How to Fill Out Form SSA-3376-BK (w/Examples) + FAQs

The Social Security Administration’s Form SSA-3376-BK is the Function Report – Adult – Third Party, and it asks a person who knows the disability claimant well to describe how the claimant’s medical conditions limit daily life. You fill it out by answering each question with concrete, consistent, and specific facts about what the claimant can and cannot do on a typical day, then signing and returning it to the state Disability Determination Services (DDS) office before the deadline on the cover letter.

The form exists because adjudicators must decide whether a claimant meets the strict definition of disability under the Social Security Act § 223(d) and 20 C.F.R. § 404.1505. Third-party statements help DDS evaluate the credibility and consistency of the claimant’s own SSA-3373-BK Function Report under SSR 16-3p symptom evaluation. A vague, exaggerated, or inconsistent SSA-3376-BK can quietly sink an otherwise strong claim.

According to the SSA Annual Statistical Report, only about 38% of initial disability applications are approved, and the Bureau’s program data show that incomplete or contradictory function reports are among the top reasons for denial at the initial and reconsideration levels.

Here is what you will learn in this guide:

📝 How to complete every section of SSA-3376-BK line by line, with the right level of detail
⚖️ Which federal rules, including 20 C.F.R. § 404.1529 and SSR 16-3p, shape how DDS reads your answers
👨‍👩‍👧 Real-world named examples for back pain, PTSD, autism, and cognitive impairment claims
🚫 The seven most common mistakes third parties make and the consequences of each
❓ Answers to the ten questions caregivers and representatives ask most about the form

What Form SSA-3376-BK Is and Why DDS Sends It

Form SSA-3376-BK is a 10-page questionnaire mailed to a non-medical third party such as a spouse, parent, adult child, friend, neighbor, or caregiver. The state DDS, working under contract with SSA per 20 C.F.R. § 404.1503, uses the form to gather lay evidence about the claimant’s daily activities, social functioning, concentration, and physical abilities.

The plain-English purpose is simple. DDS wants someone other than the claimant to describe what an average day looks like, so the agency can compare that description to the claimant’s own SSA-3373-BK, to the medical records, and to any SSA-3380-BK Function Report – Child when the case involves a minor. Adjudicators use the POMS DI 22510 development guidelines when reviewing your answers.

The consequence of ignoring or rushing the form is steep. If you do not return it, DDS may issue an insufficient evidence denial under 20 C.F.R. § 404.1516, and the claimant must restart the medical and functional development process at reconsideration. A real-world example: when 62-year-old Robert Hayes with severe COPD failed to return the SSA-3376-BK his daughter received, DDS denied his claim for failure to cooperate, and he lost six months waiting for a reconsideration decision.

A common misconception is that the third-party form is just a formality. It is not. Federal courts, including the Ninth Circuit in Smolen v. Chater, 80 F.3d 1273 (9th Cir. 1996), have held that lay witness statements must be considered and that an Administrative Law Judge who rejects them must give specific, germane reasons.

Who SSA Sends the Form To

DDS picks the third party based on whoever the claimant lists on the SSA-3368-BK Disability Report or the SSA-3441-BK Reconsideration Disability Report. The chosen person should know the claimant well and see them often, ideally at least weekly.

The consequence of picking the wrong person is a weaker record. If a coworker who sees the claimant only at lunch fills out the form, DDS may give that statement little weight under SSR 16-3p. For example, Jasmine Ortiz, who lives with her mother who has bipolar I disorder, is a stronger third party than a former coworker who has not seen the mother in two years.

A common misconception is that the third party must be a relative. Federal regulations at 20 C.F.R. § 404.1513(a)(4) accept evidence from any non-medical source, including clergy, neighbors, and case managers.

How the Form Connects to the Sequential Evaluation

DDS uses the five-step sequential evaluation to decide every adult disability claim. The SSA-3376-BK feeds directly into Steps 4 and 5, where the agency assesses residual functional capacity (RFC) and the ability to perform past or other work.

