior Editions Social Security Administration FUNCTION REPORT - ADULT Page 1 of 10 O M B Number 0960-0681 Function Report - Adult - Form SSA-3373-BK READ ALL OF THIS INFORMATION BEFORE YOU BEGIN COMPLETING THIS FORM IF YOU NEED HELP If you need help with this form, complete as much of it as you can and call the phone number provided on the letter sent with the form, or contact the person who asked you to complete the form. If you need the address or phone number for the office that provided the form, you can get it by calling Social Security at 1-800-772-1213. HOW TO COMPLETE THIS FORM The information that you give us on this form will be used by the office that makes the disability decision on your disability claim. You can help them by completing as much of the form as you can. It is important that you tell us about your activities and abilities. • Print or type. • DO NOT LEAVE ANSWERS BLANK. If you do not know the answer or the answer is "none" or "does not apply," please write "don't know" or "none" or "does not apply." • Do not ask a doctor or hospital to complete this form. • Be sure to explain an answer if the question asks for an explanation, or if you think you need to explain an answer. • If more space is needed to answer any questions, use the "REMARKS" section on Page 10, and show the number of the question being answered. • If a specific activity is performed with the help of others, please indicate that. REMEMBER TO GIVE US THE NAME AND ADDRESS OF THE PERSON COMPLETING THIS FORM ON PAGE 10 | Text | |
| Page 2 of 10 Privacy Act Statements Collection and Use of Personal Information Sections 205(ay), 223(d), and 1631 of the Social Security Act, as amended, allow us to collect this information. Furnishing us this information is voluntary. However, failing to provide all or part of the information may prevent an accurate and timely decision on any claim filed. We will use the information you provide to determine benefits eligibility. We may also share the information for the following purposes, called routine uses: • To third party contacts (e.g., employers and private pension plans) in situations where the party to be contacted has, or is expected to have, information relating to the individual's capability to manage his or her benefits or payments, or his or her eligibility for entitlement to benefits or eligibility for payments, under the Social Security program; and • To contractors and other Federal agencies, as necessary, for the purpose of assisting the Social Security Administration (S S A) in the efficient administration of its programs. We will disclose information under this routine use only in situations in which we may enter into a contractual or similar agreement to obtain assistance in accomplishing an SSA function relating to this system record. In addition, we may share this information in accordance with the Privacy Act and other Federal laws. For example, where authorized, we may use and disclose this information in computer matching programs, in which our records are compared with other records to establish or verify a person's eligibility for Federal benefit programs and for repayment of incorrect or delinquent debts under these programs. A list of additional routine uses is available in our Privacy Act System of Records Notices (S O R N) 60-0089, entitled Claims Folders System, as published in the Federal Register (FR) on October 31, 2019, at 84 FR 58422, and 60-0320, entitled Electronic Disability Claim File, as published in the FR on June 6, 2020 at 85 FR 34477. Additional information, and a full listing of all of our S O R N s, is available on our website at www.ssa.gov/privacy | Text | |
| Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take about 61 minutes to read the instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your local Social Security office through SSA's website at www.socialsecurity.gov. Offices are also listed under U. S. Government agencies in your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). You may send comments regarding this burden estimate or any other aspect of this collection, including suggestions for reducing this burden to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate or other aspects of this collection to this address, not the completed form. PLEASE REMOVE THIS SHEET BEFORE RETURNING THE COMPLETED FORM | Text | |
| Form SSA-3373 (02-2024) U F Discontinue Prior Editions Social Security Administration FUNCTION REPORT - ADULT Page 3 of 10 O M B Number 0960-0681 How your illnesses, injuries, or conditions limit your activities For SSA Use Only Do not write in this box. Anyone who makes or causes to be made a false statement or representation of material fact for use in determining a payment under the Social Security Act, or knowingly conceals or fails to disclose an event with an intent to affect an initial or continued right to payment, commits a crime punishable under Federal law by fine, imprisonment, or both, and may be subject to administrative sanctions. SECTION A - GENERAL INFORMATION 1. NAME OF DISABLED PERSON (First, Middle Initial, Last) | Text | |
| 2. SOCIAL SECURITY NUMBER | Text | |
| 3. YOUR DAYTIME TELEPHONE NUMBER (If there is no telephone number where you can be reached, please give us a daytime number where we can leave a message for you.) Area Code | Text | |
| Phone Number | Text | |
| Your Number | CheckBox | |
| Message Number | CheckBox | |
| None | CheckBox | |
| 4. ay. Where do you live? (Check one.) House | CheckBox | |
| Apartment | CheckBox | |
| Boarding House | CheckBox | |
| Nursing Home | CheckBox | |
| Shelter | CheckBox | |
| Group Home | CheckBox | |
| Other | CheckBox | |
| If other is checked (What?) | Text | |
| 4 b. With whom do you live? (Check one.) Alone | CheckBox | |
| With Family | CheckBox | |
| With Friends | CheckBox | |
| Other | CheckBox | |
| If other is checked (Describe relationship.) | Text | |
| SECTION B - INFORMATION ABOUT YOUR ILLNESSES, INJURIES, OR CONDITIONS 5. How do your illnesses, injuries, or conditions limit your ability to work | Text | |
| Page 4 of 10 SECTION C - INFORMATION ABOUT DAILY ACTIVITIES 6. Describe what you do from the time you wake up until going to bed | Text | |
| 7. Do you take care of anyone else such as a wife/husband, children, grandchildren, parents, friend, other? Yes | CheckBox | |
| No | CheckBox | |
| If "YES answered in question 7," for whom do you care, and what do you do for them | Text | |
| 8. Do you take care of pets or other animals? Yes | CheckBox | |
| No | CheckBox | |
| If "YES answered in question 8," what do you do for them | Text | |
| 9. Does anyone help you care for other people or animals? Yes | CheckBox | |
| No | CheckBox | |
| If "YES answered in question 9," who helps, and what do they do to help | Text | |
| 10. What were you able to do before your illnesses, injuries, or conditions that you can't do now | Text | |
| 11. Do the illnesses, injuries, or conditions affect your sleep? Yes | CheckBox | |
| No | CheckBox | |
| If "YES answered in question 11," how | Text | |
| 12. PERSONAL CARE. Ay. Explain how your illnesses, injuries, or conditions affect your ability to: Dress | Text | |
| Bathe | Text | |
| Care for hair | Text | |
| Shave | Text | |
| Feed self | Text | |
| Use the toilet | Text | |
| Other | Text | |
| CheckBox1 | CheckBox | |
| 13. MEALS. A. Do you prepare your own meals? Yes | CheckBox | |
| No | CheckBox | |
| If "YES answered in question 13. Ay.," what kind of food do you prepare? (For example, sandwiches, frozen dinners, or complete meals with several courses.) | Text | |
| How often do you prepare food or meals? (For example, daily, weekly, monthly.) | Text | |
| How long does it take you | Text | |
| Any changes in cooking habits since the illness, injuries, or conditions began | Text | |
| 13 B. If "NO answered in question 13 Ay," explain why you cannot or do not prepare meals | Text | |
