Thank you for choosing Trajector Disability as your advocacy group. You may have already, or will in the near future, receive a “Function Report-Adult” (form SSA-3373) from the Social Security Administration. This function report is a necessary part of the application process.
As part of giving the Social Security Administration the most relevant and important information about your impairments and how they impact your everyday life, Trajector Disability has prepared these instructions to assist you in completing this form accurately.
Please refer to these instructions as a guideline as to how this form should be completed. Also, should you require the assistance of a friend or a family member to fill out this form due to an impairment or disability please have them fill out their information at the bottom of Section E.
Take your time filling out this lengthy form. You do not need to complete this form in one sitting. Please feel free to take breaks so that your responses continue to be insightful throughout the entire form.
Please answer questions in light of your disabilities, impairments, injuries, illnesses, and conditions. This form will be used by the Social Security Administration to determine if your disabilities prevent you from working. Therefore it is important to remember to respond accurately and with your disabilities in mind.
Please keep in mind when filling out this form:
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Please respond with why your physical or mental health impairments prevent you from working. You must be truthful about what you can and cannot do. The Social Security Administration would like to know how your impairments would prevent you from doing your prior jobs or any other work.
For example you can mention:
These are just examples. You should think about each one of your disabilities and then mention why that disability would prevent you from working.
It is important to keep in mind your responses relate to your current impairments and disabilities.
As a person with impairments and disabilities, you may have difficulties performing the activities, chores, and tasks you were able to do when you were healthy.
Please respond with the activities, chores, and tasks you are able to perform independently on a regular basis despite your impairments and disabilities. If you require assistance or help in performing an activity, chore, or task, please set this forth as well.
You can mention what you are able to do on a good day. You can also mention what you are not able to do on a bad day.
You are strongly encouraged to fill out this section and not leave it blank. Please do not mention that you cannot do anything or that you do nothing all day. Please provide a substantive response.
Please check “Yes” if even as a disabled person, you spend a portion of the day independently taking care of another person. Please also mention the care you provide.
Please check “No” if you do not spend any portion of the day taking care of the other person, or if you cannot care for another person independently.
Please check “Yes” if even as a disabled person, you are responsible for the direct care of any pets or animals. For example you independently walk, bathe, or are responsible for buying food and supplies for a pet.
However, if you only enjoy the company of a household pet or animal, or if you do not have a pet, please check “No”
Please check “Yes” if there is a babysitter, relative, friend, home health aid, or visiting nurse who assists you in the care of another person or a pet. Please set that forth who they are and what they do to help in the space provided.
Please check “No” here if you responded “No” to either Question 7 and/or Question 8.
Please respond with the tasks you now have difficulty with. For example this can include not being able to go for walks, exercising, spending time with friends or family, maintaining hygiene, taking public transportation or driving, or any other chore, activity, task, or hobby which you can no longer perform or enjoy as a result of your illnesses, injuries, or conditions.
Please also mention if your disabilities and impairments prevent you from working.
Please check “Yes” if your physical or mental health impairments or disabilities prevent you from getting sleep at night time. For example pain, frequent urination, racing thoughts, or anxiety prevent you from getting restful sleep at night time. Please explain how in the space provided.
Also, please check “Yes” if your physical or mental health impairments or disabilities contribute to your fatigue or exhaustion where you are unable, or lack the motivation, to get out of bed. (for example, you oversleep) Please explain how in the space provided.
Finally, please check “Yes” if your medications, or their side effects, prevent you from sleeping, or force you to oversleep. Please explain how in the space provided.
Please check “No” if your illnesses, injuries, or conditions have no impact on your sleep.
Please respond with any articles of clothing which you have difficulty putting on by yourself. For example, you may have difficulty tying shoelaces or putting on socks. You may have difficulties with buttons or zippers. You may have difficulties putting on an undergarment or a T-shirt. If you receive assistance in putting on clothing, please mention that here.
Please respond with how often you are able to shower, bathe, or clean yourself with a cloth by yourself. For example, you may skip days showering if you’re in pain or you lack motivation to do so. If you receive assistance in showering, bathing, or cleaning yourself with a cloth, please mention that here.
Please respond with the difficulties you may have shampooing, cleaning, braiding, or maintaining your hair. Please also mention if you are unable to go to a salon or barber shop due to either your disabilities, being in pain, or a mental health impairment (ie- anxiety). If you receive assistance in caring for your hair, please mention that here
Please respond with the difficulties you may have and being able to shave your face or body parts. If you receive assistance in shaving, or are no longer able to shave, please mention that here.
Please respond with any difficulties you have in preparing food. Please mention if you receive assistance with either eating or drinking, or if there are restrictions using the stove. You can also mention why you may have a lack of appetite due to pain, chemotherapy, a psychiatric impairment, an eating disorder, or due to a lack of motivation, etc. If you receive assistance in preparing meals, please mention that here.
