TN 1 (02-01)

DI 25205.025 Function Report - Child Forms

A. Introduction

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 child's parents.

B. Definition

The term “caregiver,” as used in this section, means a person who has a close, familial-type relationship with a child . A child's parent is usually a caregiver, but other individuals may also be caregivers. For example, grandparents, siblings, other relatives, or nonrelatives with whom the child lives or spends a lot of time. There may be more than one caregiver. The applicant is usually a caregiver.

C. Policy

1. Who Requests A Function Report - Child

The FO requests the applicant to complete an FRC. (See DI 20501.030 for a full description of the process.)

EXCEPTION: The FO will not request an FRC if the interview is curtailed in accordance with DI 11005.020. If the DDS later finds that functioning is an issue in such a case, the DDS should request the form from the applicant, unless it is clear that the applicant is not a caregiver.

The DDS determines whether there are caregivers other than the applicant who may be able to provide useful functional information. If so, the DDS requests FRCs from those other caregivers.

2. Do Not Use Other General Information Requests

The FRC forms replace all other general requests for functional information from a child's caregiver(s). More specialized forms, (e.g., requests to schools about a child's functioning in school) may still be used.

3. Followups on Content Must Be Targeted

The FRC obtains a comprehensive picture of the child from a caregiver's viewpoint. Followups concerning the content of the FRC should be done only if the form is incomplete, unclear, or raises material issues that cannot be resolved with the information in file.

If a followup is necessary, it should consist of targeted questions to resolve the pertinent issues. Another general request for information should not be made.

4. Correct Form is Based on the Child's Age

Each FRC is designed for a specific age-range, indicated in the full name of the form:



Function Report – Child From Birth To First Birthday


Function Report - Child Age 1 Up To Third


Function Report - Child Age 3 Up To 6th Birthday


Function Report - Child Age 6 Up To 12th Birthday


Function Report - Child Age 12 Up To 18th

There is enough overlap in content between FRCs that a recently completed FRC does not become obsolete when a child moves into the next age-range. The DDS should not request another FRC just because a child has passed his or her 1st, 3rd, 6th, or 12th birthday since an FRC was completed.

If the DDS is mailing an FRC for completion, the FRC corresponding to the child's age on the mailing date should be used. If the child's 1st, 3rd, 6th, or 12th birthday is quite close as of the mailing date, the caregiver should be told to use the form that was mailed even if the child's birthday has passed by the time the form is filled out. (If a child's birthday is so close that it will almost surely have passed by the time the form is filled out, the DDS may elect to use the FRC appropriate to the higher age-range.)

D. Procedure

1. Request FRCs as Necessary

a. FO Should Have Obtained FRC From Applicant

Request an FRC from the applicant only if the FO has not done so, and the exception below does not apply.

b. Consider Other Caregivers

If information in file indicates there are caregivers other than the applicant who should be contacted for functional information, mail suc