Form SSA-3385-BK Report of Adult Functioning-Employer

Form SSA-3385-BK (XX-XXXX)

Page 2 of 5

Privacy Act Statement
Collection and Use of Personal Information

See Revised Privacy Act
Statement Attached

Sections 205(a}, 223(a) and (d), and 1631 of the Social Security Act, as amended, and 20 CFR 404.1512,
416.912, and 416.924a, allow us to collect this information. We will use the information you provide to
determine eligibility for disability benefits.
Furnishing us this information is voluntary; however, failing to provide us with all or part of the information
may prevent us from making an accurate and timely decision on eligibility, or could result in the loss of
benefits.
We rarely use the information you supply for any purpose other than what we state above; however, we
may use the information for the administration of our programs including sharing information:
1. 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); and,
2. To facilitate statistical research, audit, or investigative activities necessary to ensure the integrity and
improvement of our programs (e.g., to the Bureau of the Census and to private entities under contract
with us).
A complete list of when we may share your information with others, called routine uses, is available in our
Privacy Act System of Records Notice 60-0089, entitled Claims Folders Systems. Additional information
about this and other system of records notices and our programs is available from our Internet website at
www.socialsecurity.gov, or at your local Social Security office.
We may share the information you provide to other agencies through 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 or administered benefit programs and for repayment of incorrect payments or delinquent
debts under these programs.
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 (0MB) control number. We estimate that it will take about 20 minutes to
read the instructions, gather the facts, and answer the questions. If you have questions about how to
complete the form, contact Requesting Office; see page 1, upper left corner, for the name, address, and
phone number of the Requesting Office. If you need the address or phone number for the Requesting
Office, you can get it by calling Social Security at 1-800-772-1213 (TTY 1-800 328-0778). SEND THE
COMPLETED FORM TO THE REQUESTING OFFICE. You may send comments on our time estimate
above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401. Send only comments relating to our
time estimate to this address, not the completed form.
PLEASE REMOVE THIS SHEET BEFORE RETURNING THE COMPLETED FORM

SSA will insert the following revised Privacy Act Statement into the form as soon
as possible:
Privacy Act Statement
Collection and Use of Personal Information

Sections 205(a), 223(a) and (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 us from making an accurate and timely
decision on any claim filed or could result in the loss of benefits.
We will use the information you provide to determine eligibility for disability benefits. We may
also share your information for the following purposes, called routine uses:
•

To contractors and other Federal agencies, as necessary, for the purpose of assisting
Social Security Administration (SSA) in the efficient administration of its programs; and

•

To student volunteers and other workers, who technically do not have the status of
Federal employees, when they are performing work for SSA as authorized by law, and
they access to personally identifiable information in SSA records to perform their
assigned Agency functions.

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 Notice
(SORN) 60-0089, entitled Claims Folders System, as published in the Federal Register (FR) on
April 01, 2003, at 68 FR 15784 and 60-0103, entitled Supplemental Security Income Record and
Special Veterans Benefits, as published in the FR on January 01, 2006, at 71 FR 1830.
Additional information, and a full listing of all of our SORNs, is available on our website at
www.ssa.gov/privacy.