FUNCTION REPORT - ADULT - THIRD PARTY Form SSA-3380-BK

READ ALL OF THIS INFORMATION BEFORE YOU BEGIN COMPLETING THIS FORM
IF YOU NEED HELP If you need help with this form, complete as much of it as you can and call the phone number provided on the letter sent with the form, or contact the person who asked you to complete the form. If you need the address or phone number for the office that provided the form, you can get it by calling Social Security at 1-800-772-1213 (TTY 1-800-325-0778).

Function Report - Adult - Third Party Form SSA-3380-BK

HOW TO COMPLETE THIS FORM The information that you give on this form will be used to make a decision on the disabled person's claim. You can help by completing as much of the form as you can. When a question refers to the "disabled person," it refers to the person who is applying for or receiving disability benefits. It is important that you tell us what you know about the disabled person's activities and abilities. DO NOT ASK THE DISABLED PERSON TO GIVE YOU ANSWERS Print or type. DO NOT LEAVE ANSWERS BLANK. If you do not know the answer or the answer is "none" or "does not apply," please write "don't know" or "none" or "does not apply." Do not ask a doctor or hospital to complete this form. Be sure to explain an answer if the question asks for an explanation, or if you think you need to explain an answer. If you need more space to answer any questions, use the "REMARKS" section on Page 8, and show the number of the question being answered.

REMEMBER TO GIVE US THE NAME AND ADDRESS OF THE PERSON COMPLETING THIS FORM ON PAGE 8

Privacy Act and Paperwork Reduction Act Statements

Sections 205(a), 1631(d)(1) and 1631(e)(1) of the Social Security Act, as amended, authorize us to collect this information. The information on this form is needed by Social Security to make a decision on the named claimant's claim. While giving us the information on this form is voluntary, failure to provide all or part of the requested information could prevent an accurate or timely decision on the named claimant's claim. We generally use the information you supply for the purpose of making decisions regarding claims. 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 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 the 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 of Social Security programs. We may also use the information you provide in computer matching programs. Matching programs compare our records with those 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 any 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 61 minutes to read the instructions, gather the facts, and answer the questions. SEND THE COMPLETED FORM TO THE OFFICE THAT REQUESTED IT. If you do not have that address, 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.

PLEASE REMOVE THIS SHEET BEFORE RETURNING THE COMPLETED FORM.

SOCIAL SECURITY ADMINISTRATION

How the disabled person's illnesses, injuries, or conditions limit his/her activities

FUNCTION REPORT- ADULT - THIRD PARTY

Form Approved OMB No . 0960 - 0635

SECTION A - GENERAL INFORMATION

1. NAME OF DISABLED PERSON (First, Middle, Last)

2. YOUR NAME (Person completing the form) 3. RELATIONSHIP

(To disabled person)

4 . DATE (Month, Day, Year)

5. YOUR DAYTIME TELEPHONE NUMBER (If there is no telephone number where you can be reached, please
give us a daytime number where we can leave a message for you.)

Area Code

Phone Number

Your Number

Message Number

None

6. a. How long have you known the disabled person? b. How much time do you spend with the disabled person and what do you do together?

7. a. Where does the disabled person live? (Check one.)

House Shelter Apartment Group Home Boarding House Other (What?) Nursing Home

b. With whom does he/she live? (Check one.)

Alone

With Family

With Friends

Other (Describe relationship.)

SECTION B - INFORMATION ABOUT ILLNESSES, INJURIES, OR CONDITIONS

8. How do this person's illnesses, injuries, or conditions limit his/her ability to work?

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SECTION C - INFORMATION ABOUT DAILY ACTIVITIES

9. Describe what the disabled person does from the time he/she wakes up until going to bed.

10. Does this person take care of anyone else such as a wife/husband, children,
grandchildren, parents, friend, other? If "YES," for whom does he/she care, and what does he/she do for them?

Yes

No

11. Does he/she take care of pets or other animals? If "YES," what does he/she do for them?

Yes

No

12. Does anyone help this person care for other people or animals? If "YES," who helps, and what do they do to help?

Yes

No

13. What was the disabled person able to do before his/her illnesses, injuries, or conditions that he/she can't do now?

14. Do the illnesses, injuries, or conditions affect his/her sleep? If "YES," how?

Yes

No

15 . PERSONAL CARE (Check here

if NO PROBLEM with personal care.)

a. Explain how the illnesses, injuries, or conditions affect this person's ability to: Dress Bathe Care for hair Shave Feed self Use the toilet Other
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b. Does he/she need any special reminders to take care of personal needs and grooming? If "YES," what type of help or reminders are needed?

Yes

No

c. Does he/she need help or reminders taking medicine? If "YES," what kind of help does he/she need?

Yes

No

16. MEALS
a. Does the disabled person prepare his/her own meals?

Yes

No

If "Yes," what kind of food is prepared? (For example, sandwiches, frozen dinners, or complete meals w ith several courses.)

