How to Fill Out an Activities of Daily Living Questionnaire / Adult Function Report (SSA-3373-BK)

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Elizabeth D’Angelo

You may receive a form called Activities of Daily Living Questionnaire or Adult Function report.

Different states use slightly different forms.  Here is an example form.

Social Security sends out this form to learn more about your functioning and activities.

Social Security will usually send this form to you about month or two after you first apply for disability. They also sometimes send it to people who are already on disability during medical reviews.

Sometimes they will not send you the form, but instead will call and ask you the questions. If you’d like to be spared this fate, here’s How to Avoid Scary Phone Calls

If you get a form like this, it’s helpful if you can take time to really think about each question, but please don’t stress out about it. It is a common form and often does not have a major impact on your case. Your medical records will be much more important.

How To Fill Out an Adult Function Report

💮 Be honest with Social Security. It is best to just write what is actually true for you.

💮 Be honest with yourself. This is the biggest mistake people make. It’s so important that you really admit exactly how bad things are and how much help you really need. If you cannot do this you will hurt your case and hurt yourself.

💮 Be brave. Don’t be shy. Write exactly how bad things are for you. If you feel really shy or embarrassed, please find a way to write it anyway. This is incredibly important.

💮 Try to avoid saying something is “always” or “never” true or that you “can” or “cannot” do something, unless it really is always or never. Instead you can say “sometimes” “on my bad days….” or “when I am having symptoms…” or “most of the time…”

💮 Be aware of work-like activities. For example, cooking, cleaning and watching children are all things that could be a job. If you list any work-like activities, you can also make a brief note about any limitations with these activities, or anyone who assists you in any way.

💮 It is best to be honest and be consistent. Social Security may look to see that what you are saying to your doctors is the same thing you are writing on this form.

💮 Your answers do not need to be long. A few words or a few sentences is all they are requesting for most questions.

💮 Don’t forget side effects. If your med side effects are making it hard to function, you can include this. For example: If meds are making you tired, dizzy, in pain, or causing difficulty with focusing and concentrating.

How Can I Make it PERFECT?

Some people stress about this form because they think this is their “big chance” to explain themselves and prove they are disabled. It doesn’t really work that way.

This is just a standard form they use to check on your ability function and make sure that what you say about your condition is similar to what your doctor says. No matter what you write, this form won’t “prove” you are disabled. Your medical records are far more important.

Getting Ready

You do not need to do these things. These are things some other readers have found helpful:

💮 Some people are helped a lot by asking a person they know well or a person who lives with them to review the form and point out any limitations they have seen.

💮 Some people also find it helpful to keep a symptom diary for a week, and note any time they are struggling with any activities. You will be surprised how long your list is! This list is for you, you don’t need to send it to Social Security. It is to help your notice and remember things.

Tips for Tricky Questions

“How does your illness limit your ability to work?”

💮 Write down if there are any medical reasons why you can’t work or why you are limited (for example, if you have problems with lifting, walking, sitting, standing, bending, focusing, remembering or concentrating). Social Security will not consider reasons that are not medical. More ideas for how to answer the question: “Why Can’t You Work?”. They only give you room for a few sentences, so you can just put down a few basic ideas.

“Describe what you do from the moment you wake up to the moment you go to bed”

💮 They give you room to write just a few words. Luckily, many of us just lie down all day so there isn’t much to write. Please don’t stress out about the this question. Just list a few things you struggle with most days, or a few things you often do along with any ways you are limited or need assistance with those tasks. Good advice from SGB law office: “Many people feel guilty and ashamed that they do not do more throughout the day, so they exaggerate their activities. Do not do this. Also, do not minimize your average daily activities. You do not need to be bedridden to obtain disability benefits.”

“Yes or No?”

💮 There are a lot of “yes” and “no” boxes. You don’t have to check a box if neither answer is true for you. You can just write “sometimes” or “depends on symptoms” or “see below.” Never write something or check a box that is not true.

Do you take care of children/animals/other people?”

