How to Fill Out Form SSA-3375-BK (w/Examples) + FAQs

Form SSA-3375-BK is the Function Report – Child Age 6 to 12th Birthday that the Social Security Administration uses to evaluate how a child’s medical condition limits daily activities for Supplemental Security Income (SSI) disability benefits. You fill it out by answering questions about your child’s communication, learning, behavior, physical movement, self-care, and health, then signing and dating the certification on the last page.

The form exists because federal law under 20 C.F.R. § 416.924 requires SSA to measure whether a child’s impairment causes “marked and severe functional limitations.” Without a complete and detailed Function Report, the Disability Determination Services (DDS) examiner cannot rate the six domains of functioning under 20 C.F.R. § 416.926a, and the claim is often denied for insufficient evidence.

According to the SSA Annual Statistical Report on the SSI Program, 2024, only about 35% of child SSI applications are approved at the initial level, and incomplete Function Reports are a leading reason cited in denial notices issued under the rules in the HALLEX I-2-5-14 manual.

Here is what you will learn in this guide:

• 📝 How to answer every line of Form SSA-3375-BK in a way that links daily limits to the six functional domains.
• ⚖️ The federal rules and POMS DI 25210.000 standards that DDS examiners apply to your answers.
• 👨‍👩‍👧 Real named-person examples for ADHD, autism, asthma, cerebral palsy, and learning disability claims.
• 🚫 The seven most common mistakes that lead to denial and how to avoid them.
• 🔁 What to do after you submit, including reconsideration and hearing appeal rights.

What Form SSA-3375-BK Is and Why SSA Uses It

Form SSA-3375-BK is a 17-page Function Report designed for children who are at least age 6 but have not yet reached their 12th birthday. The form is part of the SSI child disability evidence packet, and it sits alongside the medical release Form SSA-827 and the Disability Report-Child (SSA-3820-BK). DDS uses your answers as non-medical evidence of how the child actually functions at home, at school, and in the community.

The legal authority comes from the Social Security Act § 1614(a)(3)(C), which defines childhood disability as a medically determinable impairment that causes marked and severe functional limitations and has lasted or is expected to last at least 12 months. The plain-English meaning is that SSA must see proof that the child cannot do age-appropriate activities the way other 6-to-12-year-olds can. The consequence of skipping or rushing answers is that the examiner has no factual basis to find a “marked” or “extreme” limitation, and the claim fails the functional equivalence test under the rules in SSR 09-1p.

A common misconception is that medical records alone will win the case. They will not. The Function Report is the parent’s sworn statement of real-world limits, and it carries weight that a doctor’s office note often does not, especially when the doctor only sees the child for 15 minutes every six months.

Who Should Complete the Form

The person who knows the child best should fill it out, which is almost always a parent, step-parent, grandparent, foster parent, or legal guardian. SSA expects the answer-giver to have daily contact with the child, because the questions ask about routines like dressing, eating, playing, and homework. If a teacher or therapist also has detailed knowledge, their input belongs on the separate Teacher Questionnaire SSA-5665-BK, not on the 3375.

The consequence of having the wrong person sign the form is that DDS may treat the report as unreliable hearsay, and the examiner can call a different family member for a second statement. A real-world example is Maria Lopez, a grandmother raising her 8-year-old grandson with autism. Maria sees him every day, so she signed the 3375. The boy’s mother, who lives out of state, would not have been the right signer.

A misconception is that the child must sign or write part of the form. They do not. The certification on page 17 is signed only by the adult informant who completed the answers.

Where the Form Fits in the SSI Process

After you file the SSI application through your local field office or ssa.gov/apply, SSA sends the file to your state DDS. DDS mails or hands you the 3375-BK packet with a return deadline, usually 10 to 15 days. The form then becomes part of the exhibit file used at every level of review, including the initial decision, the reconsideration stage, and any Administrative Law Judge hearing.

The consequence of missing the deadline is a “failure to cooperate” denial under 20 C.F.R. § 416.1411, which is one of the most avoidable losses in SSI practice. A real-world scenario: David Chen received the form on a Monday, set it aside, and missed the 10-day window. DDS denied for non-cooperation, and David had to refile from scratch, losing months of back pay.