The consequence of vague answers is a higher RFC than the medical evidence supports, which often leads to denial. For instance, if you write “she can walk fine,” DDS may assign a light work RFC even when treating notes show severe lumbar stenosis.

A common misconception is that the form only matters for physical impairments. In mental health claims, POMS DI 24510.060 shows that third-party observations about concentration, persistence, and pace are often the deciding evidence.

Section-by-Section Walkthrough of SSA-3376-BK

The form has seven main sections plus a remarks page. Each section maps to a domain of functioning that the Listing of Impairments and the Mental Disorders Listings 12.00 measure.

Section A: General Information

You enter the claimant’s name, your name, your relationship, how often and how long you have known them, and your contact details. Be precise. “Daughter, lives with claimant since 2019, sees her daily” is far stronger than “family member.”

The consequence of leaving relationship details thin is reduced weight. DDS adjudicators trained under POMS DI 22505.008 score lay evidence based on opportunity to observe.

A real-world example: Carlos Mendez, the live-in fiancé of a claimant with schizoaffective disorder, listed “fiancé, 4 years, 7 days a week, all hours.” That single line raised his statement above a casual neighbor’s. A common misconception is that you should hide the relationship to seem objective. Hiding context backfires, because adjudicators must assess credibility under SSR 16-3p.

Section B: Information About the Disabled Person

This section asks how the claimant’s illnesses, injuries, or conditions limit activities. Write a narrative, not a label. Instead of “bad back,” write “lumbar disc herniation at L4-L5 confirmed on MRI, causes shooting pain down right leg after 10 minutes of standing.”

The consequence of using diagnostic labels alone is that DDS cannot translate them into functional limits. Under 20 C.F.R. § 404.1529(c)(3), symptoms must be tied to functional effects.

A real-world example: when Lakeisha Brown described her brother’s PTSD as “he wakes up screaming three nights a week and cannot ride the bus alone,” DDS gave her statement strong weight at reconsideration. A common misconception is that you should list every diagnosis. Stick to what you personally observe, because hearsay diagnoses get discounted under SSR 06-03p superseded by SSR 16-3p.

Section C: Daily Activities

This is the longest and most important section. It walks you through a typical 24-hour day, personal care, meals, household chores, getting around, shopping, money handling, hobbies, and social activities.

The consequence of overstating activities is fatal to a claim. If you write that the claimant “cooks dinner every night,” DDS may use that to find she can sustain sedentary work eight hours a day, even when she actually heats one frozen meal and lies down for the rest of the evening.

A real-world example: Hannah Liu, caring for her father with Parkinson’s, wrote “he microwaves oatmeal in the morning but I cut all his other food because his hands shake too much to use a knife.” That precise carve-out preserved his claim. A common misconception is that trying an activity equals doing it. Under SSR 96-8p RFC assessment, the agency cares about sustained ability, not occasional attempts.

Personal Care Subsection

Questions cover dressing, bathing, hair care, shaving, feeding, using the toilet, and remembering to take medication. Answer each with a clear before vs. after the impairment, then describe current help needed.

The consequence of glossing over personal care is a higher RFC than warranted. For example, Derek Foster, a Marine veteran with severe PTSD and TBI, “forgets to shower for 5–7 days unless his wife reminds him hourly,” and that detail supported a marked limitation in adapting and managing oneself under Listing 12.15.

A common misconception is that hygiene is too personal to mention. It is required evidence, and silence reads as no limitation.

Meals Subsection

Describe what the claimant prepares, how often, how long it takes, and any changes since the impairment began. Compare before and after.

The consequence of an answer like “she cooks” is that DDS treats meal prep as full functional cooking. By contrast, “she used to cook three-course meals daily; now she pours cereal twice a week and forgets the milk in the cabinet” shows cognitive decline consistent with Listing 12.02 neurocognitive disorders.

A common misconception is that you should describe the best day. Always describe a typical day, because SSR 96-8p defines RFC as what a person can do on a regular and continuing basis.

House and Yard Work Subsection

Cover cleaning, laundry, ironing, repairs, lawn mowing, and gardening. Note time spent, breaks, help required, and tasks no longer attempted.