💮 If you take care of children, be honest about this. Please don’t forget to include if you need any assistance or if there are any things you are unable to do for your kids, or any limitations you have. Remember: They are not asking if you care about your kids. They are not asking if you are a good parent. They are asking about physical activities you do to take care of your kids. They are asking if you can hold down a job as a babysitter.

Explain how your illness or injury affects your ability to dress, bathe, care for hair, shave, feed self, and use the toilet.

💮 From the SGB law offices: “Tip: Even if you are physically able to do these tasks, you still have problems in these areas if you don’t do them with normal regularity. For example:

  • Dressing: Do you stay in your pajamas during the day?
  • 
Bathing: Do you shower or bathe with the regularity that you had before you got sick. If not, you should note this!
  • Shopping: If you are able to go shopping but typically need someone with you while shopping, be sure to note this.”

Have you ever been fired from a job due to inability to get along with others?

💮 They are asking this because inability to get along with others is one of the limitations they consider for people applying for mental illness. If you answer yes to this question, they ask for the employer’s name. If you list an employer here, there is a chance they will contact the employer or send a form to ask questions about your ability to function and take care of yourself. This doesn’t happen often, and some employers just chose not to respond.

How do you handle stress? Changes in routine? Fears? Authority figures?

💮 These questions are all for people applying for mental health. Just answer honestly. If you don’t know the answer, it is OK to write “I don’t know.”

All questions

💮 Try your best to answer as much as you can. If you get really stuck its OK to leave some questions blank. A blank answer is better than writing something untrue. Just do the best you can. Many times people with very severe disabilities are unable to complete these forms.

Once again, if they ask a question and you don’t know the answer, it’s OK to write that you don’t know.

“I’m Stuck!”

If you get stuck, here’s four easy things you can do:

💮  Try writing the magic words. The magic words are: “When I am in pain…” or “When I am having severe symptoms….” or “When my symptoms are bad…” Many disability lawyers suggest using these words. Write down the magic words and then just finish the sentence. Roselyn applied for Paratransit, and here’s how she got approved by Using the Magic Words

💮 Try asking yourself this question: How is this activity different for me now then it was before I got sick? Then write down the answer.

💮  Try asking yourself this question: Does anyone help me in any way, even in a small way, to do this activity? Then write down the answer.

💮  If you are still stuck, here’s a list of questions you can ask yourself about How To Describe Your Activities. Just pick any activity and ask yourself these questions. You will definitely think of things!

How Much Should I Write?

There are different opinions by lawyers and advocates about how to fill out this form. Some people say be detailed about your condition, tell them all your struggles, and attach extra pages.

Other people say be very brief, never attach extra pages, and be careful not to write anything that could hurt your case.

There is no wrong or right way to do it. However, it is totally fine to be brief and simple. It’s fine to answer questions in just a few words or a few sentences. If you send something longer, it might not be read.

Who Should I List As My Contact Person?

Some forms ask you to list the names and contact information for two or three people who can provide information about your life. Some forms don’t have this question. You can list anyone who knows your life well – a friend, family member, or caregiver is often the best person.

They will be contacting this person and asking them some very personal questions about you! Such as what kind of help you need to get dressed, eat, brush your teeth, or take a bath.

The form may offer some friendly suggestions like “You can list your landlord or Social Worker”. Think carefully about this: Is your landlord going to be able to answer questions about how you brush your teeth?

It is best to only list someone who truly knows your daily life well and knows your limitations and the kind of care you need. If there is only one person who knows this, then you can just list that one person and write “No one else knows my daily life.”

If there is truly no one who can provide information on your life, you can write this, but it is better if you can list at least one person. They may call or write your contact person. If your contact person does not wish to be called, just provide mailing address.

What’s Next?

If possible, make a copy of the form before you send it. It may be helpful for you later on.

Whenever sending anything, it’s always a good idea to contact the person handling your case and make sure that it was received and placed in your file.

Next up, they may send a similar form to your contact person to answer questions about you. Here’s how to handle an Adult Function Third Party Report (SSA-3380-BK)

If this is a new application, Social Security may also send you a Work History Form. How to fill Out a Work History Report (SSA-3639-BK)

If you are already approved and being reviewed, learn more about How to Complete a Continuing Disability Review


 

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