Ssa 4734 F4 Sup PDF Details

Ssa 4734 F4 Sup Form is a request for supoort from the social security administration. This form can be used to ask for help with a variety of issues, including benefits, disability, and child support. The form can be filled out by hand or online, and must be submitted either way in order to receive help. If you need assistance with Ssa 4734 F4 Sup Form or any other social security administration forms, please contact us for help. We are happy to provide support and walk you through the process.

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QuestionAnswer
Form NameSsa 4734 F4 Sup
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesmental residual functional capacity assessment, mental functional capacity, mental residual functional capacity, mental residual functional

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.

 

 

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5.

 

 

 

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4.

 

5.

 

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5.

 

 

 

2.

 

 

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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.

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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.

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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

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