Form SSA-3371-BK Pain Report-Child

Pain Report - Child
Filling Out The Pain Report
IF YOU NEED HELP COMPLETING ANY PART OF THIS FORM, CONTACT YOUR
SOCIAL SECURITY OFFICE. WE WILL HELP YOU.
The information that you give us on this form will be used by the office that makes the disability
decision on this disability claim. You can help them by completing as much of the form as you
can.
•

Print or type.

•

Do not ask a doctor or hospital to complete this form.

•

Be sure to explain your answer if an explanation is requested or needed.

•

If more space is needed to answer any of the questions, please use the
"REMARKS" section and show the number of the question being answered.

The information we ask for on this form tells us about any pain the child has. The information
includes where the pain is, how long the pain lasts, how often the pain occurs, how bad the pain
is, what causes the pain, what relieves the pain and what treatment or medication makes it better.

PLEASE REMOVE THIS SHEET BEFORE
RETURNING THE COMPLETED FORM.
Form SSA-3371-BK (01-2010) ef (01-2010)

Prior edition may be used until stock is exhausted

Continued on the Reverse

u

The Privacy
And Paperwork
Reduction Acts

See Revised PRA
and Privacy
Act1631(e)(1) of the Social Security Act, as
Sections 205(a),
223(d) and
Statement
amended, authorize us to collect this information. The information
you provide us on this form will be used to make a decision on the
named individual's disability claim.

Completion of this form is voluntary; however, failure to provide all
or part of the information could prevent an accurate and timely
decision on the named individual's claim.
We rarely use this information you supply for any purpose other than
for determining continuing eligibility. However, we may use it for the
administration and integrity of Social Security programs. We may
also disclose information to another person or to another agency in
accordance with approved routine uses, which include but are not
limited to the following: 1. To enable a third party or an agency to
assist Social Security in establishing rights to Social Security benefits
and/or coverage; 2. To comply with Federal laws requiring the
release of information from Social Security records (e.g., to the
Government Accountability Office and Department of Veterans'
Affairs); 3. To make determinations for eligibility in similar health
and income maintenance programs at the Federal, State, and local
level; and, 4. To facilitate statistical research, audit, or investigative
activities necessary to assure the integrity and improvement of Social
Security programs.
We may also use the information you provide in computer matching
programs. Matching programs compare our records with records
kept by other Federal, State, or local government agencies.
Information from these matching programs can be used to establish
or verify a person's eligibility for Federally-funded or administered
benefit programs and for repayment of payments or delinquent debts
under these programs.
Additional information regarding this form, routine uses of
information, and our programs and systems, is available on-line at
www.socialsecurity.gov or at your local Social Security office.
PAPERWORK REDUCTION ACT:

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 15 minutes to read
the instructions, gather the facts, and answer the questions.
SEND OR BRING THE COMPLETED FORM TO YOUR
LOCAL SOCIAL SECURITY OFFICE. The office is 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 on our time
estimate above to: SSA, 6401 Security Boulevard, Baltimore,
MD 21235-6401. Send only comments relating to our time
estimate to this address, not the completed form.

Form SSA-3371-BK (01-2010) ef (01-2010)

Form Approved
OMB No. 0960-0540

SOCIAL SECURITY ADMINISTRATION

PAIN REPORT - CHILD

SECTION 1 - IDENTIFYING INFORMATION

1. A. Print NAME OF CHILD:
FIRST

MIDDLE

LAST

B. CHILD'S SOCIAL SECURITY NUMBER:

-

-

C. YOUR NAME (if you represent an agency, provide agency name):

DAYTIME TELEPHONE NUMBER (including Area Code):
(

)

-

MAILING ADDRESS (Number and Street, Apt. No. (if any), P.O. Box, or Rural Route):
STATE

CITY

ZIP CODE

PAIN DESCRIPTION
Please answer the questions on the following pages concerning the pain related to the child's illnesses or
injuries. Answer the questions the best you can based on what the child has told you and what you have
observed. If he or she has pain in more than one part of his or her body (for example, chest pain and ear
pain), please describe each one separately. Use Section 2 for the first pain, Section 3 for the second pain,
and so on. If he or she has pain in more than three parts of the body, use Section 5, REMARKS, to describe
the other pains.

Form SSA-3371-BK (01-2010) ef (01-2010)
Prior edition may be used until stock is exhausted

Page 1

SECTION 2 - FIRST PAIN

2. A. Where does the child have pain? For example, chest, ear, etc.

B. When the child is in pain, what does he or she do? For example, cries constantly, pulls at
the ear, etc.

C. How often does he or she have the pain?
per
Number of times

Minute

Day

Month

OR
Hour

Week

Continuously

Year

D.How long does the pain generally last? Try to answer in terms of length of time he or
she has pain without stopping; for example, 30 minutes, 2 hours, all day, etc.

