Ssa 4734 F4 Sup PDF Details

The SSA 4734 F4 SUP form, known as the Mental Residual Functional Capacity Assessment, plays a critical role in evaluating individuals' mental capabilities in the context of social security disability benefits. This comprehensive document assesses various mental activities to determine an individual's ability to function in a working environment over a normal workday and workweek, on a continuous basis. The form is structured to capture detailed information across four main categories: Understanding and Memory, Sustained Concentration and Persistence, Social Interaction, and Adaptation. Each category meticulously evaluates the degree of limitation in specific mental activities, ranging from the ability to remember locations and work-like procedures to the capacity for social interaction and adaptation to changes in the work setting. Notably, the form insists on evidence-based conclusions, urging assessors to specify additional documentation needed if substantial limitations are identified or if the records are inadequately documented for a precise assessment. Additionally, the form provides space for elaborate narrative explanations in the Functional Capacity Assessment section, ensuring that summary conclusions are thoroughly explained, thereby accommodating discrepancies between medical sources or the individual’s assertions and the assessor's findings. This careful consideration of mental health in assessing work capacity underscores the form's importance in the process of adjudicating social security disability claims.

QuestionAnswer
Form NameSsa 4734 F4 Sup
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesssa 4734 f4 sup pdf, residual functional capacity assessment, mental residual capacity, social security form ssa 4734 f4 sup

Form Preview Example

MENTAL RESIDUAL FUNCTIONAL CAPACITY ASSESSMENT

NAME

SOCIAL SECURITY NUMBER

CATEGORIES (FROM IB OF THE PRTF)

ASSESSMENT IS FOR:

Current Evaluation

Date Last

Insured:

(DATE)

Other:to

(DATE)

12 Months After Onset:

(DATE)

(DATE)

I.SUMMARY CONCLUSIONS

This section is for recording summary conclusions derived from the evidence in file. Each mental activity is to be evaluated within the context of the individual's capacity to sustain that activity over a normal workday and workweek, on an ongoing basis. Detailed explanation of the degree of limitation for each category (A through D), as well as any other assessment information you deem appropriate, 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 make the assessment. If you conclude that the record is so inadequately documented that no accurate functional capacity assessment can be made, indicate in Section II what development is necessary. but DO NOT COMPLETE SECTION III.

A.UNDERSTANDING AND MEMORY

1.The ability to remember locations and work-like procedures.

2.The ability to understand and remem- ber very short and simple instructions.

3.The ability to understand and remem- ber detailed instructions.

Not

Significantly

Limited

1.

1.

1.

 

 

 

 

 

 

No Evidence of

Not Ratable on

Moderately

Markedly

Limitation in this

Available

Limited

Limited

Category

Evidence

2.

 

 

3.

 

 

4.

 

 

5.

 

 

 

 

 

 

 

 

 

 

2.

 

 

3.

 

 

4.

 

 

5.

 

 

 

 

 

 

 

 

 

 

2.

 

 

3.

 

 

4.

 

 

5.

 

 

 

 

 

 

 

 

 

 

B.SUSTAINED CONCENTRATION AND PERSISTENCE

4.

The ability to carry out very short and

1.

 

simple instructions.

 

 

5.

The ability to carry out detailed instruc-

1.

 

tions.

 

 

6.

The ability to maintain attention and

1.

 

concentration for extended periods.

 

 

7.

The ability to perform activities within a

 

 

schedule, maintain regular attendance.

1.

 

and be punctual within customary toler-

 

 

 

ances.

 

8.

The ability to sustain an ordinary routine

1.

 

without special supervision.

 

 

9.

The ability to work in coordination with

 

 

or proximity to others without being dis-

1.

 

tracted by them.

 

10. The ability to make simple work-related

1.

decisions.

 

2.

 

3.

 

4.

 

5.

2.

 

 

4.

 

5.

 

3.

 

 

2.

 

3.

 

4.

 

5.

 

 

 

2.

 

 

4.

 

5.

 

3.

 

 

2.

 

3.

 

4.

 

5.

 

 

 

2.

 

 

4.

 

5.

 

3.

 

 

2.

 

3.

 

4.

 

5.

 

 

 

Form SSA-4734-F4-SUP (8-85)

1

Continued—SUSTAINED CONCENTRATION

AND PERSISTENCE

11.The ability to complete a normal work- day and workweek without interruptions from psychologically based symptoms and to perform at a consistent pace without an unreasonable number and length of rest periods.

Not

 

 

No Evidence of

Not Ratable on

Significantly

Moderately

Markedly

Limitation in this

Available

Limited

Limited

Limited

Category

Evidence

1.

 

2.

 

3.

 

4.

 

5.