A misconception is that you can call DDS for an unlimited extension. You can ask once, and the examiner has discretion. Always request the extension in writing and keep proof.

Section-by-Section Walkthrough of Form SSA-3375-BK

The form has a cover page, an information section, eleven lettered sections (A through K), a remarks page, and a certification. Each lettered section maps to one or more of the six functional domains used under 20 C.F.R. § 416.926a(b)(1). Knowing which domain a question feeds into is the secret to writing answers that actually move the needle.

The six domains are Acquiring and Using Information, Attending and Completing Tasks, Interacting and Relating with Others, Moving About and Manipulating Objects, Caring for Yourself, and Health and Physical Well-Being. A “marked” limitation in two domains, or an “extreme” limitation in one, equals disability under the rules in POMS DI 25225.005. Every answer you give should connect, in plain language, to at least one domain.

A real-world example is Aisha Williams, mother of a 9-year-old with ADHD. She wrote, “Liam cannot finish a 20-minute homework page without three reminders, and he loses his pencil four times during it.” That one sentence supports limits in Attending and Completing Tasks and Acquiring and Using Information at the same time.

Cover Page and Identifying Information

The first page asks for the child’s name, Social Security number, date of birth, and the informant’s name and relationship. Use the legal name on the child’s birth certificate, not a nickname. Match the SSN to the one on the SSI application exactly.

The consequence of a mismatched name or number is that DDS cannot link the form to the electronic file, which delays the decision under the rules in POMS GN 00301.286. A real-world example: Jasmine Patel wrote “Jay” instead of “Jayesh,” and the form sat unmatched for three weeks. She had to fax a corrected first page.

A misconception is that you can leave the SSN blank for privacy. You cannot. The SSN is the primary key that ties the form to the claim.

Section A: Information About the Child

Section A asks for the child’s age, grade in school, and whether the child attends regular or special education. Be specific about the school name, the type of class (general education, resource room, self-contained, or homebound), and any current Individualized Education Program (IEP) or 504 Plan under federal disability education law.

The plain-English reason this matters is that DDS gives heavy weight to school placement evidence, because an IEP is a legal finding that the child cannot access general curriculum without supports. The consequence of writing only “regular school” when the child is actually in a resource room is that the examiner may rate Acquiring and Using Information as “less than marked” by mistake. A real-world example is Noah Garcia, who attended a self-contained autism classroom; once his mother corrected the form, the rating moved to “marked.”

A common misconception is that a 504 Plan is the same as an IEP. It is not. A 504 Plan provides accommodations, while an IEP provides specialized instruction, and SSA treats them differently in the file.

Section B: Physical Abilities

Section B asks whether the child can see, hear, talk, walk, run, climb stairs, ride a bike, throw a ball, and use hands for buttons, zippers, and writing. This section feeds the Moving About and Manipulating Objects domain and parts of Health and Physical Well-Being.

Answer each item with a side-by-side comparison to other children the same age. The consequence of a vague answer like “okay” is that the examiner has no measurable limit to record. A real-world example is Sofia Brown, age 7, with cerebral palsy: her father wrote, “Sofia can walk 50 feet on flat ground, then she has to sit. She cannot ride a two-wheel bike, climbs stairs only with a railing, and drops her pencil every two minutes.”

A misconception is that you should only mention the worst day. You should describe the typical day and then note how often bad days happen. SSA uses the rule in SSR 09-2p to weigh frequency and duration of episodes.

Section C: Communication

Section C asks how the child speaks, reads, writes, and is understood by family and strangers. It supports the Interacting and Relating with Others and Acquiring and Using Information domains.

Use the Flesch-Kincaid idea of describing what a stranger would understand, because DDS examiners are strangers. The consequence of writing “talks fine” when the child only uses two-word phrases is a false negative finding. A real-world example is Ethan Nguyen, age 6, with a speech-language disorder: his mother wrote, “Ethan uses 3-word sentences, his teacher understands about half of what he says, and a cashier at the store understands almost none.”

