Form SSA-4734-F4-SUP at a glance
What it is: Form SSA-4734-F4-SUP (8-85) is the Mental Residual Functional Capacity Assessment.
Who signs: The Medical Consultant signs and dates the form.
A filled-in Form SSA-4734-F4-SUP example: a current evaluation
How to fill out Form SSA-4734-F4-SUP, box by box
Name and Social Security Number
Enter the Name and the Social Security Number.
Assessment is for
The assessment is for the Current Evaluation, 12 Months After Onset, the Date Last Insured or Other.
Summary conclusions
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).
Understanding and memory: The ability to remember locations and work-like procedures.
The ability to understand and remember very short and simple instructions.
The ability to understand and remember detailed instructions.
Sustained concentration and persistence: The ability to carry out very short and simple instructions.
The ability to carry out detailed instructions. 1.
The ability to maintain attention and concentration for extended periods.
The ability to perform activities within a schedule, maintain regular attendance, and be punctual within customary tolerances.
The ability to sustain an ordinary routine without special supervision.
The ability to work in coordination with or proximity to others without being distracted by them. 1.
The ability to make simple work-related decisions.
Continued, sustained concentration and persistence: The ability to complete a normal workday and workweek without interruptions from psychologically based symptoms and to perform at a consistent pace without an unreasonable number and length of rest periods.
Social interaction: The ability to interact appropriately with the general public.
The ability to ask simple questions or request assistance.
The ability to accept instructions and respond appropriately to criticism from supervisors.
The ability to get along with coworkers or peers without distracting them or exhibiting behavioral extremes.
The ability to maintain socially appropriate behavior and to adhere to basic standards of neatness and cleanliness.
Adaptation: The ability to respond appropriately to changes in the work setting.
The ability to be aware of normal hazards and take appropriate precautions.
The ability to travel in unfamiliar places or use public transportation.
The ability to set realistic goals or make plans independently of others.
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.
More rules for Form SSA-4734-F4-SUP
If you checked box 5 for any of the preceding items or if 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.
Record in Section III 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.
On the Continuation Sheet, indicate the section(s) being continued.
Common questions about Form SSA-4734-F4-SUP
Who signs it?
The Medical Consultant signs and dates the form.
Sources
[1] Form SSA-4734-F4-SUP (8-85), Mental Residual Functional Capacity Assessment (the Official source link on this page).