The consequence of saying “he does yard work” without limits is that DDS may infer medium-exertion capacity. A precise answer like “he tries to mow for 5 minutes, then sits 20 minutes with his nebulizer, and his son finishes” preserves a sedentary RFC.

A common misconception is that occasional chores prove ability to work. Courts disagree. The Eighth Circuit in Reed v. Barnhart, 399 F.3d 917 (8th Cir. 2005) held that sporadic light housework does not equal full-time work capacity.

Getting Around Subsection

Describe how often the claimant leaves home, modes of travel, ability to drive, and whether they can go out alone. Mention any panic attacks, dizziness, or assistive devices.

The consequence of writing “he drives” without context is that DDS infers normal concentration and reaction time. “He drives only to his Tuesday therapy 4 miles away, has had two fender benders since the stroke, and his daughter rides with him” tells the real story.

A common misconception is that owning a license proves driving ability. Many claimants keep licenses they no longer safely use, and adjudicators trained under POMS DI 24510.057 look for actual practice, not paperwork.

Shopping, Money, and Hobbies Subsections

Detail how often, how long, where, with whom, and what changed. For money, address the ability to count change, pay bills, handle a checkbook, and use a debit card.

The consequence of skipping money handling is a missed Listing 12.05 intellectual disorder finding. A real-world example: Aaliyah Washington wrote that her adult son “cannot count past $5 in change and his case manager pays his rent,” which supported a paragraph B marked limitation in understanding and applying information.

A common misconception is that hobbies must be eliminated to count. Reduced or modified hobbies are often the most credible evidence, because total denial of any hobby reads as exaggeration.

Section D: Social Activities

Cover how often the claimant spends time with others, where, what they do, and any problems getting along with family, friends, neighbors, landlords, bosses, or police.

The consequence of glossing over social conflict is a missed marked limitation in interacting with others under Paragraph B criteria. For instance, Tomás Rivera with autism spectrum disorder “has been fired from 4 jobs in 18 months for yelling at supervisors,” which directly supported a Step 5 denial of work capacity.

A common misconception is that social withdrawal is too vague to matter. Be specific. “He has not left his bedroom for a meal with the family in 9 months” is concrete and persuasive under SSR 16-3p.

Section E: Abilities

This section uses checkboxes for physical and mental functions: lifting, squatting, bending, standing, reaching, walking, sitting, kneeling, talking, hearing, stair climbing, seeing, memory, completing tasks, concentration, understanding, following instructions, using hands, and getting along with others. Below the checkboxes are critical narrative prompts.

The consequence of checking boxes without explaining is weak evidence. Always write how far the claimant can walk before resting, how long the rest must be, how well written and spoken instructions are followed, how the claimant handles stress, and how they handle changes in routine.

Walking Distance and Rest

State a specific distance and rest time. “He can walk about half a block, then must sit 10 minutes before continuing” is far stronger than “not far.”

The consequence of vague answers is that DDS picks the longest reasonable distance. A common misconception is that exact distances are unknowable. Use landmarks, such as “from the front door to the mailbox,” to anchor the answer.

Instructions, Stress, and Routine

Describe handling of written and spoken instructions separately, because Listing 12.00 paragraph B2 treats them as different domains. Address stress and change directly.

The consequence of skipping these is a missed marked limitation. A real-world example: Priya Patel, sister of a claimant with major depressive disorder, wrote “any change in her morning routine triggers a 2-day shutdown where she does not eat or speak,” and DDS found a marked limitation in adapting.

Section F: Other Information

This is the open mic of the form. Use it. Discuss assistive devices, side effects of medications, and anything else not yet captured.

The consequence of leaving Section F blank is missing your one chance to add medication side effects under 20 C.F.R. § 404.1529(c)(3)(iv), such as drowsiness from gabapentin or nausea from methotrexate.

A common misconception is that you must keep the form short. Use the SSA-795 Statement of Claimant or Other Person for overflow if needed.

Section G: Signature

Sign, date, print your name, address, and phone. Unsigned forms get returned, and the claim sits in limbo.