A misconception is that texting or tablet use proves typical communication. It does not. The form asks about expressive and receptive language, not screen skills.

Section D: Cognitive/Communicative Functioning

Section D goes deeper into thinking, problem solving, memory, and following directions. Examiners read this section to rate Acquiring and Using Information and Attending and Completing Tasks. Answer with specific tasks the child cannot start, finish, or remember.

The consequence of generic answers is generic ratings. A real-world example: Olivia Reed, age 10, with a specific learning disability, “Olivia reads at a first-grade level, cannot tell time on an analog clock, forgets a 3-step direction by step two, and needs me to read every word problem in math homework.”

A misconception is that average grades mean no cognitive limit. They do not, because IEP accommodations and modified grading often hide the underlying deficit, and SSA recognizes this in POMS DI 25215.001.

Section E: Social Activities

Section E asks about playing with other children, sharing, taking turns, following game rules, and behavior in groups. This is the heart of Interacting and Relating with Others.

The plain-English consequence of writing “plays fine” when the child actually plays alone is that the examiner cannot find a marked limit. A real-world example is Mason Taylor, age 8, with autism spectrum disorder: his grandmother wrote, “Mason plays only with his train set, screams when another child touches it, has had two playdates this year that ended early, and has no friends at school.”

A misconception is that one cousin or one neighbor counts as a friend group. SSA looks for age-appropriate peer relationships, which usually means multiple sustained friendships at school.

Section F: Concentration, Persistence, or Pace

Section F is one of the most important sections for ADHD, anxiety, and depression claims, because it feeds the Attending and Completing Tasks domain directly. Describe how long the child can stay on one activity, how often you must redirect, and whether the child finishes what they start.

The consequence of writing only “short attention” is a missed marked limit. A real-world example is Liam Foster, age 9, with ADHD combined type: his father wrote, “Liam stays on homework for 4 minutes before getting up, I redirect about 15 times per hour, and he finishes maybe 1 of every 5 tasks I ask him to do.”

A misconception is that medication makes the limit disappear for SSA purposes. Under SSR 18-3p, SSA evaluates limits even when medicated, because side effects, dose changes, and non-school hours all matter.

Section G: Personal Needs

Section G covers dressing, bathing, brushing teeth, eating, toileting, and choosing weather-appropriate clothes. This section drives the Caring for Yourself domain.

The consequence of skipping detail is a serious undercount. A real-world example is Chloe Martinez, age 11, with intellectual disability: her mother wrote, “Chloe needs help with shampoo, cannot tie shoes, eats with fingers about half the time, has bathroom accidents twice a week, and would wear shorts in the snow if I let her.”

A misconception is that age-typical milestones (like tying shoes by age 6) are private and irrelevant. They are highly relevant, because Caring for Yourself is rated against age peers under POMS DI 25215.005.

Section H: Behavior

Section H asks about tantrums, aggression, self-harm, lying, stealing, and rule-breaking. It informs both Interacting and Relating with Others and Caring for Yourself.

Answer with frequency, duration, and trigger for each behavior. The consequence of vague labels like “moody” is no rating change. A real-world example is Jackson Lee, age 7, with disruptive mood dysregulation disorder: his foster mother wrote, “Jackson has 3-to-5 rage episodes per week, each lasts 20 to 45 minutes, he hits and kicks, and I have called the school 6 times this year.”

A misconception is that behavior at home does not count if school says he is “fine.” It counts equally, because 20 C.F.R. § 416.924a(b)(7) requires SSA to consider functioning in all settings.

Section I: Other Information

Section I is a free-text area for anything that did not fit above. Use it. Mention seizures, hospitalizations, ER visits, medication side effects, and assistive devices. This section often becomes the bridge to the Health and Physical Well-Being domain.

The consequence of leaving Section I blank is leaving evidence on the table. A real-world example: Ava Robinson, age 10, with severe asthma, “Ava had 4 ER visits this year, uses a nebulizer 3 times a day, missed 28 school days, and her inhaler makes her shaky and unable to write neatly for 30 minutes after.”

A misconception is that the doctor will tell SSA all of this. The doctor often will not, because the medical chart records the visit, not the life impact between visits.