Please respond with any difficulties you may have cleaning yourself, reaching the bathroom in time, and with what frequency/infrequency you use the bathroom. For example, some people may use the bathroom infrequently because of pain or constipation, or others may use the bathroom frequently due to a stomach or gastrointestinal issue. If you receive assistance in using the toilet, or require the use of an assistive device in the toilet, please mention that here.
Please respond with any other difficulties you may have with your personal care.
Please check “Yes”and respond with how often and why you need reminders for your personal needs and grooming. For example, if you have a friend or a family member who reminds you to shower, or who assists you in dressing, bathing, caring for your hair, shaving, feeding yourself, or using the toilet, please mention that here. Also, if you have a home health aide, nurse, assisted-living, companion, or attendant who assist you with your personal needs and grooming, please mention that here.
Please check “Yes” if a friend, family member, attendant, addiction recovery personnel, assisted-living personnel, parent, sibling, or child remind you to take medication. This could be medication for pain, psychiatric treatment, or for treatment of a condition such as diabetes. Same with any assistance you need in laying out your medication for the day or the week, or any assistance you need in administrating shots and injectables such as insulin. Please mention how you receive assistance.
Please check “Yes” only if you are able to independently fix and prepare your own meals including meal prep, cooking, feeding yourself, and then cleaning up afterwards. Please explain what food preparation tasks are difficult for you.
Please check “No” if you are unable to independently fix and prepare meals.
Please respond with how often you can independently prepare meals for yourself. However, if a friend or a family member prepares your food for a few days at a time, if someone drops off food, or if you rely on delivery or fast food please mention that here.
If you are independently preparing meals for yourself, please respond with the number of minutes per day or week you are able to prepare food.
Please respond with any changes in your cooking ability or food consumption, including dietary restrictions as a result of your disabilities or conditions. For example this can also include a low sugar, low-salt, or high fiber diet as instructed by your doctors.
Please respond with household chores, tasks, and outdoor activities you are able to perform independently on your bad days despite your disabilities, impairments, or conditions.
Please respond with the number of minutes each day or week you are able to perform household chores, tasks and outdoor activities.
Please check “Yes” if a friend or a family member assists you with household chores, tasks or outdoor activities or if a friend or family member must remind you to do them. Also, please mention if you require a longer time to perform household chores, tasks, or outdoor activities.
Please respond with how your physical and mental health impairments prevent you from performing household chores, tasks or outdoor activities. For example, you can mention that pain, discomfort, anxiety, or lack of motivation interfere with your abilities.
Please respond with a number of minutes per day or per week you are able to spend time outside. Also, please respond with how often you leave your home to visit doctors or other physical or mental health treating sources.
However, if you are unable to spend time outside, please respond as to how your disabilities, impairments, and conditions prevent you from doing so.
Please check all of the modes of travel you are able to take since you have been disabled.
Please check “Yes” only if you are able to individually, independently, and safely go outside on your own.
However, if your disabilities, impairments, or conditions prevent you from going outside independently, please check “No”. Please provide an explanation as to how your physical and mental health disabilities prevent you from safely and independently going outside.
Please check “Yes” only if you are able to legally, independently, and safely able to drive and operate a motor vehicle. In addition, if there are restrictions on your ability to drive at night time, or during bad weather, then please explain here. These are restrictions which you may have placed upon yourself, placed by your doctors, or by your state’s motor vehicle commission. Please also mention here if you have a handicap tag.
However if you are unable to drive independently and safely, please check “No”, and explain.
Please check the appropriate boxes for the types of shopping you can do since becoming disabled. If you are unable to shop, or if friends or family now provide for you, then please explain in the space provided.
Please respond with what you are able to independently shop for when it comes to groceries, clothing, household items, or supplies, etc., since you have become disabled.
Please respond with the number of minutes per day or week you are able to independently shop since becoming disabled.
PAY BILLS - Please check “Yes” only if you are able to independently pay bills.
However, if you are unable to pay bills because of your physical or mental disabilities and impairments, or if you do not have money to pay bills, then please check “No”.
HANDLE A SAVINGS ACCOUNT - Please check “Yes” only if you independently handle and manage a checking/savings account.
However, if you are unable to independently handle a checking/savings account because of your physical or mental disabilities and impairments, or if a guardian, spouse, etc., oversee, manage, or help you, then please check “No”.
COUNT CHANGE - Please check “Yes” only if you’re able to independently count and handle change.
However, if you are unable to independently count and handle change because of your physical or mental disabilities and impairments, or if you are unable to perform the math, then please check “No”.
USE A CHECKBOOK/MONEY ORDERS - please check “Yes” only if you are able to independently use and balance a checkbook or handle money orders.
However, if you are unable to independently use and balance the checkbook or handle money orders because of your physical or mental disabilities and impairments, or if you do not have access to a checkbook or money orders, then please check “No”.
Please check “Yes” if your illnesses, injuries, disabilities, or conditions have affected your ability to handle money. This includes both being able to physically count money as well as having the ability to calculate change during a transaction.
Please respond by checking off any and all boxes when it comes to the listed activities that your disabilities, illnesses, or conditions have affected.
