DI 11005.035 Forms SSA-3375-BK through SSA-3379-BK (Function Report-Child)
These forms collect information on how the child's impairment(s) affects his or her functional abilities. This information is needed to determine his or her ability to function.
B. FO Responsibility
The FO is responsible for obtaining from the applicant the completed appropriate form for the child's age group (i.e., birth to attainment of age 1, 1 to attainment of age 3, 3 to attainment of age 6, 6 to attainment of age 12, 12 to attainment of age 18). The form to use is the one corresponding to the child's age at the time of completion (or if mailed, the child's age at the time of mailing).
SSA-3375–BK — Function Report - Child Birth to 1st Birthday
SSA-3376–BK — Function Report - Child Age 1 to 3rd Birthday
SSA-3377–BK — Function Report - Child, Age 3 to 6th Birthday
SSA-3378–BK — Function Report - Child, Age 6 to 12th Birthday
SSA-3379–BK — Function Report - Child, Age 12 to 18th Birthday