Form Disability Evaluation – Fill Out and Use This PDF

	Form Approved
Social Security Administration	OMB. No. 0960-0568

CHILDHOOD DISABILITY EVALUATION FORM

I. SUMMARY

A.IMPAIRMENTS:

B.DISPOSITION: Check one entry that best describes your findings in this case. Complete this section last.

1. NOT SEVERE - No medically determinable impairment OR impairment or combination of impairments

is a slight abnormality or a combination of slight abnormalities that results in no more than minimal functional limitations. (Explain below.)

Explanation:

									Continued in Section III
2.				MEETS LISTING				. (Cite complete Listing and subsection(s),
				including any applicable B criteria for 112.00.)
3.				MEDICALLY EQUALS LISTING					. (Cite complete Listing and

subsection(s), including any applicable B criteria for 112.00 and explain below.) Explanation:

Continued in Section III

4. FUNCTIONALLY EQUALS THE LISTINGS - The child's medically determinable impairment or combination

of impairments results in marked limitations in two domains or an extreme limitation in one domain (Explained in Section II A&B), OR the impairment or combination of impairments is one of the examples cited in POMS

DI 25225.060 (20 CFR 416.926a(m)), example #

(Explained in Section III.)

5. IMPAIRMENT OR COMBINATION OF IMPAIRMENTS IS SEVERE, BUT DOES NOT MEET, MEDICALLY EQUAL, OR FUNCTIONALLY EQUAL THE LISTINGS. (Explained in Section(s) II A&B and, if applicable, III.)

6. DOES NOT MEET THE DURATION REQUIREMENT - The child's medically determinable impairment(s) is or was of listing-level severity, but is not expected to be, or was not, of listing-level severity for 12 continuous months, and is not expected to result in death. (Explained in Section(s) IIA&B and, if applicable, III.)

7.

Other (Specify)

(Explained in Section III.)

Form SSA-538-F6 (1-2001) ef (10-2004)	1
Use Prior Editions

C. ASSESSMENT OF FUNCTIONING THROUGHOUT SEQUENTIAL EVALUATION

I affirm, by signing below, that when I evaluated the child's functioning in deciding:

•If there is a severe impairment(s);

•If the impairment(s) meets or medically equals a listing (if the listing includes functioning in its criteria); and

•If the impairment(s) functionally equals the listings;

I considered the following factors and evidence.

FACTORS:

1.How the child's functioning compares to that of children the same age who do not have impairments; i.e., what the child is able to do, not able to do, or is limited or restricted in doing.

2.Combined effects of multiple impairments and the interactive and cumulative effects of an impairment(s) on the child's activities, considering that any activity may involve the integrated use of many abilities. So,

•A single limitation may be the result of one or more impairments, and

•A single impairment may have effects in more than one domain.

3.How well the child performs activities with respect to:

•Initiating, sustaining, and completing activities independently (range of activities, prompting needed, pace of performance, effort needed, and how long the child is able to sustain activities);

•Extra help needed (e.g., personal, equipment, medications);

•Adaptations (e.g., assistive devices, appliances);

•Structured or supportive settings (e.g., home, regular or special classroom), including comparison of functioning in and outside of setting, ongoing signs or symptoms despite setting, amount of support needed to function within regular setting.

4.Child's functioning in unusual settings, (e.g., one-to-one, a CE) vs. routine settings (e.g., home, childcare, school).

5.Early intervention and school programs (e.g., school records, comprehensive testing, IEPs, class placement, special education services, accommodations, attendance, participation).

6.Impact of chronic illness, characterized by episodes of exacerbation and remission, and how it interferes with the child's activities over time.

7.Effects of treatment, including adverse and beneficial effects of medications and other treatments, and if they interfere with the child's day-to-day functioning.

EVIDENCE:

For all dispositions, wherever appropriate, I have explained how I considered the medical, early intervention, school/pre-school, parent/caregiver, and other relevant evidence that supports my findings, how I weighed medical opinion evidence, evaluated physical and mental symptoms, resolved any material inconsistencies, and weighed evidence when material inconsistencies in the file could not be resolved. I have considered and explained test results in the context of all the other evidence.

The consultant with overall responsibility for the findings in this SSA-538 must complete the first signature line (See DI 2523O.OOlB4). If any additional consultants provided input to these findings, they must also sign in the boxes following.

THESE FINDINGS COMPLETE THE MEDICAL PORTION OF THE DISABILITY DETERMINATION.

Form SSA-538-F6 (1-2001) ef (10-2004)

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II. FUNCTIONAL EQUIVALENCE

Consider functional equivalence when the child's medically determinable impairment(s) is "severe" but does not meet or medically equal a listing. An impairment(s) functionally equals the listings if it results in "marked and severe functional limitations," i.e., the impairment(s) causes "marked" limitations in two domains or an "extreme" limitation in one domain. FOR DEFINITIONS OF "MARKED" AND "EXTREME" see page 5.

Describe and evaluate the child's functioning in all domains; see POMS DI 25225.025-.055 (20 CFR 416.926a(f)-(I)). Then discuss the factors that apply in the child's case and how you evaluated the evidence as described in Section IC above and in POMS DI 25210.001ff. (20 CFR 416.924a). Rate the limitations that result from the child's medically determinable impairment(s).

Check one box for each domain to indicate the degree of limitation assessed.

