DISABILITY REPORT—ADULT—Form SSA-3368-BK

READ ALL OF THIS INFORMATION BEFORE

YOU BEGIN COMPLETING THIS FORM

IF YOU NEED HELP

If you need help with this form, do as much of it as you can, and your interviewer will
help you finish it.

HOW TO COMPLETE THIS FORM

The information that you give us on this form will be used by the office that makes the disability
decision on your disability claim. You can help them by completing as much of
the form as you can.

Disability Report – Adult – Form SSA – 3368 - BK

• Fill out as much of this form as you can before your interview appointment.
• Print or type.
• DO NOT LEAVE ANSWERS BLANK. If you do not know the answers, or the answer
is “none” or “does not apply,” please write: “don’t know,” or “none,” or “does not ap-
ply.”
• IN SECTION 4, PUT INFORMATION ON ONLY ONE DOCTOR/HOSPITAL/
CLINIC IN EACH SPACE.
• Each address should include a ZIP code. Each telephone number should include an
area code.
• DO NOT ASK A DOCTOR OR HOSPITAL TO COMPLETE THE FORM. However,
you can get help from other people, like a friend or family member.
• If your appointment is for an interview by telephone, have the form ready to discuss
with us when we call you.
• If your appointment is for an interview in our office, bring the completed form with
you or, mail it ahead of time, if you were told to do so.
• When a question refers to “you,” “your,” or the “Disabled Person,” it refers to the
person who is applying for disability benefits. If you are filling out the form for
someone else, please provide information about him or her.
• Be sure to explain an answer if the question asks for an explanation, or if you want to give
additional information.
• If you need more space to answer any questions or want to tell us more about an
answer, please use the “REMARKS” section on Pages 9 and 10, and show the number
of the question being answered.

ABOUT YOUR MEDICAL RECORDS

If you have any medical records and copies of prescriptions at home for the person who is
applying for disability benefits, send them to the office with your completed forms or
bring them with you to your interview. Also, bring any prescription bottles with you. If
you need the records back, tell us and we will photocopy them and return them to you.

YOU DO NOT NEED TO ASK DOCTORS OR HOSPITALS FOR ANY MEDICAL

RECORDS THAT YOU DO NOT ALREADY HAVE. With your permission, we will do
that for you. The information we ask for on this form tells us to whom we should send a request
for medical and other records. If you cannot remember the names and addresses
of any of the doctors or hospitals, or the dates of treatment, you may be able to get this
information from the telephone book or from medical bills, prescriptions and prescription
bottles.

WHAT WE MEAN BY “DISABILITY”

“Disability” under Social Security is based on your inability to work. For purposes of this
claim, we want you to understand that “disability” means that you are unable to work as defined
by the Social Security Act. You will be considered disabled if you are unable to
do any kind of work for which you are suited and your disability is expected to last (or
has lasted) for at least a year or to result in death. So when we ask, “when did you
become unable to work,” we are asking when you became disabled as defined by the
Social Security Act.

The Privacy and Paperwork Reduction Acts

The Social Security Administration is authorized to collect the information on this form under
sections 205(a), 223(d) and 1631(e)(1) of the Social Security Act. The information on this form is
needed by Social Security to make a decision on the named claimant’s claim. While giving us the
information on this form is voluntary, failure to provide all or part of the requested informa-tion could
prevent an accurate or timely decision on the name claimant’s claim. Although the information you
furnish is almost never used for any purpose other than making a determination about the claimant’s
disability, such information may be disclosed by the Social Security Administration as follows: (1) to
enable a third party or agency to assist Social Security in estab-lishing rights to Social Security
benefits and/or coverage; (2) to comply with Federal Laws requiring the release of information from
Social Security records (e.g., to the General Accounting Office and the Department of Veteran
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 the information you give us when we match records by computer. Matching
programs compare our records with those of other Federal, State, or local government 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 information you provide us may be used or given out are
available in Social Security offices.

The Paperwork Reduction Act of 1995 requires us to notify you that this information
collection is in accordance with the clearance requirements of Section 3507 of the Paperwork
Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a
collection of information unless it displays a valid OMB control number. We estimate that it
will take you about 30 minutes to complete this form. This includes the time it will take to read the
instructions, gather the necessary facts, and fill out the form.

REMOVE THIS SHEET BEFORE RETURNING THE COMPLETED FORM.

 SOCIAL SECURITY ADMINISTRATION Form Approved

OMB No. 0960-0579

For SSA Use Only

Do not write in this box.
DISABILITY REPORT
ADULT Related SSN
Number Holder

SECTION 1 — INFORMATION ABOUT THE DISABLED PERSON

A. NAME (First, Middle Initial, Last) B. SOCIAL SECURITY NUMBER

C. DAYTIME TELEPHONE NUMBER (If you have no number where you can be reached, give us
a daytime number where we can leave a message for you.)

Disability Report – Adult – Form SSA – 3368 - BK

Your Number Message Number None
Area Code Number
D. Give the name of a friend or relative that we can contact (other than your doctors) who knows about
your illnesses, injuries or conditions and can help you with your claim.

NAME RELATIONSHIP

ADDRESS
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)

DAYTIME
City State ZIP PHONE Area Code Phone Number

E. What is your height F. What is your weight

without shoes? without shoes?
feet inches pounds

G. Do you have a medical assistance card? (For example, Medicaid or Medi-Cal) YES NO
If “YES,” show the number here:

H. Can you speak English? YES NO If “NO,” what languages can you speak?

If you cannot speak English, give us the name of someone we may contact who speaks English and will
give you messages. (If this is the same person as in “D” above, show “SAME” here.)

