Form SSA-3820-BK, Disability Report - Child Instructions

Provide any additional information about the child that may be relevant to the disability report.

Check this box if there are other individuals or entities with medical records or information about the child's conditions, or if the child is scheduled to see someone else.

Check this box if there are no other individuals or entities with medical records or information about the child's conditions.

Enter the name of the person or entity that has additional medical records or information about the child's conditions.

Enter the address of the person or entity that has additional medical records or information about the child's conditions.

Provide the area code for the agency's phone number.

Provide the phone number for the agency, excluding the area code.

If you answered 'Yes' to any of the above questions A or B, provide the name of the agency involved.

Provide the address of the agency, including number, street, apartment number (if any), P.O. Box, or rural route.

Provide the city where the agency is located.

Provide the state where the agency is located.

Provide the ZIP code for the agency's location.

Enter the name of the agency that conducted the test or holds the test records.

Provide the full address of the agency, including street number, apartment number (if any), P.O. Box, or rural route.

Enter the city where the agency is located.

Enter the state where the agency is located.

Enter the ZIP code for the agency's location.

Enter the area code for the agency's phone number.

Enter the phone number of the agency, excluding the area code.

Check this box if the child was tested for behavioral or learning problems.

Check this box if the child was not tested for behavioral or learning problems.

If the child was tested for behavioral or learning problems, specify the type of test conducted.

Enter the date when the behavioral or learning test was conducted.

Specify the type of a second test conducted for behavioral or learning problems, if applicable.

Enter the date when the second behavioral or learning test was conducted.

Indicate whether the child has been tested for behavioral or learning problems by checking 'Yes'.

Indicate whether the child has not been tested for behavioral or learning problems by checking 'No'.

If the child has been tested for behavioral or learning problems, specify the type of test conducted.

Provide the date or time period when the behavioral or learning test was conducted.

Specify another type of test conducted for behavioral or learning problems, if applicable.

Provide the date or time period when the additional behavioral or learning test was conducted.

Specify your relationship to the child, such as parent, guardian, or other.

Enter the full address where the child resides, including street number, apartment number, P.O. Box, or rural route.

Enter the city part of the address where the child resides.

Enter the state part of the address where the child resides.

Enter the ZIP code part of the address where the child resides.

Check 'Yes' if there is another adult who helps care for the child and can assist in providing information. Enter their name, address, phone number, and relationship to the child.

Check 'No' if there is no other adult who helps care for the child and can assist in providing information.

Enter the full name of the contact person who helps care for the child.

Enter the complete address of the contact person, including number, street, apartment number (if any), P.O. Box, or rural route.

Enter the city where the contact person resides.

Enter the state where the contact person resides.

Enter the ZIP code of the contact person's address.

Enter the area code of the contact person's daytime phone number.

Enter the contact person's daytime phone number.

Specify the relationship of the contact person to the child.

Enter your full name. If you are representing an agency, provide the name of the agency and the contact person. This information is needed to identify the person or agency completing the form.

Provide your complete mailing address, including number and street, apartment number (if any), P.O. Box, or rural route. This is required for correspondence related to the child's disability report.

Enter the city of your mailing address. This is part of the address information required for correspondence.

Enter the city where the child resides.

Enter the state where the child resides.

Enter the ZIP code for the child's residence.

Check this box if the child can speak and understand English.

Check this box if the child cannot speak and understand English.

If the child cannot speak and understand English, specify the languages they can speak.

List any other languages the child understands.

Provide details about the child's disabling illnesses, injuries, or conditions.

Estimate the date when the child became disabled. Use the format MM/DD/YYYY.

Indicate whether the child's illnesses, injuries, or conditions cause pain or other symptoms by checking 'Yes'.

Indicate whether the child's illnesses, injuries, or conditions do not cause pain or other symptoms by checking 'No'.

Enter the child's full name, including first name, middle initial, and last name. This information is required to identify the child applicant for the disability report.

Provide the child's Social Security Number. This is necessary for the identification and processing of the child's disability report.

Enter the child's height without shoes.

Enter the child's weight without shoes.

Enter the name of the county where the child resides.

Enter the state where the child resides.

Enter the ZIP code of the child's residence.

Enter the type of test that was conducted for the child. This could include medical, psychological, or educational tests.