For example, if your physical disabilities or conditions cause pain, fatigue, discomfort which impacts your ability to lift, squat, bend, stand, reach, walk, sit, kneel, talk, hear, stair climb, using your hands, or to see, then you should check the appropriate box.
Similarly, if your mental health impairments for conditions interfere with your memory, ability to complete tasks, concentrate, understand, follow instructions, or getting along with others, then you should check the appropriate box.
Please respond by explaining your limitations since you have been disabled.
Please respond appropriately about your dominant hand. In addition, if you are an amputee and are missing a portion of your hands or fingers, please explain in the space provided.
Please respond with how far you can walk in minutes or blocks before you feel pain or discomfort and feel the need to sit, rest, or lean on something. Please keep your disabilities, impairments, and conditions in mind.
Please respond with how long you need to sit or rest on something before you can walk again. If you are unable to continue walking even after resting, then please explain.
Please respond in minutes with how long you can pay attention for, and maintain concentration. Please keep your disabilities, impairments, and conditions in mind.
Please check “Yes” only if you are able to finish tasks which you start independently and safely. However, if you are unable to finish tasks due to your disabilities, impairments, or conditions then please check “No”.
Please respond with how your disabilities, impairments, or conditions interfere with your ability to understand directions and instructions which are provided to you in writing. Please keep in mind that your pain, or mental health impairments, may impact your ability to read and understand instructions. If this is the case, then please explain.
Please respond with how your disabilities, impairments, or conditions interfere with your ability to understand directions and instructions which are spoken to you. Please keep in mind that your pain, or mental health impairments, may impact your ability to understand instructions. If this is the case, then please explain.
Please respond with how your physical and mental health disabilities, impairments, or conditions interfere with your ability to interact with supervisors, bosses, landlords, teachers, law enforcement, etc.
Please check “Yes” if your physical or mental health disabilities, impairments, or conditions have resulted in job loss, dismissal, termination, or suspension. Furthermore, respond with any warnings, probationary periods, or reduction of hours you have experienced as results of your physical or mental health disabilities.
However, if your physical or mental health disabilities, impairments, or conditions have never resulted in job loss, dismissal, termination, or suspension, then please check “No”.
Please respond with how your physical and mental health disabilities, impairments or conditions impact your ability to handle stress. Please keep in mind that pain and anxiety both contribute to stress. In addition, please mention how stress impacts your everyday life.
Stress is a feeling of emotional or physical tension that makes you frustrated, angry, or nervous.
Please respond with how your physical and mental health disabilities, impairments, or conditions impact your ability to respond to changes in routine.
For example, have your physical or mental health impairments interfered with your ability to maintain a sleep schedule, maintain your hygiene, prepare meals, or interact with others. Please keep your disabilities and impairments in mind while responding to this question.
Please respond with how your physical and mental health disabilities, impairments or conditions have impacted your normal and usual habits and behavior. Additionally please explain if you are now fearful for your health, safety, or well-being as a result of being physically or mentally impaired.
Please respond by checking any and all boxes for assistive devices you have used, or are using, as a result of your disabilities, impairments, or conditions.
Please check “Other” if you use a tens unit, pacemaker, catheter, defibrillator, electrical stimulation device, incontinence pouch, medication port, diabetic monitor, etc., or any other surgically installed, or medically necessary assistive device. Please explain.
Please respond, to the best of your ability, as to which of the assistive devices you use, were prescribed by a doctor, given to you in an emergency room, recommended by a treating source,or even purchased from a pharmacy or a surgical supply store.
Please respond, to the best of your ability, as to when any of the assistive devices you use were prescribed or recommended by a doctor or a treating source, became necessary.
Please respond to as to how often, and under what circumstances, you use an assistive device.
Please check “Yes” if you take any medications both prescribed and over-the-counter, for your physical and mental health impairments. This includes medications you take on a set schedule, or on an as-needed basis. This includes tablets, injections, inhalers, ear and eye drops, suppositories, patches for pain, etc.
If you do not take any medications, then please check “No”.
Please check “Yes” if any of your medications have side effects. A side effect is an unintended consequence of a medication. For example this can include dizziness, confusion, fatigue, tiredness, headaches, anxiety, irritability, anger, stomach or abdominal discomfort, giddiness, etc.
Please explain in the space provided.
Please respond with any information about your physical or mental health impairments which impact your ability to work. If there is something unique about your disabilities or impairments which you would like for Social Security to know, please use this section to explain.
Alternatively, you can also choose to leave this section blank if this form covered how your physical and mental health impairments impact your life.
If you have filled out this form on your own, and without the assistance of anyone else, please fill in your own name, address, email address, city, state, and ZIP Code. Please also date this form.
If however, you received assistance in reading, writing, understanding, or responding to this form, then please mention the name and contact information of the person who assisted you.
Thank you for taking the time to carefully respond to this form. It is used by the Social Security Administration as part of the process in determining if you are able to work.
Please reach out to our office 1-800-652-9626 if you do not understand, or if you have any difficulty responding to any portion of this form.
Thank you for trusting Trajector Disability!