SSA-3377-BK, Function Report - Child Age 3 to 6th Birthday

SSA uses Forms SSA-3375-BK through SSA-3379-BK in the disability determination process to request information from a child's parent or guardian for children applying for Supplemental Security Income (SSI). The five different versions of the form contain questions about the child's day-to-day functioning appropriate to a particular age group; thus, respondents use only one version of the form for each child.

The adjudicative team (disability examiners and medical or psychological consultants) of State disability determination services offices collect the information on the appropriate version of this form (in conjunction with medical and other evidence) to form a complete picture of the children's ability to function and their impairment-related limitations. The adjudicative team uses the completed profile to determine whether each child's impairment(s) results in marked and severe functional limitations and whether each child is disabled. The respondents are parents and guardians of child applicants for SSI.