Navigating the complexities of disability assistance in North Carolina involves a plethora of paperwork and the DMA-5009 form represents a key component in this process. Crafted by the State of North Carolina Department of Health and Human Services, this comprehensive document serves as a Social History Summary for the Disabled, and it's integral in assessing an individual's eligibility and need for support services. The form meticulously gathers data across several domains, including personal identification details, the nature and onset of the impairment, a detailed account of the claimant's work history and vocational skills, educational background, and a thorough listing of medical consultations related to the disability. Additionally, it probes into the claimant's daily life and how their disability impacts their routine activities and work capabilities. The DMA-5009 form also emphasizes the importance of vocational information, highlighting past jobs, educational achievements, and current employment status, if any. Moreover, it ensures that any mental health issues, substance abuse problems, or housing instability are flagged for appropriate referral and assistance. By compiling this critical information, the form not only facilitates a nuanced understanding of the claimant’s condition but also guides the Social Services in crafting a tailored support system. Therefore, for individuals navigating the path through disability assistance in North Carolina, understanding and accurately completing the DMA-5009 form is a vital step toward securing the necessary services and support.
| Question | Answer |
|---|---|
| Form Name | Dma 5009 Form |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | nc fast form 5009, dma 5009 form, form dma 5009, nc dma 5009 |
STATE OF NORTH CAROLINA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
SOCIAL HISTORY SUMMARY FOR THE DISABLED
______________________County Department of Social Services |
Date_______________ |
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Claimant ____________________________________ |
SSN ___________________________ |
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County Case # ________________________________ |
District # ________________________ |
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Telephone # or a number you can be reached ________________________________________
Person Providing Information and Telephone # (if different from claimant)
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Nature of Disability (based on claimant’s description or statement)
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I.Onset of Impairment
A.Date of illness or injury began_______________________________________________________________
B.Date claimant stopped work ________________________________________________________________
C.Date the illness or injury became disabling_____________________________________________________
D.If still working:
Name of Employer _______________________________________________________________________
Supervisor’s name and telephone #___________________________________________________________
Hours worked ___________________________________________________________________________
Gross earnings ____________ weekly __________ monthly ____________________________________
II.Claimant’s Description of Impairment
A. Indicate how the claimant describes the symptoms of the disability and how they affect his ability to work.
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B.Describe claimant’s daily activities and explain how the impairments affect him such as seeing, hearing, speaking, reading, walking, writing, standing, breathing, sitting, using hands, arms, and other joints. Describe how his impairments limit what he can do.
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C.Worker’s Observation of Difficulties
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III.Vocational Information (include self employment)
A. Principal Job (job done the longest in 15 years prior to onset)
1. Job Title __________________________________________________ 4. Hrs. /day _____________
2.Industry ____________________________________________________ 5. Days/week __________
3.Beginning date ______________________________________________ 6. Rate of pay/average earnings
Ending date _____________________________________________ $________per ___________
Other Jobs – List of jobs done in last 15 years prior to alleged onset date. Give approximate dates of employment ( use additional sheet if necessary)
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B.Education/Highest Grade Completed ______________________________________________________
High School Graduate?_________________________________________________________________
Name and address of school if known ____________________________________
Additional education _____ Type _______________ Is claimant currently attending school?________
Name of school and address if known ____________________________________
Can claimant read and write? ________________________________________________
IV. |
List all Medical Sources (physicians, hospitals, emergency facilities, health departments, |
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therapists, nursing homes, clinics, mental health centers,) including names and dates seen in |
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the last twelve months. Give hospital or clinic number, which is on hospital or clinic card or |
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hospital bills. (Twelve months prior to and including application month, plus any future medical |
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appointments) |
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Medical Source |
Condition Treated |
Dates Seen at Dr.’s office, |
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Name, Address, Ph. # |
EKG, |
clinic, hospital |
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Is claimant still being treated? Yes ____ |
No ____ |
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V.VR Referral ___ Yes ___ No Date last seen ______________________
VR Office ___________________________________________________
Counselor’s Name ________________________Phone #______________
VI. |
If a mental impairment is alleged, if there is evidence of drug or alcohol abuse or if the |
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person is homeless, in a shelter or in a halfway house, please give name, address and phone |
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number of someone who can be contacted as a third party. |
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Signature ____________________________ |
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Title_________________________________ |
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Telephone # __________________________ |