ARIZONA DEPARTMENT OF ECONOMIC SECURITY DISABILITY DETERMINATION SERVICE 4710 S PALO VERDE ROAD TUCSON, AZ 85714 LOCAL (520) 638-2000 TOLL FREE 1-(800) 362-6368 “e Date: May 17, 2024, Case ID: 10463695 NEVAEH WHITE 20716 N 60TH DR GLENDALE.AZ 85308-6764 oy m ‘We are the office that makes disability decisions forthe Social Security Administration. We are writing to you because We ‘need more information about Jenna Christine White’ is (e's condition, daily activities, or work history. Jenna Christine White gave us YouF name asa person who would beable o provide us witht Information, 7 ‘What You Need To Do Complete the enclosed form(s) to the best of your ability based on your knowledge. Please use black or blue ink and return Covrla tes eeased fern) y y your knowledge. Please use black or blue ink and retu How To Return The Form(s) ‘You may use the enclosed return envelope or fax your completed form(s) to us at (866) 820-4376. Please note the return a may bbe'to a scanning center who works with us. The completed form(s) must include the barcode page on top of the form(s). «| If You Have Any Questions If you have any questions or wish to provide more information, please call us atthe number(s) shown below Monday - Friday between B:00 am and 5:00 pm. When you call or leave a message, please provide the Case ID: 10463695, your name, Jenna Christine White's name, and a call back number. ‘Thank you for your help. Renee C/CAR/Joshua R/JJR (520) 638-0034 (866) 820-4378 (FAX) Enclosure(s): ‘§$A-3380 BK Function Report - Adult - Third Party Return Envelope iii 9 10463555) Assigned JR U4Y DCPS // OMB No. 09600555 50022168 i aan areata2 f Form $8a.3373 . (10-2020) 4 escontinue Prior Editions Page 3 of 10 2! Secunty Administration (OMB No. 0960-0681 FUNCTION REPORT - ADULT 5 How your ilinesses, injuries, or conditions limit your activities a Do not write in this box. pao: ES 34087 SITEsvi6 ons + *DOCTYPetee7s web sites tS ‘Anyone who makes or causes to be made a false statement or representation of material fact for use in determining @ payment underthe Social Security Act, or knowingly conceals or fails to disclose an event with an intent to affect an initial oF continued right to payment, commits a crime punishable under Federal law by fine, imprisonment, or both, and may be subject fo administrative sanctions. ¢ ‘SECTION A - GENERAL INFORMATION 1. NAME OF DISABLED PERSON (First, Middle Inifal, Lasi) [2. SOCIAL SECURITY NUMBER Jenna Christine white 3. YOUR DAYTIME TELEPHONE NUMBER (If there is no telephone number where you can be reached, please give us a daytime number where we can leave a message for you.)n Form $8A-3380-8K (10-2020) papal a SECTION C- INFORMATI ION ABOUT DAILY ACTIVITIES “Tbe what the disabled person does from the ime helahe wakes up unt gomngio bed wien mel os LE Se Fees ner dogs (SAY Very WHE Oehivity, YON | Orber qyories omine And apes fo sieep eariy. 10, Does this person take care of anyone el arandchitiren, parents, fend, other? re ON "YES," for whom does he/she care, and what does he/she do for them? SMe Vaves care OF Buy ad dovgnrery She ‘. COOKS Meals) mawed Sure She Jets or tna WUS+ uch a8 a wifefhusband, children, 11, Does heshe take care of pes orator animale? Wve Ot \E-YES; what does helshe do for them? He Feely Her REE 1 BES Yhem wallrs And Vet Anem play svrside , 12, Does anyone help this person care for other people or animals? Yeo No If "YES," who helps, and what do they do to help? eMYSEIE AND WET Aerdrror HVED \ner (ESO BOSS | viqent care , FHends house. 73. What was the disabled person able to do before his/her linesses, injuries, or conditions that helshe can't do now? SINCE We rad o WIA \NJECr) Mae efecetS OF Me ‘rama wave ercectcch wes Bead dear ey ond rortihy AO Locus OB give WET Des pretorman work. . 