| Page 5 of 10 12 b. Do you need any special reminders to take care of personal needs and grooming? Yes | CheckBox | |
| No | CheckBox | |
| If "YES answered in question 12B," what type of help or reminders are needed | Text | |
| 12 c. Do you need help or reminders taking medicine? Yes | CheckBox | |
| No | CheckBox | |
| If "YES answered in question 12c," what kind of help do you need | Text | |
| 14. HOUSE AND YARD WORK. Ay. List household chores, both indoors and outdoors, that you are able to do. (For example, cleaning, laundry, household repairs, ironing, mowing, etc.) | Text | |
| 14 b. How much time does it take you, and how often do you do each of these things | Text | |
| 14 c. Do you need help or encouragement doing these things? Yes | CheckBox | |
| No | CheckBox | |
| If "YES answered in question 14C," what help is needed | Text | |
| d. If you don't do house or yard work, explain why not | Text | |
| 16. SHOPPING. Ay. If you do any shopping, do you shop: (Check all that apply.) In stores | CheckBox | |
| By phone | CheckBox | |
| By mail | CheckBox | |
| By computer | CheckBox | |
| 16b. Describe what you shop for | Text | |
| 16c. How often do you shop and how long does it take | Text | |
| Page 6 of 10 15. GETTING AROUND. Ay. How often do you go outside | Text | |
| If you don't go out at all, explain why not | Text | |
| 15 b. When going out, how do you travel? (Check all that apply.) Walk | CheckBox | |
| Drive a car | CheckBox | |
| Ride in a car | CheckBox | |
| Ride a bicycle | CheckBox | |
| Use public transportation | CheckBox | |
| Other | CheckBox | |
| If other is checked (Explain) | Text | |
| 15 c. When going out, can you go out alone? Yes | CheckBox | |
| No | CheckBox | |
| If "NO to question 15C," explain why you can't go out alone | Text | |
| 15 d. Do you drive? Yes | CheckBox | |
| No | CheckBox | |
| If you don't drive, explain why not | Text | |
| 17. MONEY. Ay. Are you able to: Pay bills Yes | CheckBox | |
| No | CheckBox | |
| Count change Yes | CheckBox | |
| No | CheckBox | |
| Handle a savings account Yes | CheckBox | |
| No | CheckBox | |
| Use a checkbook/money orders Yes | CheckBox | |
| No | CheckBox | |
| Explain all "NO" answers. in 17. A | Text | |
| 17 b. Has your ability to handle money changed since the illnesses, injuries, or conditions began? Yes | CheckBox | |
| No | CheckBox | |
| If "YES in question 17 B," explain how the ability to handle money has changed | Text | |
| c. List the places you go on a regular basis. (For example, church, community center, sports events, social groups, etc.) | Text | |
| b. describe the kinds of things you do with others | Text | |
| How often do you do these things | Text | |
| 19. Social Activities. ay. How do you spend time with others? (Check all that apply.) In person | CheckBox | |
| On the phone | CheckBox | |
| CheckBox | ||
| Texting | CheckBox | |
| CheckBox | ||
| Other | CheckBox | |
| If other is checked (Explain) | Text | |
| Video Chat (for example Skype or Facetime) | CheckBox | |
| Page 7 of 10 18. HOBBIES AND INTERESTS. A. What are your hobbies and interests? (For example, reading, watching TV, sewing, playing sports, etc.) | Text | |
| 18 b. How often and how well do you do these things | Text | |
| 18 c. Describe any changes in these activities since the illnesses, injuries, or conditions began | Text | |
| Do you need someone to accompany you? Yes | CheckBox | |
| No | CheckBox | |
| d. Do you have any problems getting along with family, friends, neighbors, or others? Yes | CheckBox | |
| No | CheckBox | |
| If "Yes", explain | Text | |
| e. Describe any changes in social activities since the illnesses, injuries, or conditions began | Text | |
| If "Yes," explain | Text | |
| Do you need to be reminded to go places? Yes | CheckBox | |
| No | CheckBox | |
| How often do you go and how much do you take part | Text | |
| Page 8 of 10 SECTION D - INFORMATION ABOUT ABILITIES 20. A. Check any of the following items that your illnesses, injuries, or conditions affect: Lifting | CheckBox | |