The consequence of an unsigned form is delay and possible denial under POMS DI 22505.001. A common misconception is that an electronic signature works. SSA still requires a wet signature on most paper SSA-3376-BK submissions returned by mail.

Three Real-World Scenarios with Tables

Each scenario shows how a third-party answer choice changes the disability outcome.

Scenario 1: Back Pain Claimant (SSDI)

What the Third Party Writes	What DDS Concludes
“He does yard work and grocery shopping every week.”	Light or medium RFC, denial likely at Step 5
“He tries to mow 5 minutes, rests 30, son finishes; rides motorized cart at store, leans on it 15 minutes max.”	Sedentary RFC with off-task time, allowance possible

Scenario 2: PTSD Claimant (SSDI and SSI Concurrent)

What the Third Party Writes	What DDS Concludes
“She gets along fine and goes to church.”	No marked limitation in interacting, denial at Step 3
“She has not attended church in 14 months, screams at delivery drivers, and last left home 9 days ago for an ER visit.”	Marked limitation in interacting with others, Listing 12.15 met

Scenario 3: Cognitive Impairment Claimant (SSI)

What the Third Party Writes	What DDS Concludes
“He handles his own money.”	No limitation in understanding, denial at Step 3
“He cannot count past $10, his payee handles all bills, and he was scammed out of $400 in March.”	Marked limitation in understanding and applying information, Listing 12.05 considered

Mistakes to Avoid

Avoid these errors, because each one carries a direct consequence on the disability decision.

Writing diagnostic labels instead of observed behavior, which leaves DDS unable to translate symptoms to functional limits under 20 C.F.R. § 404.1529
Describing the claimant’s best day instead of a typical day, which inflates the RFC under SSR 96-8p
Contradicting the claimant’s SSA-3373-BK on driving, cooking, or shopping, which damages credibility under SSR 16-3p
Leaving Section F blank, which forfeits the chance to document medication side effects required by 20 C.F.R. § 404.1529(c)(3)(iv)
Returning the form past the deadline on the cover letter, which can trigger an insufficient evidence denial
Using vague distance and time terms like “not far” or “a while,” which let DDS assume the longest reasonable interpretation
Forgetting to sign, which causes the form to be rejected under POMS DI 22505.001
Listing every diagnosis you have ever heard about, which dilutes credibility because hearsay carries no weight
Saying the claimant has “no problems” with memory or instructions when in fact you redirect them daily, which costs a paragraph B finding under Listing 12.00
Throwing the form away thinking it is junk mail, which can stop the claim cold

Do’s and Don’ts for Third Parties

These rules apply whether you are a spouse, parent, friend, or paid representative.

Do write in plain, specific English with measurable details such as minutes, blocks, and pounds, because adjudicators reward concrete observations
Do compare before the impairment to now, because change over time is a core piece of evidence under SSR 16-3p
Do read the claimant’s SSA-3373-BK before answering, because consistency matters
Do attach an SSA-795 if you run out of space, because cramped handwriting hurts comprehension
Do keep a copy for your records, because reconsideration and hearings often revisit these answers
Don’t guess about medical diagnoses, because that invites credibility findings against you
Don’t use legal jargon, because the form is read by lay adjudicators first
Don’t try to help by exaggerating, because exaggeration triggers an SSR 16-3p credibility hit on the entire record
Don’t skip questions, because blanks read as “no problem” to DDS
Don’t sign a blank form for the claimant, because that may be a violation of 18 U.S.C. § 1001

Pros and Cons of Submitting a Detailed SSA-3376-BK

Even a perfect form has trade-offs the third party should weigh.

