SSA-3373

Function Report - Adult

Download and Print the SSA-3373

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.

HOW TO COMPLETE THIS FORM
The information that you give us on this form will be used by the office that makes the disability decision on your disability claim. You can help them by completing as much of the form as you can.
It is important that you tell us about your activities and abilities.
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Print or type.
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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."
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Do not ask a doctor or hospital to complete this form.
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Be sure to explain an answer if the question asks for an explanation, or if you think you need to explain an answer.
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If more space is needed 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
Function Report - Adult Form SSA-3373-BK

And much more...