| Squatting | CheckBox | |
| Bending | CheckBox | |
| Standing | CheckBox | |
| Reaching | CheckBox | |
| Walking | CheckBox | |
| Sitting | CheckBox | |
| Kneeling | CheckBox | |
| Talking | CheckBox | |
| Hearing | CheckBox | |
| Stair Climbing | CheckBox | |
| Seeing | CheckBox | |
| Memory | CheckBox | |
| Completing Tasks | CheckBox | |
| Concentration | CheckBox | |
| Understanding | CheckBox | |
| Following Instructions | CheckBox | |
| Using Hands | CheckBox | |
| Getting Along With Others | CheckBox | |
| Please explain how your illnesses, injuries, or conditions affect each of the items you checked. (For example, you can only lift [how many pounds], or you can only walk [how far]) | Text | |
| 20 b. Are you: Right handed | CheckBox | |
| Left Handed | CheckBox | |
| 20 c. How far can you walk before needing to stop and rest | Text | |
| If you have to rest, how long before you can resume walking | Text | |
| 20 d. For how long can you pay attention | Text | |
| 20 e. Do you finish what you start? (For example, a conversation, chores, reading, watching a movie.) Yes | CheckBox | |
| No | CheckBox | |
| f. How well do you follow written instructions? (For example, a recipe.) | Text | |
| 20 i. Have you ever been fired or laid off from a job because of problems getting along with other people? Yes | CheckBox | |
| No | CheckBox | |
| If "Yes" to question 20 i, please explain | Text | |
| If "Yes" to question 20 i, please give name of employer | Text | |
| 20 g. How well do you follow spoken instructions | Text | |
| h. How well do you get along with authority figures? (For example, police, bosses, landlords or teachers.) | Text | |
| 21. Do you use any of the following? (Check all that apply.) Crutches | CheckBox | |
| Cane | CheckBox | |
| Hearing Aid | CheckBox | |
| Walker | CheckBox | |
| Brace/Splint | CheckBox | |
| Glasses/Contact Lenses | CheckBox | |
| Wheelchair | CheckBox | |
| Artificial Limb | CheckBox | |
| Artificial Voice Box | CheckBox | |
| Other | CheckBox | |
| If Other is checked in question 21, explain | Text | |
| Which of these were prescribed by a doctor | Text | |
| When was it prescribed | Text | |
| When do you need to use these aids | Text | |
| Page 9 of 10 20 j. How well do you handle stress | Text | |
| 20 k. How well do you handle changes in routine | Text | |
| 20 l. Have you noticed any unusual behavior or fears? Yes | CheckBox | |
| No | CheckBox | |
| If "Yes" to question 20 l, please explain | Text | |
| SECTION E - REMARKS Use this section for any added information you did not show in earlier parts of this form. When you are done with this section (or if you didn't have anything to add), be sure to complete the fields at the bottom of this page | Text | |
| Name of person completing this form (Please print) | Text | |
| Date (MM/DD/YYYY) | Text | |
| Email address (optional) | Text | |
| Address (Number and Street) | Text | |
| City | Text | |
| State | Text | |
| ZIP Code. This is the end of the form. If you tab, you will be at the beginning of the form | Text | |
| Page 10 of 10 22. Do you currently take any medicines for your illnesses, injuries, or conditions? Yes | CheckBox | |
| No | CheckBox | |
| If "YES, "do any of your medicines cause side effects? Yes | CheckBox | |
| No | CheckBox | |
| If "YES," please explain. (Do not list all of the medicines that you take. List only the medicines that cause side effects.) This is a table of 2 Columns and 5 rows. First column is Name of Medicine and Second column is Side Effects you have. Row 1 NAME OF MEDICINE 1 | Text | |
| SIDE EFFECTS YOU HAVE for Medicine 1 | Text | |
| Row 2 NAME OF MEDICINE 2 | Text | |
| SIDE EFFECTS YOU HAVE for Medicine 2 | Text | |
| Row 3 NAME OF MEDICINE 3 | Text | |
| SIDE EFFECTS YOU HAVE for Medicine 3 | Text | |
| Row 4 NAME OF MEDICINE 4 | Text | |
| SIDE EFFECTS YOU HAVE for Medicine 4 | Text | |
| Row 5 NAME OF MEDICINE 5 | Text | |
| SIDE EFFECTS YOU HAVE for Medicine 5 | Text |