Pro: It can be the deciding lay evidence at Step 3 listings analysis under Listing 12.00
Pro: It often triggers favorable RFC limitations such as off-task time and absenteeism under SSR 96-8p
Pro: It satisfies the duty to develop the record under 20 C.F.R. § 404.1512
Pro: It supports later appeals to the Office of Hearings Operations and federal court
Pro: It gives caregivers a place to document side effects and unsafe behaviors
Con: An inconsistent or rushed form can sink an otherwise winnable claim under SSR 16-3p
Con: Filling it out is emotionally difficult for spouses and parents
Con: It takes 1 to 3 hours to do well, which is unpaid time
Con: Detailed answers may surface family conflict, especially around money handling
Con: A poorly written form can be cherry-picked by an Administrative Law Judge at hearing

Federal Statutes, Regulations, and Rulings to Know

Start with federal law. The Social Security Act § 223(d) defines disability for SSDI, and § 1614(a)(3) defines it for SSI. Both require a medically determinable impairment that prevents substantial gainful activity for at least 12 continuous months.

The implementing regulations live at 20 C.F.R. Part 404 Subpart P and 20 C.F.R. Part 416 Subpart I. The five-step sequential evaluation at § 404.1520 controls every adult claim, and the symptom evaluation framework at § 404.1529 is where SSA-3376-BK answers do the most work.

SSR 16-3p replaced the older “credibility” framework with a “consistency” framework, meaning DDS now compares third-party reports to medical and other evidence rather than judging character. SSR 96-8p requires a function-by-function RFC assessment that draws on lay statements.

The consequence of ignoring these rules is a record that cannot survive federal court review. The Ninth Circuit in Smolen v. Chater and the Eighth Circuit in Lorenzen v. Chater, 71 F.3d 316 (8th Cir. 1995) both reversed denials where the ALJ ignored or summarily rejected third-party statements. A common misconception is that lay statements bind the agency. They do not, but they must be considered with reasons.

State DDS Nuances

Although disability is a federal program, the state DDS actually adjudicates the file. State practices vary in formatting, deadlines, and follow-up calls, but every DDS must follow POMS DI 22510.

In California DDS, adjudicators routinely call third parties to clarify ambiguous answers, so leave a working phone number. In Texas DDS, turnaround on incomplete forms is shorter, often 10 days from the date on the cover letter. In New York DDS, Spanish-language forms are widely available, and you should request one if English is not the third party’s first language.

The consequence of missing a state nuance is delay. A common misconception is that mailing the form to a national SSA address works. It does not. Always mail or upload through the address printed on the cover letter, or through the SSA online portal where authorized.

Named Examples Across Impairment Types

Three named scenarios illustrate strong third-party reporting.

Maria Gonzalez, the wife of 54-year-old José with degenerative disc disease and diabetic neuropathy, filled out SSA-3376-BK by writing, “He sits in his recliner with a heating pad 6–7 hours a day, walks to the bathroom 8 times, drops utensils because his fingers go numb, and cannot tie his own shoes.” DDS adopted a less than sedentary RFC, and José was approved at the initial level under the Medical-Vocational Guidelines Rule 201.14.

David Kim, the brother of 31-year-old Joon with schizophrenia, wrote, “He hears voices that tell him neighbors are poisoning the water, has not bathed in 11 days, and cannot complete a 3-step instruction such as ‘go to the kitchen, get the milk, bring it back.’” DDS found marked limitations in two paragraph B areas under Listing 12.03 and approved at reconsideration.

Sarah O’Connell, the mother of 22-year-old Liam with autism spectrum disorder and intellectual disability, documented, “He cannot ride the bus alone, becomes nonverbal in crowds of more than 5 people, and was fired from a sheltered workshop after biting a coworker.” DDS approved under Listing 12.10 and Listing 12.05 on a concurrent claim.

How SSA-3376-BK Differs from Related Forms

Several forms look similar but serve different functions. Knowing the difference saves time and avoids confusion.

Form	Who Completes It	Purpose
SSA-3373-BK	The adult claimant	Self-report of function
SSA-3376-BK	A non-medical third party for an adult claimant	Lay corroboration of function
SSA-3380-BK	A parent or guardian for a child claimant	Function report for childhood disability
SSA-3368-BK	The claimant or representative	Initial disability report
SSA-3441-BK	The claimant or representative	Reconsideration disability report
SSA-795	Anyone	Free-form statement, often used as overflow

The consequence of mixing them up is wasted weeks. A common misconception is that the SSA-3380-BK substitutes for SSA-3376-BK in adult claims. It does not, because the child form measures age-appropriate domains, not adult work-related functions.

