SSA-3881 BK Questionnaire for Children Claiming SSI Benefits

Form SSA-3881-BK (06-2018) UF
Discontinue Prior Editions
Social Security Administration

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OMB No. 0960-0499

QUESTIONNAIRE FOR CHILDREN CLAIMING SSI BENEFITS
Please print, type, or write clearly and answer all items to the best of your ability. If you need help
completing any part of this form, we will help you. If you are filing on behalf of someone else, enter his or her
name and social security number in the space provided and answer all questions. If you do not know the
answer, enter "unknown." If the question does not apply, enter "N/A." If you need more space to answer any
of the questions, please use "REMARKS" and enter the number of the question next to your answer.
Child's Full Name

Informant's Name

Social Security Number

Relationship to Child

Date (mm/dd/yyyy)

Daytime Telephone Number
(including Area Code)

1. Is (was) the child cared for by a baby sitter? Does (did) the child attend any type of preschool, daycare and/or after
school program? If so, please specify. If more than one of the above, use the "REMARKS" section.
Name

Address (Number, Street, City, State, ZIP Code)

Telephone Number (including Area Code)

Dates Attended

2. a. Is (was) the child in school?

Yes

No

If "yes," and the school was not listed in Item 12A of the SSA-3820-F6, please show it here.
(If more than one, use the "REMARKS" section.)
Name

Address (Number, Street, City, State, ZIP Code)

Telephone Number (including Area Code)

Dates Attended

Grade Level Completed

Last Teacher's Name

Form SSA-3881-BK (06-2018) UF

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2.b. Is the child in a special education program?
c. Does the school make any special accommodations for the
child; e.g., adaptive furniture, wheelchair ramps, extra
assistance or attention?
If "yes" in 2.b. or 2.c., indicate type of program and/or
accommodations:

Yes

No

Don't Know

Yes

No

Don't Know

Specify number of hours per week the child is
in special education program:

d. Do you have a copy of the child's individual education plan
(IEP), the report in which the teacher outlines the child's
problems and lists the plans for correcting them?

Yes

No

a. In school

Yes

No

b. Outside school

Yes

No

If "yes," please provide a copy.
3. Does the child receive any special counseling or tutoring?

If "yes," in 3.a. or 3.b., please indicate: (If more than one, use the "REMARKS" section.)
Type of Counseling, Tutoring

Date Began and Ended (If completed)

Frequency of Visits

Counselor's or Tutor's Name

Telephone Number (including Area Code)

Address (Number, Street, City, State, ZIP Code)

4. Does the child or family have a child welfare, social services or
early intervention caseworker?

Yes

No

If "yes," please provide the following information: (If more than one, use the "REMARKS" section.)
Caseworker's Name

Organization

Address (Number, Street, City, State, ZIP Code)

Telephone Number (including Area Code)

File or Record Number

Date First Saw/Last Saw Caseworker

Form SSA-3881-BK (06-2018) UF

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5. Has the child ever been tested or evaluated by any of the following agencies or organizations? If "yes," indicate in
the space provided below the agency name, address, telephone number, record number, and the type and date of
test or evaluation performed (e.g., vision, hearing, speech, physical).

a. Public/Community Health Department

Yes

No

b. Child Welfare/Social Services Agency

Yes

No

c. Developmental Evaluation Center

Yes

No

d. Mental Health/Intellectual Disability

Yes

No

e. Special Needs/Crippled Children Agency

Yes

No

f. Speech and Hearing Center

Yes

No

g. Women, Infants, and Children (WIC) Program

Yes

No

Use the letter designation (5a, 5b, etc.) to identify the agency.

If additional space is needed, use "REMARKS" section.

Form SSA-3881-BK (06-2018) UF

6. Does (did) the child receive any special therapy (physical, speech and
language, occupational), exercises, or any other services for his/her
impairments?