How often does he/she prepare food or meals? (For example, daily, weekly, monthly.)

How long does it take him/her? Any changes in cooking habits since the illness, injuries, or conditions began?

b. If "No," explain why he/she cannot or does not prepare meals.

17. HOUSE AND YARD WORK

a . List household chores , both indoors and outdoors , that the disabled person is able to do . (For example, cleaning, laundry, household repairs, ironing, mowing, etc.)

b. How much time do chores take, and how often does he/she do each of these things?

c. Does he/she need help or encouragement doing these things? If "YES," what help is needed?

Yes

No

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d. If the disabled person doesn't do house or yard work, explain why not.

18. GETTING AROUND

a. How often does this person go outside? If he/she doesn't go out at all, explain why not.

b. When going out, how does he/she travel? (Check all that apply.)

Walk

Drive a car

Ride in a car Other (Explain)

Ride a bicycle

Use public transportation

c. When going out, can he/she go out alone?

Yes

No

If "NO," explain why he/she can't go out alone.

d. Does the disabled person drive? If he/she doesn't drive, explain why not.

Yes

No

19. SHOPPING
a. If the disabled person does any shopping, does he/she shop: (Check all that apply.)

In stores

By phone

By mail

By computer

b. Describe what he/she shops for.

c. How often does he/she shop and how long does it take?

20. MONEY
a. Is he/she able to: Pay bills Count change

Yes Yes

No No

Handle a savings account Use a checkbook/money orders

Yes Yes

No No

Explain all "NO" answers.

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b. Has the disabled person's ability to handle money changed since the illnesses, injuries, or conditions began? If "YES," explain how the ability to handle money has changed.

Yes

No

21. HOBBIES AND INTERESTS

a. What are his/her hobbies and interests? (For example, reading, watching TV, sewing, playing sports, etc.)

b. How often and how well does he/she do these things?

c. Describe any changes in these activities since the illnesses, injuries, or conditions began.

22. SOCIAL ACTIVITIES

a. Does the disabled person spend time with others? (In person, on the phone, on the computer, etc.) If "YES," describe the kinds of things he/she does with others.

Yes

No

How often does he/she do these things?

b. List the places he/she goes on a regular basis. (For example, church, community center, sports events, social groups, etc.)

Does he/she need to be reminded to go places? How often does he/she go and how much does he/she take part?

Yes

No

Does he/she need someone to accompany him/her?

Yes

No

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c. Does this person have any problems getting along with family, friends, neighbors, or others? If "YES," explain.

Yes

No

d. Describe any changes in social activities since the illnesses, injuries, or conditions began.

SECTION D - INFORMATION ABOUT ABILITIES

23. a. Check any of the following items the disabled person's illnesses, injuries, or conditions affect:

Lifting Squatting Bending Standing Reaching

Walking Sitting Kneeling Talking Hearing

Stair Climbing Seeing Memory Completing Tasks Concentration

Understanding Following Instructions Using Hands Getting Along With Others

Please explain how his/her illnesses, injuries, or conditions affect each of the items you checked. (For example, he/she can only lift [how many pounds], or he/she can only walk [how far])

b. Is the disabled person:

Right Handed?

Left Handed?

c. How far can he/she walk before needing to stop and rest? If he/she has to rest, how long before he/she can resume walking?

d. For how long can the disabled person pay attention?

Yes e. Does the disabled person finish what he/she starts? ( For example, a conversation, chores, reading, watching a movie.) f. How well does the disabled person follow written instructions? (For example, a recipe.)

No

g. How well does the disabled person follow spoken instructions?

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h. How well does the disabled person get along with authority figures? (For example, police, bosses, landlords or teachers.)

i. Has he/she ever been fired or laid off from a job because of problems getting along with other people? If "YES," please explain.

Yes

No

If "YES," please give name of employer. j . How well does the disabled person handle stress?

k. How well does he/she handle changes in routine?

l. Have you noticed any unusual behavior or fears in the disabled person? If "YES," please explain.

Yes

No

24. Does the disabled person use any of the following? (Check all that apply.)
Crutches Walker Wheelchair Other (Explain)
Which of these were prescribed by a doctor?

Cane Brace/Splint Artificial Limb

Hearing Aid Glasses/Contact Lenses Artificial Voice Box

When was it prescribed?

When does this person need to use these aids?

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25. Does the disabled person currently take any medicines for his/her illnesses, Yes No injuries, or conditions? Yes No If " YES," do any of the medicines cause side effects? If "YES," please explain. (Do not list all of the medicines that the disabled person takes. List only the medicines that cause side effects for the disabled person.)

NAME OF MEDICINE

SIDE EFFECTS PERSON HAS

SECTION E - REMARKS
Use this section for any added information you did not show in earlier parts of this form. When you are done with this section (or if you didn't have anything to add), be sure to complete the fields at the bottom of this page.

Name of person completing this form (Please print) Address (Number and Street) City
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Date (month, day, year)

Email address (optional)

State

Zip Code
-

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