How to Fill Out Form SSA-3378-BK (w/Examples) + FAQs

Form SSA-3378-BK is the Social Security Administration’s Function Report — Adult — Third Party, and you fill it out by describing, in plain and specific language, how the disability claimant’s medical conditions limit their daily activities, personal care, social functioning, and ability to work. You complete it by answering every question on every page, using concrete examples (not adjectives), staying consistent with the claimant’s own SSA-3373-BK Function Report, and signing the certification on the final page under penalty of federal law.

The form exists because the Social Security Act § 223(d) and 20 CFR § 404.1529 require the Disability Determination Services (DDS) examiner to weigh non-medical evidence about a claimant’s daily functioning. The third-party report gives DDS an outside perspective to corroborate or contradict the claimant’s own statements, and inconsistencies often trigger denials under SSR 16-3p.

According to the SSA’s 2024 Annual Statistical Report, only about 38% of initial SSDI applications are approved, and incomplete or vague Function Reports are among the top reasons for denial.

Here is what you will learn in this guide:

📝 How to answer every section of Form SSA-3378-BK with concrete, examiner-ready detail
⚖️ Which federal statutes, regulations, and SSA rulings govern third-party statements
🧠 How to handle physical, mental, and cognitive impairment questions without exaggeration
🚫 The most common mistakes that get a third-party report dismissed or used against the claim
✅ Real-world named examples, do’s and don’ts, scenario tables, and 12 FAQs

What Form SSA-3378-BK Is and Why It Exists

Form SSA-3378-BK, titled Function Report — Adult — Third Party, is a multi-page questionnaire the Social Security Administration sends to a person who knows the disability claimant well. The form is published by SSA under OMB Control No. 0960-0635 and is available as a fillable PDF on the official SSA forms page. The third party is usually a spouse, parent, adult child, sibling, close friend, neighbor, or paid caregiver who has regular contact with the claimant.

The form gives DDS a window into the claimant’s life that medical records cannot show. Doctors record symptoms during short visits, but a spouse sees the claimant struggle to button a shirt every morning. SSA uses this lay evidence under 20 CFR § 404.1513(a)(4) and the parallel 20 CFR § 416.913 for SSI claims.

The consequence of refusing to complete the form, or of returning it blank, is significant. Under 20 CFR § 404.1516, SSA can decide the claim on the existing record, which usually means denial because the claimant has not met the burden of proof. A common misconception is that the third-party form is optional fluff, but DDS examiners read it line by line and flag any contradiction with the claimant’s SSA-3373-BK.

A real-world mini-scenario: Maria, the wife of a 52-year-old welder with degenerative disc disease, returned the form with one-word answers like “bad” and “limited.” DDS treated the report as low-probative and denied the claim at the initial level. After her appeal, she completed a new Function Report with paragraph-length answers and won at reconsideration.

Who Should Complete It

The third party should be someone who observes the claimant at least several times a week and across different activities. SSA’s POMS DI 22505.020 prefers a non-medical observer who shares meals, errands, or a household with the claimant. A roommate who only sees the claimant in the kitchen is less useful than a live-in spouse who watches them dress, sleep, and shop.

The consequence of choosing the wrong third party is reduced credibility. If a coworker who sees the claimant only at company picnics fills out the form, DDS may discount the entire submission. A common misconception is that a doctor should fill it out, but medical providers complete different forms such as the Medical Source Statement.

A real-world example: James, the adult son of a 70-year-old mother with Alzheimer’s, was the right third party because he visited daily, prepared her meals, and managed her medications. His detailed answers about her wandering and forgetfulness aligned with the neurologist’s notes and helped secure approval at the initial step.

Legal Authority and Penalties

The form is authorized under Sections 205(a), 233(d)(5)(A), 1614(a)(3)(H)(i), and 1631(d)(1) of the Social Security Act. The certification at the end of the form invokes 42 U.S.C. § 408 and 42 U.S.C. § 1383a, which make it a federal felony to knowingly make a false statement on a Social Security disability document. Penalties include up to five years in federal prison and fines up to $250,000 under 18 U.S.C. § 3571.