Provide the date or time period when the test was conducted.

Enter the file or record number associated with the test. This helps in identifying the specific test record.

Enter the type of test that was conducted for the child. This could include medical, psychological, or educational tests.

Provide the date or time period when the test was conducted.

Enter the type of test that was conducted for the child. This could include medical, psychological, or educational tests.

Provide the date or time period when the test was conducted.

Enter the file or record number associated with the test. If the child has had other tests, list them in Section 10.

Enter the claim number if there is an existing claim related to the child's disability.

Enter the state where you currently reside.

Enter the ZIP code of your current residence.

Provide your email address. This is optional.

Enter the area code of your daytime phone number. If you do not have a phone number, provide a number where a message can be left for you.

Enter the remaining digits of your daytime phone number.

Check this box if the phone number provided is your own.

Check this box if the phone number provided is for leaving messages.

Check this box if you do not have a phone number where you can be reached.

Enter the area code of your daytime phone number.

Enter the remaining digits of your daytime phone number.

Enter the ZIP code of the child's current residence.

Enter the area code of the daytime phone number for contacting the child's caregiver or guardian.

Enter the daytime phone number for contacting the child's caregiver or guardian.

Enter the area code for the phone number of the medical facility or caregiver.

Enter the phone number of the medical facility or caregiver, excluding the area code.

Enter the name of the medical facility or caregiver.

Enter the area code of the phone number for the medical provider or facility.

Enter the phone number for the medical provider or facility, excluding the area code.

Enter the street address of the medical provider or facility.

Enter the city where the medical provider or facility is located.

Enter the state where the medical provider or facility is located.

Enter the ZIP code for the location of the medical provider or facility.

Enter the area code of the phone number for the medical provider or facility.

Enter the phone number for the medical provider or facility, excluding the area code.

Enter the area code of the phone number for contacting the child's residence.

Enter the phone number for contacting the child's residence, excluding the area code.

Enter the area code of the phone number for contact purposes.

Enter the phone number for contact purposes, excluding the area code.

Enter the date on which you completed this disability report in the format MM/DD/YYYY.

Enter the current grade level of the child if they are enrolled in school.

Provide the reason why the child is not enrolled in school if it is not due to age.

Indicate whether the child is currently enrolled in any school by checking this box if the answer is 'Yes'.

Check this box if the child is not enrolled in school because they are too young.

Check this box if the child is not enrolled in school for a reason other than being too young, and complete section B.

Indicate if the child has been tested or examined by Head Start (Title 5) by checking 'Yes'.

Indicate if the child has not been tested or examined by Head Start (Title 5) by checking 'No'.

Indicate if the child has been tested or examined by a Public or Community Health Department by checking 'Yes'.

Indicate if the child has not been tested or examined by a Public or Community Health Department by checking 'No'.

Indicate if the child has been tested or examined by a Child Welfare or Social Service Agency or WIC by checking 'Yes'.

Indicate if the child has not been tested or examined by a Child Welfare or Social Service Agency or WIC by checking 'No'.

Indicate if the child has been tested or examined by Early Intervention Services by checking 'Yes'.

Indicate if the child has not been tested or examined by Early Intervention Services by checking 'No'.

List the names of all other schools the child has attended in the last 12 months and provide the dates attended.

Provide the address of the school, including number, street, apartment number (if any), P.O. Box, or rural route.

Provide the city where the school is located.

Enter the dates the child attended the specified educational institution.

Enter the name of the child's teacher.

Indicate whether the child is currently attending daycare or preschool by checking this box if the answer is 'Yes'.

Indicate whether the child is not currently attending daycare or preschool by checking this box if the answer is 'No'.

If the child is attending daycare or preschool, provide the name of the daycare, preschool, or caregiver here.

Enter the full address of the daycare, preschool, or caregiver, including number, street, apartment number (if any), P.O. Box, or rural route.

Enter the city where the daycare, preschool, or caregiver is located.

Enter the county where the daycare, preschool, or caregiver is located.

Enter the state where the daycare, preschool, or caregiver is located.

Enter the ZIP code for the location of the daycare, preschool, or caregiver.

Enter the area code of the phone number for the daycare, preschool, or caregiver.

Enter the phone number for the daycare, preschool, or caregiver, excluding the area code.