44, Do the ilinesses, injuries, or conditions affect his/her sleep? De ves No | YES," how? Ned Boe Mes She Seep? Me winsie day And AUSE HOF SieeP I Ame signt + Spe docs Woue- 2 eropem Beet s Schedure - TEPERSONAL GARE (Gheckhere [2] if NO PROBLEM wih personal care) «9, Explain how the illnesses, injuries, or conditions effec this person's ability to: Use the toilet troo Dress Bathe a. = Care fori = shave = Feed sot = Other ohPage 5 of Form $SA-3380-BK (10-2020) B. Does hae need any speci reminders oak ae of crrves Ne Personal needs ana grooming? I-YES," what type of help or reminders are needed? Does helshe need help or reminders taking medicine? beves No I(-YES," what king of help does helshe need? > mom forggtS *O awe er medicarion J For coon OF and asus me to raue nem ko ger Snes MEAS 2. Does the disabled person prepare hia/her own meals? fH Yes No Yes wal ingle pp? or exaple sani, fozen ne, cron met JED) Frozen dimers OF eon re Mave meats. How often des helshe prepare food or meals? (For examele, daly, weekly monthly) 3 every obser day i How long dose tiake Hine? ON) our gf Zomin ‘Any changes in cooking habits since the illness, injuries, or conditions began? doesnt ea 05 much 0% She did besore brain ingery b I/-No expla why halshe canat or does not prepare meas 17. HOUSE AND YARD WORK «List household chores, both indoors and outdoors, thatthe disabled person is able to do Feoraxample clesning. laundry, household repas, roning, mowing et) Cane 4 \avndtu +. How much time do chores tke, and how often does helshe do each ofthese things? Spe cleans every ueele ov! docs \aunduy every Oler Wweele = oes helshe need help or encouragement doing these things? Cre Ow \1-YES." whet hop is needed? yes + She necds Welp Wi _Mmanrenance OF tne rouse jor Worle, tegars + snesFem $84-9380-8K (10.2035 Page 6 of 10 @.tthe ; a tae Porson doesn do house or yard work, expla why not of wn ee For ee MS YA worl. and manteranc Kec up Wwith, 18. GETTING AROUND 2. How often does this person go outside? 1 ro then WHE 40 never "he/she doesn't {90 out a al, explain why not, S2aa\_ ato, WIG AS DONE And Was Aynust AO semnsor Aiton ®: When golng ou, how does helshe travel? (Check a snt apply.) O Wak * O Drive a car DR Ride in acer OF Ride a bicycle ob Use pubtic transportation Other (Expiain) ©. When going out, can he/she go out alone? O Yes [No Pak out ae IF-NO.” explain why helshe cant go out alone. i 4. Does the disabled person crive? Ci ves fi No Ithelshe doesn't drive, explain why not me doesnt Ane peawse WW wecame ROUTES COL Coc HES OFter er Car Was Stoten, 19, SHOPPING : 2. I the disabled person does any shopping, does heise shop: (Check al hat apo) O instores #8 By phone 1 by mai JD By computer b. Describeiwhat he/she shops for Food per CAC 3 Rady) Core ‘c. How often does he/she shop and how long does it tke? Once. every Ho WEEES 4 her awility Yo ma¥e decisions Ves yncresed Aime we lake her. 20, MONEY a: I helshe able to Pay bis fave ON Handea caving account =] vad Count change Ql ves ©] No Use a checkbookimoney orders Yes cunt change Explain ll"NO* answers She doesnt have any Suvinas AOUUANV EM APage 7 of 19 Form $SA-3380-BK (10-2020) .Has the dab persons ably to handle money changed since Wee” the lnesses, injures, or conditions began? I1-YES, explain now the aby to handle money has changed She ddeont ave Meh Money and Mat wills arent Pad on me 21 HOBBIES AND INTERESTS 2. What are his her hobbies and interests? (For exemple, reading, watching T, sewing, playing sports, etc) ASM, wwatetiey Wy and creating ontne soe ai »b. How often end how well does he/she do these things? AIIY» Te deer & we performance «©. Describe ay chenges in these activites since the ilnesses. injures, oF conditions began. Fete aipiilty bo concenete , Fememnloe MAiNngs hes Changedt Wer performers 22. SOCIAL ACTIVITIES 2. How does the disabled person spend time with others? (Check al that apply.) 1 inpersoi On the phone OF Email 1 Texting OD ait aL Video Chat for example Skype or Facatma) [Other (Explain) », Desenbe the kinds of things helshe does with others Cornpreahe> WS, COs “WP \wila dougater s How offen des hlahe do these things? SIE Re tno predine S cons center, sports events, social groups, ete) ier he apes VS Wwe Oforeu, Does helshe need to be reminded to oo places? five Ono : How olten does helshe go and how much does he/she take part? Tonce a week Does he/she need someone to accompany hinvher? ves Oh No- Page 8 of 10 Form S$A-2380-BK (10-2020) 4, Does thi person te rave an} lems getting along with family, friends, “x Aeghbog, or others?” AUBEME geting along wan fami fl ve, YES," explain, e re ee SOIL Cr nternteck