Section J: Remarks

Section J is the place to tie everything together in plain language. Write a short narrative that names the child’s diagnoses, lists the worst three limits, and explains how a typical week looks. Keep it factual and avoid arguing.

The consequence of an empty Remarks section is a flat record. A real-world example, written by Daniel Kim, father of a child with epilepsy and ADHD: “In a typical week, Caleb has 2 seizures, misses 1 day of school, takes 4 medications, has 3 meltdowns, and needs hand-over-hand help to finish any worksheet.”

A misconception is that Remarks should be a legal brief. It should not. Plain narrative beats legal language every time at the DDS level.

Section K: Certification

Section K is the signature, address, phone, and date block on the last page. Sign in ink (or e-sign if filing online), date the form, and provide a phone number where DDS can reach you between 8 a.m. and 4 p.m.

The consequence of an unsigned form is that DDS treats it as not received under POMS DI 11005.045, and the claim can be denied for non-cooperation. A real-world example is Rachel Adams, who mailed the form unsigned, and DDS sent it back, costing her three weeks.

A misconception is that initialing each page substitutes for the certification. It does not. The certification is a sworn statement under penalty of perjury.

Three Most Common Scenarios With Outcomes

The way you describe daily life directly drives the rating in each domain. Below are three scenarios that show how strong, specific answers change the outcome under the functional equivalence rules.

Scenario 1: ADHD With Vague vs. Specific Answers

How the Parent Answers	What DDS Records
“He has trouble paying attention.”	Less than marked in Attending and Completing Tasks.
“He stays on homework 4 minutes, I redirect 15 times an hour, and he finishes 1 of 5 tasks.”	Marked in Attending and Completing Tasks.

Scenario 2: Autism and Social Domain

How the Parent Answers	What DDS Records
“She plays with her brother.”	Less than marked in Interacting and Relating with Others.
“She plays only parallel, has no school friends, screams when touched, and had 0 successful playdates this year.”	Marked or extreme in Interacting and Relating with Others.

Scenario 3: Asthma and Health Well-Being

What the Parent Reports	How the Domain Is Rated
“He has asthma but uses an inhaler.”	Less than marked in Health and Physical Well-Being.
“He had 4 ER visits, 2 hospital stays, 28 missed school days, and uses nebulizer 3 times daily.”	Marked in Health and Physical Well-Being under SSR 09-8p.

Three Named Examples Walking Through the Form

These examples show how three different families completed Form SSA-3375-BK and what made each one effective. Each child has a different diagnosis, a different home setting, and a different school placement.

The first example, Liam Foster, is a 9-year-old with ADHD combined type living with both parents. His father focused Sections D, F, and H on minute-by-minute behavior, naming the redirections he gives and the chores Liam cannot finish. Liam was approved at the initial level because the answers translated cleanly into the Attending and Completing Tasks domain.

The second example, Sofia Brown, is a 7-year-old with spastic diplegic cerebral palsy raised by a single father. He used measurable distances and times in Section B (50 feet, 10 minutes, 2-step stairs with railing) and listed assistive devices in Section I (AFO braces, walker for long distances). DDS found marked limits in Moving About and Manipulating Objects.

The third example, Mason Taylor, is an 8-year-old with autism spectrum disorder being raised by his grandmother. She used Sections C, E, and H to show language delays, no peer friendships, and meltdown frequency. She also attached the IEP and a teacher letter. The claim was approved because the file showed consistent limits across home and school, which is the test in 20 C.F.R. § 416.924a(b)(7)(ii).

Mistakes to Avoid When Filling Out SSA-3375-BK

Even strong cases get denied because of avoidable errors on the Function Report. The list below covers the most common ones DDS examiners cite in their notes. Each mistake has a direct, traceable consequence in the file.

