SSA-3376-BK Function Report-Child Age 1 to 3rd Birthday

Function Report - Child Age 1 to 3rd Birthday
Filling Out The Function 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 the child's 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 how you think the child's illnesses or
injuries affect the way he or she does many of his or her usual activities.

PLEASE REMOVE THIS SHEET BEFORE
RETURNING THE COMPLETED FORM.

Form SSA-3376-BK (05-2014) ef (05-2014)
Prior edition may be used until stock is exhausted

Continued on the Reverse

The Privacy
And Paperwork
Reduction Acts

Sections 1614 and 1631(e)(1), of the Social Security Act, as amended, and 20
CFR 416.924(a), authorize us to collect this information. We will use the
information you provide on behalf of the child to determine his or her eligibility
for Supplemental Security Income (SSI) payments based on disability.

See Revised Privacy Act Statement Attached

Furnishing us the information is voluntary. However, failing to provide all or
part of the requested information may prevent our making an accurate and
timely decision on the claim.
We rarely use the information you supply for any purpose other than to make a
decision regarding the child’s eligibility for SSI payments. However, we may
use it for the administration and integrity of our programs. We may also
disclose the information to another person or to another agency in accordance
with approved routine uses, including but not limited to the following:
1. To enable a third party or an agency to assist us in
establishing rights to our benefits and coverage;
2

To comply with Federal laws requiring the release of
information from our 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, and investigatory
activities necessary to assure the integrity and improvement of our
programs (e.g., to the Bureau of the Census and to private entities
under contract with us).
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. We use the information from these
programs to establish or verify a person's eligibility for federally funded and
administered benefit programs and for repayment of incorrect payment's or
delinquent debts under these programs.
A complete list of routine uses of this information is available in our Privacy Act
System of Records Notices entitled, Claims Folders Systems, 60-0089.
Additional information about this and other system of records notices and our
programs are available on-line at www.socialsecurity.gov or at your local
Social Security office.
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 20 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 (TTY1-800-325-0778). 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-3376-BK (05-2014) ef (05-2014)

Form Approved
OMB No. 0960-0542

SOCIAL SECURITY ADMINISTRATION

FUNCTION REPORT - CHILD
AGE 1 TO 3rd BIRTHDAY
SECTION 1 - IDENTIFYING INFORMATION

1. A. Print NAME OF CHILD:

MIDDLE

FIRST

LAST

B. Child's SOCIAL SECURITY NUMBER:

C. Child's DATE OF BIRTH:
Month/Day/Year

D. PERSON COMPLETING FORM
NAME:
RELATIONSHIP TO CHILD:
DATE FORM COMPLETED:
Month/Day/Year

DAYTIME TELEPHONE NUMBER (including Area Code) :

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

CITY

Form SSA-3376-BK (05-2014) ef (05-2014)
Prior edition may be used until stock is exhausted

STATE

ZIP CODE
-

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SECTION 2 - FUNCTION DETAILS

2. A. Does the child have
problems seeing?

If " yes," please mark every statement below that is generally true
about the child:

Child uses glasses or contact lenses. If the child has
problems seeing even with glasses or contact lenses, please
explain:

YES (Continue)
NO (Go to 2.B.)

Child cannot be fitted for glasses or contact lenses. Explain:

Child has other seeing problems. If so, please describe:

B. Does the child have
problems hearing?

If " yes," please mark every statement below that is generally true
about the child:

YES (Continue)

Child uses hearing aid(s). If the child has problems hearing
even with a hearing aid(s) OR has trouble using a hearing aid,
please explain:

NO (Go to 2.C.)

Child cannot be fitted for hearing aid(s)
Child has other hearing problems. If so, please describe:

Child uses American Sign Language
Child reads lips
Form SSA-3376-BK (05-2014) ef (05-2014)

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2. C. Is the child totally
unable to talk?

Does the child have problems talking (for example, saying simple
words)?

Yes (answer questions below)

YES (Go to 2.D.)

No (continue to question 2.D.)