Enter the dates during which the child attended the daycare or preschool.

Provide the name of the child's teacher or caregiver at the daycare or preschool.

Specify the type of test the child has undergone.

Indicate when the test was conducted.

Indicate whether the child has received Vocational Rehabilitation or other employment support services by checking 'Yes'.

Indicate whether the child has not received Vocational Rehabilitation or other employment support services by checking 'No'.

This field is for entering the date and any additional remarks or comments you may have about the information provided in the form. Ensure that the date is current and remarks are relevant to the child's disability report.

This is the header of the SSA-3820-BK form, a Disability Report for a child. It includes the form number, edition date, and instructions to read all information before beginning.

Indicate whether the child is enrolled in a Program for Children with Special Health Care Needs by checking 'Yes'.

Indicate whether the child is not enrolled in a Program for Children with Special Health Care Needs by checking 'No'.

Indicate whether the child is receiving services from a Mental Health/Developmental Disabilities Center by checking 'Yes'.

Indicate whether the child is not receiving services from a Mental Health/Developmental Disabilities Center by checking 'No'.

Instructions for completing the form, including how to get help, what to do if you don't know an answer, and how to prepare for your interview. It also provides guidance on filling out specific sections and what to do if you need more space for answers.

Check this box if you can speak and understand English.

Check this box if you cannot speak and understand English.

If you cannot speak and understand English, specify your preferred language.

Check this box if there is someone we may contact who speaks and understands English and can give you messages. Provide their name, address, phone number, and relationship to you.

Check this box if there is no one available who can speak and understand English on your behalf.

Enter the name of the person who can speak and understand English on your behalf.

Check this box if you can read and understand English.

Check this box if you cannot read and understand English.

Check this box if the person can speak and understand English.

Check this box if the person cannot speak and understand English.

If the person cannot speak and understand English, specify their preferred language.

Check this box if the person can read and understand English.

Check this box if the person cannot read and understand English.

Check 'Yes' if the legal guardian or custodian can speak and understand English.

Check 'No' if the legal guardian or custodian cannot speak and understand English.

If the legal guardian or custodian cannot speak and understand English, specify their preferred language.

Indicate whether the person can read and understand English by checking 'Yes'.

Indicate whether the person cannot read and understand English by checking 'No'.

Indicate whether the contact person can speak and understand English by checking 'Yes'.

Indicate whether the contact person cannot speak and understand English by checking 'No'.

If the contact person cannot speak and understand English, specify their preferred language.

Indicate whether the person can read and understand English by checking 'Yes'.

Indicate whether the person cannot read and understand English by checking 'No'.

Indicate whether the child has a legal guardian or custodian other than you by checking 'No'.

If you answered 'Yes' to the previous question, enter the number of legal guardians or custodians here.

Check 'Yes' if the child has a legal guardian or custodian other than you. Provide their name, address, phone number, and relationship to the child.

Indicate whether the child has a legal guardian or custodian other than you by checking 'No'.

Enter the full name of the child's legal guardian or custodian.

Provide the complete address of the child's legal guardian or custodian, including street number, apartment number, P.O. Box, or rural route.

Enter the city where the child's legal guardian or custodian resides.

Enter the state where the child's legal guardian or custodian resides.

Enter the ZIP code for the address of the child's legal guardian or custodian.

Provide the area code for the daytime phone number of the child's legal guardian or custodian.

Enter the daytime phone number of the child's legal guardian or custodian.

Specify the relationship of the legal guardian or custodian to the child.

Check this box if the child lives with you.

Check this box if the child does not live with you. Provide the name of the person the child lives with.

Enter the name of the person the child lives with, if not living with you.

Specify the relationship of the person the child lives with to the child, such as relative, friend, etc.

Enter the full address of the person the child lives with, including street number, apartment number, P.O. Box, or rural route.

Enter the city part of the address of the person the child lives with.

Enter the state part of the address of the person the child lives with.

Enter the city where the medical facility or caregiver is located.

Enter the state where the medical facility or caregiver is located.

Enter the ZIP code for the location of the medical facility or caregiver.

Enter the street address of the medical facility or caregiver.

Enter the city where the medical facility or caregiver is located.

Enter the state where the medical facility or caregiver is located.