A.DOMAIN EVALUATIONS

Continued in Section III

Continued in Section III

Continued in Section III

Form SSA-538-F6 (1-2001) ef (10-2004)

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A. DOMAIN EVALUATIONS (continued)

Continued in Section III

Continued in Section III

Continued in Section III

Form SSA-538-F6 (1-2001) ef (10-2004)

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B. CONCLUSION

Does the impairment or combination of impairments functionally equal the listings?

Yes -- Marked limitation in two domains; findings explained in Section IIA.

Marked limitation See POMS DI 25225.020B (20 CFR 416.926a(e)(2)).

The impairment(s) interferes seriously with the child's ability to independently initiate, sustain, or complete domain-related activities. Day-to-day functioning may be seriously limited when the child's impairment(s) limits only one activity or when the interactive and cumulative effects of the child's impairment(s) limit several activities.

•"More than moderate" but "less than extreme" limitation (i.e., the equivalent of functioning we would expect to find on standardized testing with scores that are at least two, but less than three, standard deviations below the mean), or

•Up to attainment of age 3, functioning at a level that is more than one-half but not more than two-thirds of the child's chronological age when there are no standard scores from standardized tests in the case record, or

•At any age, a valid score that is two standard deviations or more below the mean, but less than three standard deviations, on a comprehensive standardized test designed to measure ability or functioning in that domain, and the child's day-to-day functioning in domain-related activities is consistent with that score.

For the "Health and Physical Well-Being" domain, we may also find a "marked" limitation if the child is frequently ill or has frequent exacerbations that result in significant, documented symptoms or signs. For purposes of this domain, "frequent" means episodes of illness or exacerbations that occur on an average of 3 times a year, or once every 4 months, each lasting 2 weeks or more. We may also find a "marked" limitation if the child has episodes that:

•occur more often than 3 times in a year or once every 4 months but do not last for 2 weeks, or

•occur less often than an average of 3 times a year or once every 4 months but last longer than 2 weeks, if the overall effect (based on the length of the episode(s) or its frequency) is equivalent in severity.

Yes -- Extreme limitation in one domain; findings explained in Section IIA.

Extreme limitation See POMS DI 25225.020C (20 CFR 416.926a(e)(3)).

The impairment(s) interferes very seriously with the child's ability to independently initiate, sustain, or complete domain-related activities. Day-to-day functioning may be very seriously limited when the child's impairment(s) limits only one activity or when the interactive and cumulative effects of the child's impairment(s) limit several activities. "Extreme" describes the worst limitations, but does not necessarily mean a total lack or loss of ability to function.

•"More than marked" limitation (i.e., the equivalent of the functioning we would expect to find on standardized testing with scores that are at least three standard deviations below the mean), or

•Up to attainment of age 3, functioning at a level that is one-half of the child's chronological age or less when there are no standard scores from standardized tests in the case record, or

•At any age, a valid score that is three standard deviations or more below the mean on a comprehensive standardized test designed to measure ability or functioning in that domain, and the child's day-to-day functioning in domain-related activities is consistent with that score.

For the "Health and Physical Well-Being" domain we may also find an "extreme" limitation if the child is ill or has frequent exacerbations that result in significant, documented symptoms or signs substantially in excess of the requirements for showing a "marked" limitation. However, if the child has episodes of illness or exacerbations of the impairment(s) that we would rate as "extreme" under this definition, the impairment(s) should meet or medically equal the requirements of a listing in most cases.

No -- Findings explained in Section IIA.

Form SSA-538-F6 (1-2001) ef (10-2004)

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III. EXPLANATION OF FINDINGS

Use this section:

·To explain any functional equivalence "example" cited in disposition 4;

·To explain disposition 7;

·For any continued explanation of dispositions 1, 3, 5, and 6, or functional equivalence findings that do not fit into Section II;

·To discuss any relevant factors and evidence not explained elsewhere; e.g., how you weighed evidence when material inconsistencies in the file could not be resolved;

·At the discretion of the adjudicative team, to explain disposition 2; to make clear other issues particular to individual cases; to record all of the required elements of a rationale rather than on an SSA-4268-U4/C4 per POMS DI 25235.001.

The Privacy and Paperwork Reduction Acts

The Social Security Administration is authorized to collect the information on this form under sections 1614 and 1633 of the Social Security Act. The information on this form is needed to make a decision on a claim for benefits. Completion of this form is required under 20 CFR section 416.924(g). If you do not provide the requested information, we may not be able to make a decision on the child's claim for benefits. Although this information is almost never used for any purposes other than making a determination about the child's claim, the information may be disclosed to another person or governmental agency as follows: (1) to enable a third party or agency to assist Social Security in establishing rights to benefits and/or coverage; (2) to comply with Federal laws requiring the release of information from Social Security Administration records (e.g., to the General Accounting Office and the Department of Veterans Affairs); and (3) to facilitate statistical research and such activities necessary to assure the integrity and improvement of the Social Security Programs (e.g., to the Bureau of the Census and private concerns under contract to Social Security).

We may also use this information when we match records by computer agencies. Many agencies may use matching programs to find or prove that a person qualifies for benefits paid by the Federal government. The law allows us to do this even if you do not agree to it.

Explanations about these and other reasons why this information you provide may be used or given out are available in Social Security offices. If you want to learn more about this, contact any Social Security office.

This information collection meets the requirements of 44 U.S.C. § 3507, as amended by Section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take about 25 minutes to read the instructions, gather the facts, and answer the questions. You may send comments on our time estimate above to: SSA, 1338 Annex Building, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.

Form SSA-538-F6 (1-2001) ef (10-2004)

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