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Yes

No

Include information about any therapy or exercises the parent,
guardian or caregiver provides the child.
If "yes," indicate below the therapist's name, the name of the person who PRESCRIBED AND/OR DESIGNED the
therapy program, the type(s) and frequency of treatment, when treatment began and ended (if completed), and
where treatment was received (e.g., home, hospital, therapist's office, clinic.)
Therapist's Name
Telephone No. (including Area Code)

Address (Number, Street, City, State, ZIP Code)

Person Who Prescribed/Designed Therapy

Information about Therapy:

Therapist's Name

Address (Number, Street, City, State, ZIP Code)

Person Who Prescribed/Designed Therapy

Information about Therapy:

Telephone No. (including Area Code)

Form SSA-3881-BK (06-2018) UF

7. Does (did) the child receive vocational rehabilitation services?

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Yes

No

If "yes," describe services received below the rehabilitation counselor's
information. Include dates and record number.
Rehabilitation Counselor's Name

Telephone No. (including Area Code)

Address (Number, Street, City, State, ZIP Code)

Services received:

(If additional space is needed, use "REMARKS" section.)

NOTE: PROVIDING INFORMATION ABOUT THE CHILD'S
INVOLVEMENT WITH THE COURT SYSTEM IS OPTIONAL
8. Has the child ever been involved with the court system other than
in custody proceedings?

Yes

No

If "yes," please explain involvement, including testing and evaluation.
Youth Development Center's Name

Address (Number, Street, City, State, ZIP Code)

Probation or Parole Officer's Name
Address (Number, Street, City, State, ZIP Code)

Involvement including any testing and evaluation:

Telephone No. (including Area Code)

Form SSA-3881-BK (06-2018) UF

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9. Does (did) the child participate in any community or school activities,
such as choir, Special Olympics, Boy's/Girl's Club, Scouts, or sports?

Yes

No

If "yes," describe involvement, amount of time spent in activity, and level of participation. Provide name, address,
and telephone number of individual who supervises the activity. Include dates of involvement. If involvement ended,
explain why.

10. If the child takes any medication on an ongoing basis, please indicate the following:
MEDICATION DOSAGE/
FREQUENCY

PRESCRIBED BY
(NAME)

REASON FOR MEDICATION

How well does the medication(s) work? Please explain:

DESCRIBE ANY SIDE EFFECTS

Form SSA-3881-BK (06-2018) UF

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11 a. If you are unable to give us information we need about the child, is there someone else who helps care for the
child and, knows of the child's impairment who can help us get the information we need, and, if necessary, bring
the child to a consultative examination?
Yes
No
b. If "yes," please provide the following information about this person
Name
Address (Number, Street, City, State, ZIP Code)

Daytime telephone number (including Area Code)
Relationship (e.g., relative, neighbor, family friend) to the child?
REMARKS:

Form SSA-3881-BK (06-2018) UF

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REMARKS (continued):

Privacy Act Statement
Collection and Use of Personal Information
Sections 223(b), 1614, and 1631(e)(1) 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 delay the determination or continued
eligibility for benefits.
We will use the information to make a decision on your claim. We may also share your information for the following purposes,
called routine uses:
1. To specified business and other community members and Federal, State, and local agencies for verification of eligibility
for benefits under section 1631(e) of the Act;
2. To the appropriate State agencies (or other agencies providing services to disabled children) to identify Title XVI
eligibles under the age of 16 for the consideration of rehabilitation services in accordance with section 1615 of the Act,
42 U.S.C. 1382d; and
3. To third party contacts where necessary to establish or verify information provided by representative payees or payee
applicants.
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; 60-0103, entitled Supplemental Security Income Record and Special Veterans Benefits; and 60-0320, entitled Electronic
Disability (eDIB) Claim File. Additional information and a full listing of all our SORNs are available on our website at
www.socialsecurity.gov/foia/bluebook.

See Revised PRA
Statement attached
- This information collection meets the requirements of 44 U.S.C. § 3507, as amended by

Paperwork Reduction Act Statement
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 30 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 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.