The consequence of exaggeration is not just denial; it is potential prosecution and a Civil Monetary Penalty of up to $8,457 per false statement under 42 U.S.C. § 1320a-8 as adjusted by the SSA OIG. A common misconception is that “everyone exaggerates a little,” but the SSA Office of the Inspector General prosecutes hundreds of cases each year for inflated Function Reports.

A mini-scenario: Robert, a neighbor, claimed a friend “could not walk at all” while social media showed the friend hiking. DDS referred the file to the Cooperative Disability Investigations Unit and the claim was denied with a fraud flag. Robert was warned in writing under 20 CFR § 404.1503B.

Where to Get the Form and How to Submit It

You usually receive Form SSA-3378-BK in the mail from your state DDS office about 30 to 60 days after the claimant files the initial application. You can also download a blank copy from the SSA forms library and complete it digitally using Adobe Acrobat. Some DDS offices accept upload through the SSA Electronic Records Express portal if your representative has an account.

Return the form within the deadline printed on the cover letter, which is usually 10 calendar days. Under 20 CFR § 404.911, late returns may be accepted only with “good cause,” such as hospitalization or natural disaster. The consequence of missing the deadline is a decision made on the existing file, often a denial.

A common misconception is that you can drop the form at a local field office and forget it, but the cover letter usually directs you to mail or fax it directly to the assigned DDS examiner. Always keep a photocopy and proof of mailing such as a USPS Certificate of Mailing.

Section-by-Section Walkthrough of Form SSA-3378-BK

The form has six numbered sections plus a remarks page and a signature certification. Every blank must be answered, even if the answer is “not applicable.” Leaving fields empty signals carelessness and weakens credibility under HALLEX I-2-6-58.

Section A — Information About the Person Completing the Form

This section asks for your name, address, daytime phone, your relationship to the claimant, and how often and how long you have known them. Be specific: write “spouse, married 14 years, live together daily” rather than “wife.” DDS uses these facts to weigh credibility under SSR 16-3p.

The consequence of vague entries is a lower weight on your statements. A common misconception is that this section is just a header; in fact, examiners use it to decide how much your observations matter. Linda, a daughter who wrote “see Dad every Sunday for dinner and twice a week for grocery runs,” gave DDS a clear basis for trusting her observations.

Section B — Information About the Disabled Person’s Illnesses, Injuries, or Conditions

You describe how the claimant’s conditions limit their ability to work. Tie each limitation to a specific function: standing, lifting, concentrating, interacting. Reference the conditions listed by the claimant in the SSA-3368-BK Disability Report so the file is consistent.

The consequence of listing conditions the claimant did not mention is confusion in the file, which DDS may interpret as exaggeration. A common misconception is that you should “help” by adding extra diagnoses; instead, stick to what you actually observe. Carlos, a brother of a claimant with rheumatoid arthritis, wrote “swollen knuckles every morning, cannot grip coffee mug until 11 a.m.,” which mapped directly to Listing 14.09.

Section C — Information About Daily Activities

This is the longest section and asks about a typical day from waking to sleeping. Write a chronological narrative: “6 a.m. wakes, takes 20 minutes to get out of bed due to back stiffness; 7 a.m. wife helps put on socks; 8 a.m. eats cereal because cannot stand to cook.” Use times, durations, and assistance details.

The consequence of writing “normal day, watches TV” is a finding that the claimant is not as limited as alleged. A common misconception is that brevity is professional, but DDS rewards specific, time-stamped detail. Aisha, the mother of an adult son with autism, described every transition cue, sensory break, and meltdown trigger across a 16-hour day and the claim was approved at the initial level.

Section D — Information About Abilities

You check boxes and explain limits in 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. Add a sentence after each checked box. SSA’s POMS DI 24510.005 requires DDS to compare these to the Residual Functional Capacity assessment.

The consequence of checking every single limitation without explanation is a credibility hit, because DDS sees an unrealistic profile. A common misconception is that more checkmarks help; instead, accuracy and explanation help. Diane, the wife of a Navy veteran with PTSD, checked memory, concentration, and getting along with others, and explained each with a story about a panic attack at Walmart.

Section E — Information About Medications

List every prescription and over-the-counter drug, the dosage, the prescriber, the side effects you observe, and how long the claimant has taken each. Side effects matter under SSR 96-7p and its successor SSR 16-3p, because drowsiness, nausea, and cognitive fog affect the ability to work.

The consequence of leaving out side effects is a missed argument for limitation. A common misconception is that the doctor’s records are enough, but third-party observation of side effects is unique evidence. Tom, the partner of a claimant on gabapentin and hydrocodone, wrote “sleeps 4 hours every afternoon, slurs words by 3 p.m.,” which DDS cited in the favorable decision.

Section F — Remarks

Use this final narrative box to explain anything the form did not capture: bad days versus good days, episodic flares, hospitalizations, falls, suicidal ideation, or social withdrawal. Under POMS DI 22505.001, DDS must consider all submitted statements.

The consequence of leaving Remarks blank is a missed chance to humanize the claim. A common misconception is that examiners skip this section; in fact, many cite it directly in their rationale. Priya, the sister of a claimant with lupus, used Remarks to describe a typical “bad week” with three ER visits, and DDS quoted her in approving disability.

Three Real-World Scenarios

Below are the three most common patterns DDS sees, presented as 2-column tables.

Scenario 1 — The Vague Spouse

Action by Third Party	Consequence on the Claim
Writes one-word answers like “bad” or “can’t”	DDS assigns low weight to the statement
Skips the Remarks section entirely	Examiner has no narrative to corroborate medical evidence
Checks every limitation box without detail	Credibility drops under SSR 16-3p
Returns form on day 11 with no good-cause letter	DDS decides on existing record, often a denial

Scenario 2 — The Over-Helpful Friend

Action by Third Party	Consequence on the Claim
Adds diagnoses the claimant never reported	File contradictions trigger CDI referral
Says claimant “never leaves the house” while photos exist	Possible fraud investigation under 42 U.S.C. § 408
Inflates side effects beyond medical record	Examiner discounts entire third-party report
Signs without reading the certification	Personal exposure to civil monetary penalties

Scenario 3 — The Detailed Caregiver

Action by Third Party	Consequence on the Claim
Writes a chronological day with times and durations	DDS quotes the narrative in the rationale
Aligns answers with the claimant’s SSA-3373-BK	Credibility raised under POMS DI 22505.020
Lists each medication with observed side effect	Strengthens RFC argument for sedentary or less
Returns form within 7 days with copy retained	Claim moves promptly through DDS queue

Named Examples That Show the Form Done Right

Sarah, a 47-year-old paralegal, completed the form for her husband David, a former roofer with lumbar radiculopathy. She wrote that David spends 6 hours a day reclined with a heating pad, can lift no more than a gallon of milk, and needs help putting on shoes. DDS combined her statement with the orthopedic MRI and approved the claim under Listing 1.15.

Miguel, a 60-year-old retired teacher, filled out the form for his adult daughter Elena, who has bipolar I disorder. He described 14-day depressive cycles, 3 hospitalizations in the past year, and her inability to follow a recipe with more than three steps. The DDS examiner cited Miguel’s narrative in finding marked limitations under the paragraph B criteria of Listing 12.04.

Janet, a home health aide, completed the form for her client Mr. Whitfield, an 80-year-old with congestive heart failure and COPD. She logged daily oxygen saturation readings, the number of pillows he sleeps on, and his shortness of breath after 15 feet of walking. The claim was approved at step three under Listing 4.02.

Mistakes to Avoid

Avoiding errors is as important as adding detail. Here are the most damaging mistakes DDS examiners flag, drawn from POMS DI 22505.020 and the Social Security Bulletin.

