BASIC (09-00)

A. Introduction

The SSA-3820 provides the DDS with a detailed explanation of a title XVI disabled child's medical history that is essential to the disability determination.

B. Procedure

1. Section 1 --Information About The Child

1. Enter identifying information about the child and about the person who is completing the form for the child and how to contact that person.

NOTE: It is extremely important that the DDS be able to contact the applicant. If the applicant has no telephone, try to obtain a telephone number where a message can be left.

2. Indicate whether the applicant speaks, reads, or writes English and, if not, whether there is someone who speaks English who can give the applicant messages.

3. Explain to the applicant that we may need to recontact him/her, or others, for assistance in obtaining information about the child's condition. Tell the applicant that the child may have to be taken to a consultative examination (at SSA's expense) if the available evidence is not sufficient to make a determination.

4. If the child is receiving medical assistance, record the medical assistance identification card number.

2. Section 2--- Contact Information

In Section 2, include information about person(s) other than the applicant (e.g., legal guardians, friends, relatives, or probation or parole officers) who know about how the child's illnesses, injuries or conditions and can help with the child’s claim.

3. Section 3 -- The Child's Illnesses, Injuries, or Conditions And How They Affect Him/Her

NOTE: Section 3 is similar to Section 2 (Your illnesses, injuries or conditions and how they affect you) of the SSA-3368, except that there are no questions about work. This is because inability to work is not part of SSA’s legal definition of disability for children.

1. List what is wrong with the child, including diagnostic name(s), if known, and any symptoms the child is experiencing, including a detailed explanation of how the child’s impairment(s), including any symptoms, interfere with the child’s functioning.

2. Enter the alleged onset date in Item C. Indicate the applicant’s own perception of when the child became disabled.

3. if there are any other, non-medical factors that affect onset, address those on the SSA-3367 in the Recommended Onset Date block.

4. Section 4 -- Information About The Child's Medical Records

Complete in the same manner as Section 4 (Information About Your Medical Records) of the SSA-3368 (DI 11005.023B.5).

5. Section 5 -- Medications

Complete in the same manner as Section 5 (Medications) of the SSA-3368 (DI 11005.023B.6).

6. Section 6 -- Tests

Complete in the same manner as Section 6 (Tests) of the SSA-3368 (DI 11005.023B.6).

7. Section 7 -- Additional Information

Record whether the child is receiving services from other Federal, State, and /or Local government agencies; include the name(s) and address(es) of each agency, phone number, type of test(s) conducted and date of test(s).

NOTE: This information can serve as valuable sources of medical and non-medical evidence.

8. Section 8 -- Education

1. Record information about the child's school attendance, including school records and information from persons at school who know about the child's impairment(s) and its effect on his/her functioning.

2. Document sources for a period of 12 months prior to the application, unless the onset of the alleged impairment was less than 12 months prior to the application.

9. Section 9 -- Work History

Record information about the child's work activities.

NOTE: While it is rare for a child under age 18 to have a work history involving SGA, evidence from employers can still be helpful in assessing the effects of the impairment(s) on the child's functioning.

10. Section 10 -- Remarks

Use to explain or continue any answers, or add any other information the applicant wishes to report.