SSA-3373-BK: Function Report - Adult
Form SSA-3373-BK is the adult function report used in Social Security disability claims. It asks, in detail, how your medical conditions limit what you can do from the moment you wake up to the end of your day.
This is the genuine SSA PDF, unmodified. Source: SSA official page.
What is SSA-3373-BK?
SSA-3373-BK, Function Report - Adult, is a questionnaire the state Disability Determination Services (DDS) sends to people who have applied for Social Security Disability Insurance or SSI. Across roughly ten pages it covers your daily activities, personal care, meal preparation, house and yard work, getting around, shopping, money handling, hobbies, social activities, and a checklist of abilities such as lifting, standing, walking, sitting, concentrating, remembering, and getting along with others.
DDS examiners and medical consultants use your answers alongside the medical evidence to assess your residual functional capacity, so the report carries real weight in the decision. The most useful answers are specific and honest: how far you can walk before resting, how long you can stand, what tasks you have stopped doing and why. Vague or inconsistent answers can hurt an otherwise strong claim.
Who files SSA-3373-BK?
- Adults with a pending SSDI or SSI disability claim who received the form from DDS
- People whose claims are at the reconsideration or continuing disability review stage and were asked to update their function information
- Friends or relatives helping a claimant complete the form, with the helper identified where the form asks
- Claimants whose representative asked them to prepare it as part of the claim file
How to fill out SSA-3373-BK
- Read the whole form first, then answer in order, describing a typical day and being specific about times, distances, and amounts.
- Describe what you could do before your conditions began compared with what you can do now, and mention help you receive from others.
- Complete the abilities checklist carefully and explain each limitation you mark; short concrete examples are more persuasive than general statements.
- Use the remarks section for anything that did not fit, including good days and bad days and how often bad days occur.
- Return the completed form to the DDS office address shown on the letter that came with it by the stated deadline, and keep a copy for your records.
Quick fill SSA-3373-BK on this page
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Frequently asked questions
Who actually reads this form?
A disability examiner and medical consultants at your state Disability Determination Services. They compare your answers with your medical records and with a similar third-party report (SSA-3380) if one was sent to someone who knows you. Consistency across these sources matters.
What if I have good days and bad days?
Describe both, and estimate how many days per week or month are bad ones. Answering only for your best days understates your limitations, and answering only for your worst days can look inconsistent with your records. The remarks section is a good place to explain the variation.
Can someone help me fill it out?
Yes. A family member, friend, or representative can help or write your answers for you. The form asks who completed it, so identify the helper. The answers should still describe your own experience in your own words.