Form Ha 1152 U3 – Fill Out and Use This PDF

Enter the name of the individual and the social security number.

Assist in determining this individual's ability to do work-related activities on a sustained basis. “Sustained basis” means the ability to perform work-related activities eight hours a day for five days a week, or an equivalent work schedule (SSR 96-8p). Give your professional opinion of what the individual can still do despite his/her impairment(s). The opinion should be based on your findings with respect to medical history, clinical and laboratory findings, diagnosis, prescribed treatment and response, and prognosis. For each activity shown, respond to the questions about the individual's ability to perform the activity. When doing so, use the following definitions for the rating terms: None - Absent or minimal limitations. If limitations are present they are transient and/or expected reactions to psychological stresses. Mild - There is a slight limitation in this area, but the individual can generally function well. Moderate - There is more than a slight limitation in this area but the individual is still able to function satisfactorily. Marked - There is serious limitation in this area. There is a substantial loss in the ability to effectively function. Extreme - There is major limitation in this area. There is no useful ability to function in this area. It is very important to describe the factors that support your assessment. (1) Is ability to understand, remember, and carry out instructions affected by the impairment? Check No or Yes. If “no,” go to question #2. If “yes,” please check the appropriate block to describe the individual's restriction for the following work-related mental activities.

Check None, Mild, Moderate, Marked or Extreme for: understand and remember simple instructions; carry out simple instructions; the ability to make judgments on simple work-related decisions; understand and remember complex instructions; carry out complex instructions; the ability to make judgments on complex work-related decisions.

Identify the factors (e.g., the particular medical signs, laboratory findings, or other factors) that support your assessment.

(2) Is ability to interact appropriately with supervision, co-workers, and the public, as well as respond to changes in the routine work setting, affected by impairments? Check No or Yes. If “no,” go to question #3. If “yes,” describe the individual's restriction for the following work-related mental activities by checking the appropriate block.

Check None, Mild, Moderate, Marked or Extreme for: interact appropriately with the public; interact appropriately with supervisor(s); interact appropriately with co-workers; respond appropriately to usual work situations and to changes in a routine work setting.

Identify the factors that support your assessment.

(3) Are any other capabilities affected by the impairment? Check No or Yes. If “yes,” please identify the capability and describe how it is affected.

Identify the particular medical signs, laboratory findings, or other factors that support your assessment.

(4) The limitations are assumed to be your opinion regarding current limitations only. However, if you have sufficient information to form an opinion within a reasonable degree of medical or psychological probability as to past limitations, on what date were the limitations you found first present? (5) If the claimant's impairment(s) include alcohol and/or substance abuse, do these impairments contribute to any of the claimant's limitations as set forth? If so, please identify and explain what changes you would make to your answers if the claimant was totally abstinent from alcohol and/or substance use/abuse.

(6) Can the individual manage benefits in his/her own best interest? Check No or Yes. Add your Signature and Date, and Print Name, Title and Medical Specialty (Legibly Please).

The office is listed under U.S. Government agencies in your telephone directory, or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778).