Enter the ZIP code for the location of the medical facility or caregiver.

Information about the child's medical and other records that you should bring or send with the completed form. This includes medical records, prescriptions, and educational plans. It also explains that you do not need to request records from doctors or hospitals yourself.

Enter the date of the child's next scheduled appointment with the medical facility or caregiver.

Enter the area code of the phone number for the hospital or clinic.

Enter the phone number for the hospital or clinic, excluding the area code.

Enter the name of the hospital or clinic where the child received medical care. If more space is needed, use Section 10. D.

Enter the street address of the hospital or clinic where the child received medical care.

Enter the city where the hospital or clinic is located.

Enter the state where the hospital or clinic is located.

Enter the ZIP code of the hospital or clinic's location.

Enter the date of the child's first visit to the medical facility or caregiver.

Enter the date of the child's most recent visit to the medical facility or caregiver.

Describe the reasons for the child's visits to the medical facility or caregiver.

Enter the date of the child's first visit to this medical provider or facility.

Enter the date of the child's most recent visit to this medical provider or facility.

Enter the date of the child's next scheduled appointment with this medical provider or facility.

Describe the reasons for the child's visits to this medical provider or facility.

Describe the treatment the child received during visits to this medical provider or facility.

Indicate whether the child has been in speech or language therapy by checking this box if the answer is 'Yes'.

Indicate whether the child has not been in speech or language therapy by checking this box if the answer is 'No'.

If the child has been in speech or language therapy and the therapist's name is different from previously mentioned, provide the name of the Speech/Language Therapist here.

Check this box if the child has a medical assistance card.

Enter the patient ID number if it is known. This is typically assigned by the medical facility.

Enter the hospital or clinic number assigned to the child.

Provide the reasons for the child's visits to the medical facility.

Describe the treatment the child received during their visits to the medical facility.

List the doctors the child regularly sees at the hospital or clinic.

Enter the child's hospital or clinic identification number, if applicable.

List the names of doctors the child regularly sees at the hospital or clinic.

List any side effects the child experiences from their medications.

Provide the name of the doctor who prescribed the second medication.

List any side effects the child experiences from their medications.

Provide the name of the doctor who prescribed the third medication.

List any side effects the child experiences from their medications.

Provide the name of the doctor who prescribed the fourth medication.

List any side effects the child experiences from their medications.

Provide the name of the doctor who prescribed the fifth medication.

Describe any side effects the child experiences from their medical treatments or medications.

Indicate whether the child has been seen by a doctor, hospital, clinic, or anyone else for the illnesses, injuries, or conditions by checking 'Yes'.

Indicate whether the child has not been seen by a doctor, hospital, clinic, or anyone else for the illnesses, injuries, or conditions by checking 'No'.

Indicate whether the child has been seen by a doctor, hospital, clinic, or anyone else for emotional or mental problems by checking 'Yes'.

Indicate whether the child has not been seen by a doctor, hospital, clinic, or anyone else for emotional or mental problems by checking 'No'.

List the name of each doctor, HMO, therapist, or other who may have medical records or information about the child's conditions. Include the child's next appointment if known.

Provide the street address of the doctor, HMO, therapist, or other listed.

Enter the patient ID number if it is known. This is typically assigned by the medical provider or facility.

Enter the name of the doctor, HMO, therapist, or other medical provider associated with the child's medical records.

Enter the patient ID number if it is known. This is typically assigned by the medical provider or facility.

Enter the name of the hospital or clinic where the child received medical treatment.

Enter the street address of the hospital or clinic where the child received medical treatment.

Enter the city where the hospital or clinic is located.

Enter the state where the hospital or clinic is located.

Enter the ZIP code of the hospital or clinic's location.

Enter the area code of the phone number for the hospital or clinic.

Enter the phone number of the hospital or clinic, excluding the area code.

Indicate whether the child has had or will have any medical tests for illnesses, injuries, or conditions by checking 'Yes'.

Indicate whether the child has had or will have any medical tests for illnesses, injuries, or conditions by checking 'No'.

Provide the date when the EKG (Heart Test) was or will be conducted. Include month, day, and year.

Enter the name of the facility where the EKG (Heart Test) was or will be conducted.

Specify who referred or sent the child for the EKG (Heart Test).