C. SOCIAL INTERACTION

12.The ability to interact appropriately with the general public.

13.The ability to ask simple questions or request assistance.

14.The ability to accept instructions and re- spond appropriately to criticism from supervisors.

15.The ability to get along with coworkers or peers without distracting them or ex- hibiting behavioral extremes.

16.The ability to maintain socially appropri- ate behavior and to adhere to basic standards of neatness and cleanliness.

1.

1.

1.

1.

1.

2.

2.

2.

2.

2.

3.

3.

3.

3.

3.

4.

4.

4.

4.

4.

5.

5.

5.

5.

5.

D.ADAPTATION

17.The ability to respond appropriately to changes in the work setting.

18.The ability to be aware of normal haz- ards and take appropriate precautions.

19.The ability to travel in unfamiliar places or use public transportation.

20.The ability to set realistic goals or make plans independently of others.

1.

1.

1.

1.

2.

2.

2.

2.

3.

3.

3.

3.

4.

4.

4.

4.

5.

5.

5.

5.

II.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.

Continued on Page 3

Form SSA-4734-F4-SUP (8-85)

2

Continued on Page 4

ILL. FUNCTIONAL CAPACITY ASSESSMENT

Record in this section the elaborations on the preceding capacities. Complete this section ONLY after the SUMMARY CONCLUSIONS section has been completed. Explain your summary conclusions in narrative form. Include any information which clarifies limitation or function. Be especially careful to explain conclusions that differ from those of treating medical sources or from the individual's allegations.

Continued on Page 4

MEDICAL CONSULTANT'S SIGNATURE

DATE

Form 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

How to Edit Ssa 4734 F4 Sup Online for Free

It shouldn’t be challenging to obtain ssa 4734 f4 sup pdf through our PDF editor. This is the way you will be able effortlessly develop your form.

Step 1: Initially, choose the orange "Get form now" button.

Step 2: The document editing page is currently available. Include information or modify current data.

Prepare the ssa 4734 f4 sup pdf PDF and enter the information for each part:

mental residual functional assessment spaces to complete

Enter the appropriate particulars in The ability to understand and, The ability to understand and, SUSTAINED CONCENTRATION AND, The ability to carry out very, The ability to carry out detailed, The ability to maintain attention, The ability to perform activities, The ability to sustain an ordinary, The ability to work in, and The ability to make simple section.

part 2 to finishing mental residual functional assessment

You're going to be required some fundamental details so that you can fill in the The ability to complete a normal, C SOCIAL INTERACTION, The ability to interact, The ability to ask simple, The ability to accept instructions, The ability to get along with, The ability to maintain socially, D ADAPTATION, The ability to respond, and The ability to be aware of normal section.

mental residual functional assessment The ability to complete a normal, C SOCIAL INTERACTION, The ability to interact, The ability to ask simple, The ability to accept instructions, The ability to get along with, The ability to maintain socially, D ADAPTATION, The ability to respond, and The ability to be aware of normal blanks to fill

The space The ability to be aware of normal, The ability to travel in, The ability to set realistic goals, and REMARKS If you checked box for is where you insert both sides' rights and obligations.

Entering details in mental residual functional assessment stage 4

Finish by reviewing these fields and completing them accordingly: Form SSAFSUP, and Continued on Page.

Form SSAFSUP, and Continued on Page in mental residual functional assessment

Step 3: When you have hit the Done button, your file is going to be ready for upload to each device or email you identify.

Step 4: Attempt to make as many duplicates of your form as you can to avoid potential problems.

Watch Ssa 4734 F4 Sup Video Instruction

Ssa 4734 F4 Sup isn’t the one you’re looking for?

Related Documents

  • Sstgb Form F0003

    "... This is a multi-state form that allows exemptions for entities. Not all states permit this exemption. If the buyer is not eligible, the seller might be required to attach the exemption certificate ce rti ficate ..."

  • Ssa 6234 F6 Form

    "... It is amazing that for every thousand and three hundred dollars you make and pay taxes to the federal governments, you will get one quarter of the coverage. If you're not working or have a ..."

  • Ssa 7050 F4

    "... Form ssa 7050 02 2121. Discontinue previous editions Social Security Administration Page of om No 0960 0525. To request social security earnings information, use this form. We can also use your information to process your ..."

  • Sss Loan Application

    "... Application no bar code Date received by part-time employee to complete all items. Ser dda.reb.mundi.rey.lp.me. No street barangay.tow district. Employer name. Province postal code. For sss only. ybde.doc.ne.ne.ser.pstn.emu. The applicant must sign the acknowledgement receipt ..."

Please rate Ssa 4734 F4 Sup

1 Votes

Related Resources

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .