Third-Party Function Report — worksheet

Maps to SSA-3380. Person filling this out should describe what they observe — not what the applicant tells them.

Who is filling this out

Name: ________________________
Relationship to applicant: __________
How long known: __________
Phone: __________

What changes have you seen since the disability began

…

What can the applicant do, and not do

…

How does it affect daily life

…
Signature
Date

Generated by Bluebook. Submit the official SSA-3380 to SSA. Not affiliated with the Social Security Administration.