Provide the date when the Treadmill (Exercise Test) was or will be conducted. Include month, day, and year.

Enter the name of the facility where the Treadmill (Exercise Test) was or will be conducted.

Specify who referred or sent the child for the Treadmill (Exercise Test).

Provide the date when the Cardiac Catheterization was or will be conducted. Include month, day, and year.

Enter the name of the facility where the Cardiac Catheterization was or will be conducted.

Specify who referred or sent the child for the Cardiac Catheterization.

Enter the name of the body part for which the biopsy was or will be conducted.

Enter the date when the tests were or will be conducted in the format month, day, year.

Provide the name of the facility where the test was conducted.

Specify who referred or sent the child for this test.

Enter the name of the body part that was scanned during the MRI or CAT scan.

Enter the date when the tests were or will be conducted in the format month, day, year.

Provide the name of the facility where the test was conducted.

Specify who referred or sent the child for this test.

Describe the treatment the child received during visits to the medical facility or caregiver.

Describe the treatment the child received during their visits to the medical facility.

Describe the treatment the child received during their visits to the medical facility. Include any procedures or therapies.

Enter the date of the child's first visit to the medical facility. Use formats like MM-DD-YYYY or Month Year.

Enter the date of the child's most recent visit to the medical facility. Use formats like MM-DD-YYYY or Month Year.

Enter the date of the child's next scheduled appointment at the medical facility. Use formats like MM-DD-YYYY or Month Year.

Provide the reasons for the child's visits to the medical facility. Include any symptoms or conditions being addressed.

Enter the date when the child was admitted or first visited the medical facility.

Enter the date when the child was discharged or last visited the medical facility.

Enter the date when the child was admitted or first visited the medical facility.

Enter the date when the child was discharged or last visited the medical facility.

Enter the date when the child was admitted or first visited the medical facility.

Enter the date when the child was discharged or last visited the medical facility.

Enter the date of the child's first visit to the medical facility.

Enter the date of the child's last visit to the medical facility.

Enter all the dates of the child's visits to the medical facility.

Enter all the dates of the child's visits to the medical facility.

Enter the date of the child's next scheduled appointment at the medical facility.

Enter the date when the child was last discharged from a medical facility.

Enter the date of the child's first visit to the medical facility.

Enter the date of the child's most recent visit to the medical facility.

Enter the dates of the child's visits to the medical facility. If there are multiple visits, list all relevant dates.

Enter additional dates of the child's visits to the medical facility, if applicable.

Enter the date of the child's next scheduled appointment at the medical facility.

Describe the reasons for the child's visits to the medical facility.

Enter the date of the child's first visit to the medical provider.

Enter the date when the child was last seen by the medical provider.

Enter the date of the child's next scheduled appointment with the medical provider.

Provide reasons for the child's medical visits. Use Section 10 if additional space is needed.

Enter the name of the second medication the child is taking.

Explain the reason for prescribing the second medication to the child.

Enter the name of the third medication the child is taking.

Explain the reason for prescribing the third medication to the child.

Enter the name of the fourth medication the child is taking.

Explain the reason for prescribing the fourth medication to the child.

Enter the name of the fifth medication the child is taking.

Explain the reason for prescribing the fifth medication to the child.

Check this box if the child currently takes any medications for illnesses, injuries, or conditions.

Check this box if the child does not currently take any medications for illnesses, injuries, or conditions.

Enter the name of the medicine the child is taking. Refer to the medicine containers if necessary.

If the medicine is prescribed, enter the name of the doctor who prescribed it.

Enter the reason why the child is taking the medicine.

Describe your relationship to the child (e.g., parent, guardian, etc.).

This section provides information about the Privacy Act and the collection and use of personal information by the Social Security Administration. It explains the legal basis for collecting this information, the voluntary nature of providing it, and the potential consequences of not providing it. It also details how the information may be used and shared.

Enter the area code of the school's phone number.

Enter the phone number of the school, excluding the area code.

List the name of the school the child is currently attending and the dates attended. If the child is no longer in school, provide the name of the last school attended and the dates.

Enter the full address of the school, including number, street, apartment number (if any), P.O. Box, or rural route.

Enter the city where the school is located.

Enter the county where the school is located.

Enter the state where the school is located.