Writing one-word answers, which signals lack of effort and triggers low evidentiary weight.
Contradicting the claimant’s own SSA-3373-BK, which can sink both reports.
Exaggerating limitations, which exposes you to penalties under 42 U.S.C. § 408.
Minimizing limitations to “be fair,” which ignores the claimant’s worst days and skews the picture.
Skipping the medication side-effects detail, which loses an SSR 16-3p argument.
Forgetting to sign and date the certification, which voids the entire form.
Returning the form late without a good-cause statement under 20 CFR § 404.911.
Using medical jargon you do not understand, which makes you look coached.
Leaving the Remarks section blank, which forfeits a free-text advocacy chance.
Listing only good days, which fails the longitudinal evidence standard.
Writing in pencil or illegible cursive, which DDS may return for redo.

Do’s and Don’ts

The do’s and don’ts below come from SSA POMS DI 22505.001 and from how examiners actually score third-party reports.

Do use specific times, distances, and weights such as “walks 100 feet before resting.”
Do align dates and conditions with the claimant’s SSA-3368-BK Disability Report.
Do describe both good days and bad days to satisfy the longitudinal evidence rule.
Do list every observed medication side effect, however minor it seems.
Do sign and date the certification only after re-reading every page.
Don’t copy the claimant’s own Function Report word for word, which DDS calls “ghosting.”
Don’t guess at medical diagnoses you have not personally observed.
Don’t leave any blank field; write “N/A” or “do not know” instead.
Don’t add irrelevant grievances about employers, insurers, or family disputes.
Don’t sign if you have any doubt about the truth of an answer, because 18 U.S.C. § 1001 penalties may apply.

Pros and Cons of Submitting Form SSA-3378-BK

There are real tradeoffs to completing the form, and weighing them helps you decide how thorough to be.

Pro: Adds non-medical evidence that DDS must consider under 20 CFR § 404.1513.
Pro: Provides longitudinal observations that doctors cannot supply from short visits.
Pro: Helps the claimant tell their story in plain language a layperson examiner understands.
Pro: Strengthens the file at reconsideration and at the ALJ hearing level.
Pro: Costs nothing and does not require an attorney to prepare.
Con: Time-consuming; thorough completion often takes 2 to 4 hours.
Con: Exposes you to federal penalties for knowingly false statements.
Con: Can hurt the claim if your answers contradict the claimant’s report.
Con: May trigger a Cooperative Disability Investigation if statements look exaggerated.
Con: Emotional toll on family members documenting a loved one’s decline.

Federal vs. State DDS Nuances

Although Form SSA-3378-BK is a federal form, it is processed by state DDS agencies under 20 CFR § 404.1503. Each state runs DDS slightly differently, and small procedural differences can affect how your form is read.

In California, the California DDS often returns forms with handwritten clarifications requested if Section C is too brief. In Texas, the Texas DDS is known for fast initial decisions, so submitting within 7 days helps. In New York, the NY DDS frequently calls third parties for telephone clarification, so include a daytime phone you actually answer. In Florida, the Florida DDS tends to weigh consistency with hospital records heavily, so attach copies of ER discharge papers when relevant.

The consequence of ignoring state nuances is a slower decision or a state-specific request for additional evidence. A common misconception is that all states process identically; in reality, the SSA Region and state DDS workload affect timing and tone.

How DDS Weighs Your Statement

Under SSR 16-3p, DDS no longer uses the term “credibility” but still evaluates the consistency of statements with the medical and other evidence. Third-party reports are weighed as “other source” evidence under 20 CFR § 404.1513(a)(4).

The examiner looks at four things: how often the third party sees the claimant, the nature of the relationship, consistency with medical records, and consistency with the claimant’s own report. The consequence of weak performance on any factor is reduced weight, not outright rejection. A common misconception is that family members are automatically discounted, but Smith v. Bowen, 849 F.2d 1222 (9th Cir. 1988) held lay testimony from family is competent evidence the agency must address.

Recap of related rulings: Lewis v. Apfel, 236 F.3d 503 (9th Cir. 2001) requires the ALJ to give “germane reasons” for rejecting lay testimony. Dodrill v. Shalala, 12 F.3d 915 (9th Cir. 1993) holds that friends and family who observe a claimant daily are competent to testify about symptoms. Burch v. Barnhart, 400 F.3d 676 (9th Cir. 2005) addresses how daily activity reports interact with RFC findings.