• Writing “fine” or “okay” anywhere on the form. The consequence is that the examiner records no limitation in that domain.
• Skipping Section I (Other Information). The consequence is missing evidence of ER visits, side effects, and devices that could move a domain rating.
• Leaving Section J (Remarks) blank. The consequence is no narrative tying diagnoses to daily life, which is the human story the examiner needs.
• Using only diagnostic labels instead of behaviors. Saying “he has ADHD” without examples gives the examiner a label, not evidence.
• Forgetting to mention the IEP, 504 Plan, or special education placement. The consequence is a missed connection to school-based functional limits.
• Describing only the best day or only the worst day. The consequence is an inaccurate average that does not match the medical record.
• Missing the return deadline without a written extension. The consequence is denial for failure to cooperate under 20 C.F.R. § 416.1411.
• Not signing or dating Section K. The consequence is the form is treated as not received.
• Letting the wrong person fill it out. The consequence is unreliable hearsay that DDS may discount.
• Failing to keep a copy. The consequence is no record for appeal if DDS loses or misreads the form.

Key Entities Involved in the SSA-3375-BK Process

Several federal and state actors handle your form once it leaves your hands. Knowing each one helps you follow up quickly when something stalls. The relationships among them are set out in POMS DI 11000.000 and the HALLEX procedural manual.

• The Social Security Administration (SSA) is the federal agency that administers SSI under Title XVI. It receives the application, sets the rules, and pays benefits.
• The Disability Determination Services (DDS) is the state agency that decides whether the child meets the medical and functional rules. DDS examiners read your 3375-BK and assign domain ratings.
• The Field Office is the local SSA office that handles the non-medical parts of SSI like income, resources, and household composition under 20 C.F.R. § 416.1100.
• The Office of Hearings Operations (OHO) is where an Administrative Law Judge reviews appeals after reconsideration.
• The Appeals Council sits in Falls Church, Virginia, and reviews ALJ decisions under 20 C.F.R. § 416.1467.

Do’s and Don’ts for Form SSA-3375-BK

These rules of thumb come from years of denied and approved files and from the SSA training materials in POMS DI 25201.000. Follow them, and your form will be a useful piece of evidence rather than a procedural box-check.

Do:

• Do answer every question, even with “not applicable,” to show you read the item.
• Do describe behaviors in minutes, feet, days per week, and visits per year, because numbers anchor a rating.
• Do compare the child to typical peers, not to siblings who may also have issues.
• Do attach extra pages when 11 lines are not enough, and label them by section letter.
• Do keep a photocopy or scan of the entire packet before mailing.

Don’t:

• Don’t use medical jargon you do not understand, because a misused term can backfire.
• Don’t exaggerate, because DDS cross-checks against medical records and school records.
• Don’t write only on good days or only on bad days; aim for the typical week.
• Don’t skip the date on Section K, because an undated certification is not valid.
• Don’t ignore DDS phone calls, because examiners often call to clarify a single answer.

Pros and Cons of Self-Filing vs. Hiring an Advocate

Many parents complete the 3375-BK on their own, and many use a lawyer or non-attorney representative under 42 U.S.C. § 406. Both routes are legal, and both have trade-offs that show up in the file.

Pros of self-filing:

• No fee comes out of any back-pay award under the 25% capped fee rule.
• The parent’s voice and tone come through naturally in Sections I and J.
• Filing is faster because there is no representation-appointment paperwork (SSA-1696) to process.
• The parent learns the system, which helps in any future appeal.
• Some claims are clearly approvable on the medical record alone, making representation less critical.

Cons of self-filing:

• Most parents do not know which answers map to which domain.
• Missed deadlines and unsigned forms cause many avoidable denials.
• Self-filers rarely cross-reference school and medical records, leaving gaps.
• The Remarks section is often blank, missing a free chance to argue the case.
• Self-filers usually do not request the Teacher Questionnaire SSA-5665, which is critical evidence.

What Happens After You Submit the Form

DDS logs the form into the electronic file and assigns it to a disability examiner who works with a state agency medical or psychological consultant. The team reviews the form against medical records, school records, and any consultative examination ordered under 20 C.F.R. § 416.917. The decision usually arrives in 3 to 6 months, although complex cases take longer.

If approved, the field office calculates payment under the SSI federal benefit rate and any state supplement, and back pay reaches up to the application date. If denied, you have 60 days plus 5 mail days to file a Request for Reconsideration (Form SSA-561) under 20 C.F.R. § 416.1409. Reconsideration uses a fresh examiner but the same evidence, so a new and improved 3375-BK or supplemental statement often makes the difference.

