BASIC (09-00)

A. Policy

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