Step-by-Step Process to Complete the Form

Here is a clear order of operations to follow from envelope opening to mailing.

Read the cover letter and write the deadline on your calendar.
Photocopy the blank form before writing anything.
Sit down with the claimant’s SSA-3373-BK for cross-reference.
Spend a full day observing the claimant and taking notes by the hour.
Draft answers in pencil first, then transfer to ink or PDF.
Have the claimant or their representative review for contradictions.
Re-read the certification language before signing.
Sign, date, and add your phone and address.
Mail by USPS Certified Mail or fax to the DDS number on the cover letter.
Keep your copy and the certified-mail receipt for at least three years.

The consequence of skipping any step is a weaker submission. A common misconception is that you can complete the form from memory in 20 minutes; thorough reports take 2 to 4 hours. Nia, a daughter who followed all 10 steps, produced a 9-page report that the ALJ later quoted verbatim in a fully favorable decision.

Key Entities You Should Know

Several agencies and roles interact with your form. Knowing them helps you address the right audience.

The Social Security Administration is the federal agency that owns the disability program under 42 U.S.C. § 401 et seq. The Disability Determination Services is the state-level partner that makes initial and reconsideration medical decisions. The DDS Examiner is the individual reading your form, often paired with a Medical Consultant physician or psychologist.

The Administrative Law Judge hears appeals at the third level under 20 CFR § 404.929. The Office of the Inspector General prosecutes fraud, including third-party false statements. The Cooperative Disability Investigations Unit investigates suspected exaggerations through field interviews and surveillance reviews authorized by POMS GN 04111.000.

Frequently Asked Questions

Is Form SSA-3378-BK mandatory if I receive it in the mail?

No. It is not legally mandatory for the third party, but if no one returns it the claimant’s case may be decided on a thin record, which usually means denial under existing evidence rules.

Can I be paid to complete Form SSA-3378-BK for someone?

No. SSA does not pay third parties, and attorneys cannot bill the claimant for a non-attorney’s lay statement under 20 CFR § 404.1720 representative-fee rules.

Is it okay to type my answers into the PDF instead of handwriting?

Yes. SSA accepts a typed, printed, and signed PDF, and typing reduces legibility issues that delay processing at most state DDS offices nationwide today.

Will the claimant see what I wrote about them?

Yes. The claimant or their representative can request the file under the Privacy Act, 5 U.S.C. § 552a, so write nothing you would not say to their face.

Can I submit additional pages if the form’s space is too small?

Yes. Attach extra sheets clearly labeled with the claimant’s name, Social Security number, the section being continued, and your signature on each added page.

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

Yes. Every blank should have an answer, even if it is “do not know” or “not applicable,” because empty fields hurt the credibility score under SSR 16-3p.

Can I refuse to sign the certification at the end?

No. Without a signature the form is invalid and DDS will treat it as not submitted, which leaves the claimant’s record without third-party support evidence.

Is my statement weighed less because I am a family member?

No. Under Dodrill v. Shalala, family observations are competent evidence, and the ALJ must give germane reasons before rejecting them.

Can I update the form later if the claimant’s condition worsens?

Yes. You can submit a supplemental statement at any stage, including reconsideration and the ALJ hearing, by writing a dated letter referencing the original form.

Will a vague or short answer get the claim denied by itself?

No. A vague answer alone rarely causes denial, but combined with thin medical records and a vague claimant report it pushes the file toward an unfavorable decision.

Is there a penalty for an honest mistake on the form?

No. Penalties under 42 U.S.C. § 408 require a “knowing” false statement, so good-faith errors are corrected without prosecution when promptly disclosed to SSA.

Can I complete Form SSA-3378-BK for a child claimant?

No. This adult form is not used for child SSI claims, which use Form SSA-3375-BK or SSA-3376-BK depending on the child’s age range.

Related reading