Court Rulings That Shape How DDS Reads Lay Evidence

Federal appellate decisions guide how ALJs and DDS treat the SSA-3376-BK. In Smolen v. Chater, 80 F.3d 1273 (9th Cir. 1996), the Ninth Circuit held that to reject lay testimony, an ALJ must give “reasons germane to the witness.”

In Dodrill v. Shalala, 12 F.3d 915 (9th Cir. 1993), the court reaffirmed that friends and family are competent to testify about what they have seen. In Buckner v. Astrue, 646 F.3d 549 (8th Cir. 2011), the Eighth Circuit allowed an ALJ to reject lay statements only when the same reasons apply that justified rejecting the claimant’s own testimony.

The consequence of these rulings is that a well-written SSA-3376-BK creates a real appellate record. A common misconception is that hearings start fresh. They do not. The ALJ must reckon with the third-party form already in the file, per HALLEX I-2-6-58.

Step-by-Step Filing and Submission Process

Follow these steps in order to make sure the form arrives on time and complete.

Open the envelope the day it arrives and note the deadline on the cover letter, usually 10 days
Photocopy the blank form before writing on it, in case you make mistakes
Read the claimant’s SSA-3373-BK if available, to keep facts consistent
Draft answers in pencil first, then ink the final version
Attach an SSA-795 for any answer that runs over the lines
Sign and date Section G in wet ink
Photocopy the completed form for your records
Mail to the address on the cover letter using tracked delivery, or upload through the secure link the DDS examiner provides

The consequence of skipping the photocopy step is losing the only contemporaneous record of what you wrote. A common misconception is that DDS will mail you a copy back. They will not.

Frequently Asked Questions

Is the SSA-3376-BK mandatory?

No. A third party is not legally compelled to fill it out, but the claimant’s case suffers without it because adjudicators rely on lay evidence required under 20 C.F.R. § 404.1513.

Can I be paid to fill out SSA-3376-BK?

No. Third-party reporters are unpaid lay witnesses; only fee-approved representatives may charge fees, and those fees come from claimant back pay under 42 U.S.C. § 406.

Will my answers be shared with the claimant?

Yes. Under the Privacy Act of 1974, the claimant generally has a right to see all evidence in the file, so write nothing you would not say in person.

Can I refuse to answer a question?

Yes. You may leave a question blank, but DDS often reads blanks as “no limitation,” which can hurt the claim under SSR 16-3p.

Do I have to sign in front of a notary?

No. SSA-3376-BK requires only your own dated signature, not notarization, per the form instructions printed on page 10.

Can a paid caregiver fill out the form?

Yes. A home health aide, case manager, or paid caregiver is a valid non-medical source under 20 C.F.R. § 404.1513(a)(4), and their daily observations often carry strong weight.

What if my answers contradict the claimant’s SSA-3373-BK?

No, you should not knowingly contradict, but honest small differences are normal; large contradictions trigger consistency analysis under SSR 16-3p that can sink the claim.

Can I fill out SSA-3376-BK online?

Yes. Many state DDS offices now accept secure uploads through links the examiner emails, although mailed paper is still standard, per POMS DI 81010.025.

Does SSA-3376-BK apply to SSI claims?

Yes. It applies to both SSDI and SSI adult claims, because 20 C.F.R. § 416.913 mirrors the SSDI rule on non-medical sources.

Can I update the form after I send it?

Yes. File a supplemental SSA-795 statement at any stage, including at the hearing level, to correct or expand earlier answers.

What happens if I miss the deadline?

No, missing the deadline is not automatically fatal, but DDS may decide on the existing record and issue an insufficient evidence denial under 20 C.F.R. § 404.1516.

Can I attach photos, videos, or letters?

Yes. Attach any lay evidence that supports your statement, because HALLEX I-2-5-13 and 20 C.F.R. § 404.1513 accept a wide range of non-medical evidence.

Related reading