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The document is a Function Report for Adults (Form SSA-3373-BK) used by the Social Security Administration to assess an individual's disabilities and how they affect daily activities. It provides instructions for completing the form, emphasizes the importance of detailed responses regarding personal care, household tasks, social interactions, and abilities. The information collected is crucial for making disability determinations and may be shared with other agencies as required by law.

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Click ‘Get Form’ to open the SSA-3373-BK in the editor.
Begin with Section A, where you will provide general information about the disabled person, including their name, Social Security number, and contact details.
Move to Section B to describe daily activities. Answer questions about your routine from waking up to going to bed, including personal care and household tasks.
In Section C, detail how your conditions affect various abilities such as lifting, walking, and memory. Be specific in your explanations for clarity.
Utilize the 'REMARKS' section at the end of the form for any additional information that may help clarify your responses.
Finally, ensure you provide your name and address on Page 8 before submitting the completed form.

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Why did I receive a SSA 3380 BK?

If SSA reaches out to your contacts, they will receive Form SSA-3380-BK or the Third Party Function Form. This does not mean that there is a problem with your application, but it does mean your case was not clear-cut. The form asks your contacts very detailed questions about your ability to function in daily life.

What is a form SSA 3373 BK?

Social Security Form SSA-3373-BK is a lengthy form that you fill out as a part of the process of applying for Social Security Disability benefits. It also goes by the Adult Disability Report or the Adult Function Report.

What is a third party function report?

Third Party Adult Function Report is a form that Social Security sometimes send to your contact person. This form is usually sent out two or three months after you first apply. It is also sometimes used during Continuing Disability Reviews, for people who are already on disability.

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What conditions limit your ability to work?

The limitation may be due to a mental disorder, cognitive disorder, distracting pain, and/or medication side-effects. If you have difficulty concentrating, focusing, remembering things, or processing information, then you may have a mental limitations.

What is a function report?

What is the Adult Function Report? The Adult Function Report examines how your disability affects your day-to-day life. Also referred to as an ADL (activities of daily living) questionnaire, the Adult Function Report is officially known as Function Report SSA-3373.

How do you fill out a BSA 3380 BK?

To complete an SSA 3380-BK, you will need to provide the following information: Section A - General Information. ... Section B - Information About Illnesses, Injuries, or Conditions. ... Section C - Information About Daily Activities. ... Section D - Information About Abilities. ... Section E - Remarks. ... Name of person completing the form.

Who can fill out SSA 3373?

After you have made a Social Security Disability claim and have had your initial interview, you may be asked to fill out Form 3373-BK, the Adult Disability Report. This form is designed to be filled out by yourself, without the aid of medical or other professionals.

What is the best way to fill out a function report for disability?

How to Fill Out an Adult Function Report for Disability (7 Tips) Answer Every Question and Be Honest! Answer Only the Questions Being Asked. Give as Much Detail as You Can. Be Consistent (Some Questions Overlap) Be Specific on Question 5 of the Function Report. Dont Limit Your Answers to the Space on the Form.

3373 bk form-2026

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What conditions limit your ability to work?

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