sand nee anxielY) ove-welim: - wer’ ° Deserbe any changes i socal activities since ihe lnesses, injuries, or conditions bagan. OVX CM and Wwss OF Hormpor ation, Ons ie aia as Shp Seca aciunys SECTION D- INFORMATION ABOUT ABILITIES 2-2. Check ony ofthe folowing Hem the Gaabid person's Messe, Turon ercondivons ise | OD uting OF Watking C0 Staiectming 1 Understanding Oi squat) sag =e 1 Fotowngigiucions Bending kneeling BL Memory Using Hends 0 Sanding Taming Kd compltng Tests JZ} eting Aang wih Other D Reaching Hearing Concentration horene 22th how she tiesses, ras, of ondltons alec ach ofthe tems you checkad (For exeme hhelshe can only th '9w many pounds], or he/she can only walk [how far]} Diomedesinipmen Kf retehanee? E unvancer © How far gan helshe walk before needing to stop and rest? wet lke IT helsh hes to rest, how long belorehelshe can resume walking? 4. For how long can the dlsabled person pay attention? ©. Does the cisabied person finish whet he/she st arts? (For example, a conversation, ‘chores, reacing, watching @ movie.) ves of No £ How well does the cisebied person folow writen instructions? (For example, @ recipe.) Wl “See urs Wouisle Cementecina ogc Concent 8: How well does the csabled person folow spoken instructs? “Nit 0 wal, Wneruu>e She Iwas istues, Cementberi ny What vooS sacl 20483695Page9o'”" Form SSA-3380-BK (10-2020) F ses, landlords oF h. How wel does he cabled person get along wth authory Sues For example oe, Paes m1 teachers ) WS Conch towses Wer 10 ioe understanding ae lee eer ben tro af fom 2b basa of bere vw oOo” ~ geting lng ith ter penis? W-YES? please explain Ss ued Neccavee in toi andl tore dein ner divorce She WAS Prose H-YES- please aive name of employer. en ic |. How well does the cisabled person handle strass? WO Vouk 0F Hes VD ner x ee _ainie 10 nandie well a + How wal dost hefshe handle changes in routine? ' ne “wk needs me Yo_adiyst ‘ L |. Have yoo noticed any unusual behavior or fears in the disabled person? ives One W-YES> please expiain Poatoid to Ave 5 00 Sexsal BANK§ 24. Does the disabled person use any ofthe folowing? (Check af that apply.) crutches Co Cane 1D Hearing Aid 1 Walker C Bracerspint 1 Glasses/Contact Lenses O Whestchair DF Astincia Limb Antica! Voice Box Tr Ofer (emien) ‘Which of these were prescribed by @ doctor? a When was't prescribed? ‘When does this person need to use these aids? re. Page 10 of 10 Form SSA-3380-BK (10-2020) = es No 25, Does the disables person cent take any medicines for hier ines m2 injuries, or conditions? q "YES," do any of the medicines cause side effects? re oe q I1-YES plese expan (Oo nol it allo ne melee athe abled paron aks, List ony ne nesees that cause sige effects forthe isables parson NAME OF MEDICINE ‘SIDE EFFECTS PERSON HAS Awokit ine Gyceping, Addera\ yee) ANd conceNMeaticrn, N Bupsoony : ‘SECTION Use this section for any added information you did not show in {are done with this section (or if you didn’t have anything to add), the bottom of this pa ‘carller paris of this form. When you be sure to complete the fields at lane _Whae Tae ORDA) Fen oor pardon completing his form (Please pint) 207i wo” De. ear aust | ‘FaGrass (Namber and Street) [Email address (optional) — = Tae ZF Coe = Mende t ¥e3oG :rm SSA-3380-BK (10-2020) - Page 10 of 10 25. Does the disabled person cu y i led person currently take any medicines for hishherilnesses, vee e injuries, or conditions? eer agen eer eget! 8 a YES," do any of the medicines cause side effects? Ble ON \W"YES," please explain. (Do not lst all ofthe medicines that the disabled person tokes. List only the medicines that cause side effects for the disabled person.) NAME OF MEDICINE SIDE EFFECTS PERSON HAS LwoXt ine Beeping Addera “Nee, OMA conceNteatiern wel Byrein , Bohan fools ond aced SECTION E - REMARKS Use this section for any added information you did not show in earlier parts of this form. When you are done with this section (or if you didn’t have anything to add), be sure to complete the fields a the bottom of this page. jabs hae. This form (Please print) Date (hiMIDDIVYYY) Darden completing tis frm (Please pri : rm Os-ar2 2014 ude [Email address (optional) Zairess (amber and Steet) Sate iP Code i (2 ¥S3OG Clendale