NO (Continue)

If " yes ," please mark every statement below that is generally true
about the child:

Says simple words like "he," "bottle," "doggy"
Uses two-word phrases, such as "mommy go" or "push toy"
Uses short sentences of 4 or more words, such as "Can I go
out?"
Has a vocabulary of at least 50 words
For each of the two statements below, mark the block that best
describes the child, and then describe any other speech problems:
The child's speech can be understood by people who know the
child well:

Most of the time, or
Some of the time, or
Hardly ever
The child's speech can be understood by people who don't know
the child well:

Most of the time, or
Some of the time, or
Hardly ever
If the child has other problems talking, please explain:

Form SSA-3376-BK (05-2014) ef (05-2014)

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2.

D. Does the child have
difficulty understanding
and learning?

If " yes," or " not sure," please tell us what the child does or can do by
checking "yes" or "no" for the following:

YES (Continue)
NO (Go to 2.E.)
NOT SURE
(Continue)

Yes

No

Waves "bye-bye"

Yes

No

Plays pat-a-cake

Yes

No

Uses one or more words (can be made-up
words) to ask for toys, food, or people

Yes

No

Follows most simple, one-step directions, such
as "come here" or "give it to me"

Yes

No

Knows and can point to parts of face or body
such as eye or hand when asked

Yes

No

Plays "pretend" with dolls or stuffed animals

Yes

No

Uses own name or "I" or "me" to refer to self

Yes

No

Listens at least 5 minutes to stories being read

Yes

No Follows two-step directions, such as "find your
shoe and bring it to me"

If necessary, please explain. In addition, please tell us anything else
you think we should know about the child's ability to understand and
learn:

Form SSA-3376-BK (05-2014) ef (05-2014)

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2. E. Are the child's physical
abilities limited?

YES (Continue)

If " yes," or " not sure," please tell us what the child does or can do by
checking "yes" or "no" for each of the following. Check "yes" if it is
something the child used to do but doesn't do any more just because
he or she is older. For example, if the child used to stand with help,
and can now stand without help, check "yes" for both.

NO (Go to 2.F.)
NOT SURE
(Continue)

Yes

No

Crawl

Yes

No

Stand with help

Yes

No

Stand without help

Yes

No

Walk holding on to someone or something

Yes

No

Walk without holding on

Yes

No

Climb onto furniture

Yes

No

Throw a ball or other object

Yes

No

Dance or jump up and down

Yes

No

Walk up and down steps by self

Yes

No

Run, but may fall down sometimes

Yes

No

Run without falling

Yes

No

Stack small blocks 2 high

Yes

No

Stack small blocks 4 high

Yes

No

Stack small blocks 6 high

Yes

No

Push and pull small toys

Yes

No

Scribble with a crayon or pencil

Yes

No

Hold crayon or pencil with thumb and fingers,
not fist

If necessary, please explain. In addition, please tell us anything else
you think we should know about the child's physical abilities:

Form SSA-3376-BK (05-2014) ef (05-2014)

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2. F. Does the child's

impairment(s) affect his
or her behavior with
other people?

If " yes," or " not sure," please tell us what the child does or can do by
checking "yes" or "no" for each of the following:

YES (Continue)
NO (Go to 2.G.)
NOT SURE
(Continue)

G. Is the child's ability to
help take care of his or
her personal needs
limited?

Yes

No

Yes

No Says "no" a lot

Yes

No Plays next to other children but not with them

Is affectionate towards parents

No Plays "catch" or other simple games with other
children
If necessary, please explain. In addition, please tell us anything else
you think we should know about the child's behavior around other
people:
Yes

If " yes," or " not sure," please tell us what the child does or can do by
checking "yes" or "no" for each of the following:

YES (Continue)
NO (Go to 2.H.)
NOT SURE
(Continue)

Cooperates in getting dressed

Yes

No

Yes

No Cooperates in brushing teeth

Yes

No

Yes

No Feeds self with spoon

Yes

No Can undress by self

Drinks from a cup or glass without help

If necessary, please explain. In addition, please tell us anything else
you think we should know about the child's ability to take care of his or
her personal needs:

H. Please tell us anything else about the child that you think we should know.

Form SSA-3376-BK (05-2014) ef (05-2014)

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SECTION 3 - REMARKS

Form SSA-3376-BK (05-2014) ef (05-2014)

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