mental residual functional capacity assessment - SSAConnect

MENTAL RESIDUAL FUNCTIONAL CAPACITY ASSESSMENTNAMESOCIAL SECURITY NUMBERCATEGORIES (From IB of the PRTF)ASSESSMENT IS FOR:Current Evaluation12 Months After Onset:Date LastInsured:Other:(Date)(Date)to(Date)(Date)I.SUMMARY CONCLUSIONSThis section is for recording summary conclusions derived from the evidence in file. Each mental activity is to be evaluated withinthe context of the individual's capacity to sustain that activity over a normal workday and workweek, on an ongoing basis. Detailedexplanation of the degree of limitation for each category (A through D), as well as any other assessment information you deemappropriate, is to be recorded in Section III (Functional Capacity Assessment).If rating Category 5 is checked for any of the following items, you MUST specify in Section II the evidence that is needed to makethe assessment. If you conclude that the record is so inadequately documented that no accurate functional capacity assessmentcan be made, indicate in Section II what development is necessary. but DO NOT COMPLETE SECTION III.Not No Evidence of Not Ratable onSignificantly Moderately Markedly Limitation in this AvailableLimited Limited Limited Category EvidenceA.UNDERSTANDING AND MEMORY1.The ability to remember locations andwork-like procedures.1.2.3.4.5.2.The ability to understand and remembervery short and simple instructions.1.2.3.4.5.3.The ability to understand and rememberdetailed instructions.1.2.3.4.5.B.SUSTAINED CONCENTRATION AND PERSISTENCE4.The ability to carry out very short andsimple instructions.1.2.3.4.5.5.The ability to carry out detailed instructions.1.2.3.4.5.6.The ability to maintain attention andconcentration for extended periods.1.2.3.4.5.7.The ability to perform activities within aschedule, maintain regular attendance.and be punctual within customary tolerances.1.2.3.4.5.8.The ability to sustain an ordinary routinewithout special supervision.1.2.3.4.5.9.The ability to work in coordination withor proximity to others without being distractedby them.1.2.3.4.5.10.The ability to make simple work-relateddecisions.1.2.3.4.5.Form SSA-4734-F4-SUP (8-85) 1

NotSignificantlyLimitedModeratelyLimitedMarkedlyLimitedNo Evidence ofLimitation in thisCategoryNot Ratable onAvailableEvidenceContinued—SUSTAINED CONCENTRATIONAND PERSISTENCEII.11.The ability to complete a normal workdayand workweek without interruptionsfrom psychologically based symptomsand to perform at a consistent pacewithout an unreasonable number andlength of rest periods.C. SOCIAL INTERACTION12.13.14.15.16.The ability to interact appropriately withthe general public.The ability to ask simple questions orrequest assistance.The ability to accept instructions and respondappropriately to criticism fromsupervisors.The ability to get along with coworkersor peers without distracting them or exhibitingbehavioral extremes.The ability to maintain socially appropriatebehavior and to adhere to basicstandards of neatness and cleanliness.D. ADAPTATION17.18.19.20.The ability to respond appropriately tochanges in the work setting.The ability to be aware of normal hazardsand take appropriate precautions.The ability to travel in unfamiliar placesor use public transportation.The ability to set realistic goals or makeplans independently of others.1.1.1.1.1.1.1.1.1.1.REMARKS: If you checked box 5 for any of the preceding items or it any other documentation deficiencies were identified,you must specify what additional documentation is needed. Cite the item number(s), as well as any other specific deficiency,and indicate the development to be undertaken.2.2.2.2.2.2.2.2.2.2.3.3.3.3.3.3.3.3.3.3.4.4.4.4.4.4.4.4.4.4.5.5.5.5.5.5.5.5.5.5.Continued on Page 3Form SSA-4734-F4-SUP (8-85)2

Ill. FUNCTIONAL CAPACITY ASSESSMENTContinued on Page 4Record in this section the elaborations on the preceding capacities. Complete this section ONLY after the SUMMARYCONCLUSIONS section has been completed. Explain your summary conclusions in narrative form. Include any informationwhich clarifies limitation or function. Be especially careful to explain conclusions that differ from those of treating medical sourcesor from the individual's allegations.MEDICAL CONSULTANT'S SIGNATUREDATEContinued on Page 4Form SSA-4734-F4-SUP (8-85) 3

Continuation Sheet—Indicate section(s) being continued.Form SSA-4734-F4-SUP (8-85) 4*U.S. Government Printing Office: 1989-241-312/80099