E. Based on what you have seen, tell us how bad the child's pain seems to be. Be specific;

describe in your own words any ways that the pain appears to stop the child from doing things other
children his or her age can do. If the child has not always had pain, explain how the pain has changed
the way(s) that he or she can do things.

F. What appears to cause the pain or make it worse?

Form SSA-3371-BK (01-2010) ef (01-2010)

Page 2

2. G.What appears to relieve the pain or make it better?

H. If the child takes any medicine(s) (prescription or non-prescription) for this pain, please
complete the following:
Name of Medicine?
(for example,
CODEINE)

Date The Child
Began Taking it
(for example,
12/06/1991)

Dosage
How Often
Taken?
(for example,
1-2 pills)
(for example,
every 4
HOURS)

Relieves
the
pain?

Always
Month/Day/Year

Sometimes
Never
Always

Month/Day/Year

Sometimes
Never
Always

Month/Day/Year

Sometimes
Never

I. Does the medication cause any side effects?
If "yes," please explain:

Form SSA-3371-BK (01-2010) ef (01-2010)

YES

NO

Page 3

SECTION 3 - SECOND PAIN

3. A. Where does the child have the pain? For example, chest, ear, etc.

B. When the child is in pain, what does he or she do? For example, cries constantly, pulls at
the ear, etc.

C. How often does he or she have the pain?
per
Number of times

Minute

Day

Month

OR
Hour

Week

Continuously

Year

D. How long does the pain generally last? Try to answer in terms of length of time he or
she has pain without stopping; for example, 30 minutes, 2 hours, all day, etc.

E. Based on what you have seen, tell us how bad the child's pain seems to be. Be specific;

describe in your own words any ways that the pain appears to stop the child from doing things other
children his or her age can do. If the child has not always had pain, explain how the pain has changed
the way(s) that he or she can do things.

F. What appears to cause the pain or make it worse?

Form SSA-3371-BK (01-2010) ef (01-2010)

Page 4

3. G.What appears to relieve the pain or make it better?

H. If the child takes any medicine(s) (prescription or non-prescription) for this pain, please
complete the following:
Name of Medicine?
(for example,
CODEINE)

Date The Child
Began Taking it
(for example,
12/06/1991)

Dosage
How Often
Taken?
(for example,
1-2 pills)
(for example,
every 4
HOURS)

Relieves
the
pain?

Always
Month/Day/Year

Sometimes
Never
Always

Month/Day/Year

Sometimes
Never
Always

Month/Day/Year

Sometimes
Never

I. Does the medication cause any side effects?
If "yes," please explain:

Form SSA-3371-BK (01-2010) ef (01-2010)

YES

NO

Page 5

SECTION 4 - THIRD PAIN

4. A. Where does the child have the pain? For example, chest, ear, etc.

B. When the child is in pain, what does he or she do? For example, cries constantly, pulls at
the ear, etc.

C. How often does he or she have the pain?
per
Number of times

Minute

Day

Month

OR
Hour

Week

Continuously

Year

D. How long does the pain generally last? Try to answer in terms of length of time he or
she has pain without stopping; for example, 30 minutes, 2 hours, all day, etc.

E. Based on what you have seen, tell us how bad the child's pain seems to be. Be specific;

describe in your own words any ways that the pain appears to stop the child from doing things other
children his or her age can do. If the child has not always had pain, explain how the pain has changed
the way(s) that he or she can do things.

F. What appears to cause the pain or make it worse?

Form SSA-3371-BK (01-2010) ef (01-2010)

Page 6

4. G.What appears to relieve the pain or make it better?

H. If the child takes any medicine(s) (prescription or non-prescription) for this pain, please
complete the following:
Name of Medicine?
(for example,
CODEINE)

Date The Child
Began Taking it
(for example,
12/06/1991)

Dosage
How Often
Taken?
(for example,
1-2 pills)
(for example,
every 4
HOURS)

Relieves
the
pain?

Always
Month/Day/Year

Sometimes
Never
Always

Month/Day/Year

Sometimes
Never
Always

Month/Day/Year

Sometimes
Never

I. Does the medication cause any side effects?
If "yes," please explain:

Form SSA-3371-BK (01-2010) ef (01-2010)

YES

NO

Page 7

SECTION 5 - REMARKS

Form SSA-3371-BK(01-2010) ef (01-2010)

Page 8