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Form Page 1 of 11 OMB No 0960-0542 Function Report

Form Page 1 of 11 OMB No 0960-0542 Function Report-2026

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The document is a Form SSA-3375-BK, titled 'Function Report - Child Birth to 1st Birthday,' issued by the Social Security Administration. It is designed for parents or guardians to report how a child's illnesses or injuries affect their daily activities and abilities. The form includes sections for identifying information, function details regarding the child's vision, hearing, and general activities, as well as remarks for additional information. It emphasizes the importance of providing accurate information for disability claims and outlines privacy considerations related to the collected data.

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Click ‘Get Form’ to open it in the editor.
Begin by filling out Section 1 - Identifying Information. Enter the child's name, Social Security number, and date of birth. Then, provide your name, relationship to the child, and contact information.
Proceed to Section 2 - Function Details. Answer questions regarding the child's vision and hearing abilities. If applicable, mark statements that are true about the child’s condition and provide explanations where necessary.
Continue through Section 2 by indicating whether the child's activities or abilities are limited. Mark 'yes' or 'no' for each developmental milestone listed and provide additional explanations in the remarks section if needed.
Once all sections are completed, review your entries for accuracy before saving or printing the form directly from our platform.

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Versions	Form popularity	Fillable & printable
2022	4.8 Satisfied (132 Votes)
2006	4 Satisfied (57 Votes)

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What is a function report form?

The SSA uses the Function Report to determine an individuals eligibility for disability benefits. This ten-page report provides detailed information about your functional abilities and ability to perform daily living activities. For example, youre ability to walk, dress, eat, and bathe.

What is a function report for SSI child?

The Function Report - Child (FRC) forms (SSA-3375 through SSA-3379) are used in child cases to obtain functional information from the applicant, and from other caregivers. The FRC forms replace all other forms used to obtain similar information from sources such as a childs parents.

Why did Social Security send me a function report?

The Function Report (SSA-3373) helps DDS to obtain information about how an applicants illness(es) and condition(s) affect their ability to function and perform everyday tasks.

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