If reconsideration is also denied, the next step is a hearing before an ALJ using Form HA-501. About half of child SSI cases that reach a hearing are approved, according to the SSA Office of Hearings Operations workload data, which makes the appeal worth pursuing when the medical record supports it.

State Nuances That Affect SSI Child Claims

While SSA is federal, state DDS agencies apply local procedures, and a few states pay an optional state supplement on top of federal SSI. California, New York, New Jersey, and Massachusetts have the largest state supplements for children, and the supplement is paid only when the federal claim is approved.

Some states, including Texas and Florida, have higher-than-average initial denial rates for child SSI cases, according to data published in the SSA Annual Statistical Supplement. The consequence is that families in those states often need to plan for reconsideration and hearing from the start.

A misconception is that moving states resets the claim. It does not. The file transfers under POMS DI 11055.001, and the application date is preserved for back-pay purposes, although you will likely receive a fresh 3375-BK from the new state’s DDS.

Recap of Key Rulings That Shape the Form

Several Social Security Rulings shape how DDS reads your 3375-BK, and a quick familiarity helps you answer better. SSR 09-1p explains the whole-child approach to functional equivalence, requiring the examiner to look at function across all settings and activities.

SSR 09-2p covers documentation, telling examiners to consider parent reports, school records, and non-medical sources like daycare staff. This is why your detail in Sections I and J carries weight equal to a doctor’s note for functional ratings.

SSR 09-8p addresses the Health and Physical Well-Being domain and gives specific examples for asthma, diabetes, sickle cell, and seizure disorders. Federal court decisions like Encarnacion v. Astrue, 568 F.3d 72 (2d Cir. 2009), reinforce that SSA must apply these rulings consistently or face remand.

FAQs About Form SSA-3375-BK

Is Form SSA-3375-BK mandatory for every child SSI applicant ages 6 to 12?

Yes. DDS sends this form on nearly every child SSI claim in the 6-to-12 age band, and refusing to complete it can result in a denial for failure to cooperate under federal regulations.

Can I fill out Form SSA-3375-BK online?

Yes. SSA accepts the form by mail, fax, in-person delivery, or upload through the iAppeals portal when one is available, but most DDS offices still prefer mailed paper packets.

Do I have to answer every single question on the form?

Yes. Leaving items blank can be read as “no limitation,” so write “not applicable” or “see attached” rather than skipping a line, even when the question seems to not fit.

Will my answers be shared with my child’s school?

No. SSA only shares information with people authorized by your signed SSA-827 release, and your school answers come back separately on the SSA-5665 Teacher Questionnaire.

Can a grandparent or foster parent sign the form instead of a biological parent?

Yes. Any adult with daily care responsibility can sign Section K, including grandparents, step-parents, foster parents, and legal guardians authorized under state law.

Does my child need to be in special education to qualify?

No. Special education placement is helpful evidence but not required, and many approved children attend general education with a 504 Plan or no formal plan at all.

Will medications my child takes hurt the claim?

No. SSA evaluates limits even when the child is medicated, and side effects, dose changes, and after-school hours all count under SSR 18-3p.

Can I attach extra pages when the lines run out?

Yes. Label each extra page with the section letter and the child’s name and SSN, and write “see attached” on the original line so the examiner finds the addition.

Is there a fee for filing or completing the form?

No. SSA charges no fee for any disability form, and any representative you hire is paid only from approved back pay under the 25% capped fee agreement rule.

Will I get a copy of DDS’s decision explaining what they did with my answers?

Yes. SSA mails a written notice that explains the decision and your appeal rights, and you can request the full file under the Freedom of Information Act to see exactly how each domain was rated.

Can I update the form if my child’s condition gets worse?

Yes. You can submit a written update to DDS at any time before the decision, and any new evidence about worsening function should be sent in writing with the child’s SSN at the top.

Does the form expire if I do not return it in time?

No. The form does not expire, but the deadline to return it does, and missing the deadline triggers a non-cooperation denial unless you request a written extension.