Enter the ZIP code of the school's location.

Provide the dates during which the child attended the school.

Enter the name of the child's teacher.

Indicate whether the child is currently enrolled in special education by checking 'Yes'.

Indicate whether the child is not enrolled in special education by checking 'No'.

If the child is in special education and the teacher's name is different from previously provided, specify the name of the special education teacher.

Check this box if the child was enrolled in special education.

Check this box if the child was not enrolled in special education.

If the child was in special education and the teacher's name is different from above, provide the name of the special education teacher.

Indicate whether the child is receiving speech or language therapy by checking 'Yes'.

Indicate whether the child is not receiving speech or language therapy by checking 'No'.

If the child is receiving speech or language therapy and the therapist's name is different from previously provided, specify the name of the speech/language therapist.

Provide the date when the EEG (Brain Wave Test) was or will be conducted, in the format month, day, year.

Provide the date when the HIV Test was or will be conducted, in the format month, day, year.

Provide the date when the Blood Test (not HIV) was or will be conducted, in the format month, day, year.

Provide the date when the Breathing Test was or will be conducted, in the format month, day, year.

Enter the date when the test was or will be conducted in the format month, day, year.

Provide the name of the facility where the test was conducted or will be conducted.

Specify the person or organization that referred the child for this test.

Enter the date when the speech/language test was or will be conducted in the format month, day, year.

Provide the name of the facility where the speech/language test was conducted or will be conducted.

Specify the person or organization that referred the child for the speech/language test.

Enter the date when the hearing test was or will be conducted in the format month, day, year.

Provide the name of the facility where the hearing test was conducted or will be conducted.

Specify the person or organization that referred the child for the hearing test.

Enter the date when the vision test was or will be conducted in the format month, day, year.

Provide the name of the facility where the vision test was conducted or will be conducted.

Specify the person or organization that referred the child for the vision test.

Enter the date when the IQ test was or will be conducted in the format month, day, year.

Provide the name of the facility where the IQ test was conducted or will be conducted.

Specify the name of the body part that was or will be X-rayed.

Enter the name of the facility where the EEG (Brain Wave Test) was or will be conducted.

Enter the name of the facility where the HIV Test was or will be conducted.

Enter the name of the facility where the Blood Test (not HIV) was or will be conducted.

Enter the name of the facility where the Breathing Test was or will be conducted.

Enter the name of the person or organization that referred the child for the test mentioned in Row 8.

Enter the name of the person or organization that referred the child for the test mentioned in Row 9.

Enter the name of the person or organization that referred the child for the test mentioned in Row 10.

Enter the name of the person or organization that referred the child for the test mentioned in Row 11.

Enter the name of the person or organization that referred the child for the test mentioned in Row 12.

Check this box if the child's visit to the medical facility was an inpatient stay, meaning they stayed overnight.

Check this box if the child's visit to the medical facility was an outpatient visit, meaning they were sent home the same day.

Check this box if the child's visit to the medical facility was an emergency room visit.

Check this box if the child's visit to the hospital or clinic was an inpatient stay, meaning they stayed at least overnight.

Check this box if the child's visit to the hospital or clinic was an outpatient visit, meaning they were sent home the same day.

Check this box if the child's visit to the hospital or clinic was an emergency room visit.

Enter the date when the child was admitted to the hospital or clinic.

Enter the date when the child was discharged from the hospital or clinic.

Enter the date when the child was admitted to the hospital or clinic for another visit.

Enter the date when the child was discharged from the hospital or clinic for another visit.

Enter the date when the child was admitted to the hospital or clinic for an additional visit.

Indicate whether the child has ever worked, including in sheltered employment, by checking 'Yes'.

Indicate whether the child has never worked by checking 'No'.

If the child has worked, provide the dates during which the child was employed.

Enter the name of the employer where the child worked.

Provide the full address of the employer, including street number, apartment number, P.O. Box, or rural route.

Enter the city where the employer is located.

Enter the county where the employer is located.

Enter the state where the employer is located.

Enter the ZIP code of the employer's location.

Provide the area code of the employer's phone number.

Provide the phone number of the employer, excluding the area code.

Enter the name of the child's supervisor at the place of employment.

List the job title and briefly describe the work the child did, including any difficulties encountered.