NAME RELATIONSHIP

ADDRESS:
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)

DAYTIME
City State ZIP PHONE Area Code Phone Number

I. Can you read English? YES NO J. Can you write more than YES NO
your name in English?
 FORM SSA-3368-BK (12/98) 7/98 EDITION MAY BE USED UNTIL EXHAUSTED PAGE 1
SECTION 2
YOUR ILLNESSES, INJURIES OR CONDITIONS AND HOW THEY AFFECT YOU

A. What are the illnesses, injuries or conditions that limit your ability to work?

B. How do your illnesses, injuries or conditions limit your ability to work?

C. Do your illnesses, injuries or conditions cause you pain? YES NO

D. When did your illnesses, injuries or conditions Month Day Year

first bother you?

E. When did you become unable to work because of Month Day Year
your illnesses, injuries or conditions?

F. Have you ever worked? YES NO (If “NO,”go to

Section 4.)

G. Did you work at any time after the date your

illnesses, injuries or conditions first bothered you? YES NO

H. If “YES,” did your illnesses, injuries or conditions cause you to: (Check all that apply,)

work fewer hours? (Explain below.)

change your job duties? (Explain below.)
make any job-related changes such as your attendance, help needed, or employers?
(Explain below.)

I. Are you working now? YES NO

If “NO,” when did you stop working? Month Day Year
Why did you stop working?

FORM SSA-3368-BK (12/98) PAGE 2

 SECTION 3 – INFORMATION ABOUT YOUR WORK

A. List all the jobs that you have had in the last 15 years that you worked.

DATES
TYPE OF WORKED HOURS DAYS
JOB TITLE BUSINESS (month & year) PER PER RATE OF PAY
(Example, Cook) (Example, Restaurant ) DAY WEEK (Per hour, day, week,
FROM TO month or year)

$ /

$ /

$ /

$ /

$ /

$ /

$ /

B. Describe the job above that you did the longest. (What did you do all day in this job?)

C. In this job, did you: Use machines, tools or equipment? YES NO

Use technical knowledge or skills? YES NO
Do any writing, complete reports, or perform
any duties like this? YES NO
Did you supervise other people? YES NO
If “YES,” was this your main duty? YES NO
D. In this job, how many total hours each day did you:
Walk? Kneel? (Bend legs to rest on knees.)
Stand? Crouch? (Bend legs and back down & forward.)
Sit? Crawl? (Move on hands & knees.)
Climb? Handle, grab or grasp big objects?
Stoop? (Bend down and forward at waist.) Write, type or handle small objects?

E. Lifting and Carrying (Explain what you lifted, how far you carried it, and how often you did this.)

F. Check heaviest weight lifted:

Less than 10 lbs. 10 lbs. 20 lbs. 50 lbs. 100 lbs. or more Other

G. Check weight frequently lifted: (By frequently, we mean from 1/3 to 2/3 of the workday.)

Less than 10 lbs. 10 lbs. 25 lbs. 50 lbs. or more Other

FORM SSA-3368-BK (12/98) PAGE 3

 SECTION 4 – INFORMATION ABOUT YOUR MEDICAL RECORDS

A. Have you been seen by a doctor/hospital/clinic or anyone else for the illnesses, injuries or conditions that
limit your ability to work? YES NO

B. Have you been seen by a doctor/hospital/clinic or anyone else for emotional or mental problems that limit
your ability to work? YES NO

If you answered “NO” to both of these questions, go to Section 5.

C. List other names you have used on your medical records.

Tell us who may have medical records or other

information about your illnesses, injuries or conditions.

D. List each DOCTOR/HMO/THERAPIST. Include your next appointment.

1. NAME DATES

STREET ADDRESS FIRST VISIT

CITY STATE ZIP LAST SEEN

PHONE CHART/HMO # NEXT APPOINTMENT

Area Code Phone Number

REASONS FOR VISITS

TREATMENT WAS RECEIVED?

2. NAME DATES

STREET ADDRESS FIRST VISIT

CITY STATE ZIP LAST SEEN

PHONE CHART/HMO # NEXT APPOINTMENT

Area Code Phone Number

REASONS FOR VISITS

WHAT TREATMENT WAS RECEIVED?

 FORM SSA-3368-BK (12/98) PAGE 4
SECTION 4 – INFORMATION ABOUT YOUR MEDICAL RECORDS

DOCTOR/HMO/THERAPIST
3. NAME DATES

STREET ADDRESS FIRST VISIT

CITY STATE ZIP LAST SEEN

PHONE CHART/HMO # NEXT APPOINTMENT

Area Code Phone Number

REASONS FOR VISITS

WHAT TREATMENT WAS RECEIVED?

If you need more space, use Remarks, Section 9

E. List each HOSPITAL/CLINIC. Include your next appointment.
1. HOSPITAL/CLINIC TYPE OF VISIT DATES
NAME INPATIENT STAYS DATE IN DATE OUT

(Stayed at least overnight)

STREET ADDRESS OUTPATIENT VISITS DATE FIRST VISIT DATE LAST VISIT

(Sent home same day)

CITY STATE ZIP EMERGENCY ROOM VISITS DATES OF VISITS

PHONE

Area Code Phone Number

Next appointment Your hospital/clinic number

Reasons for visits

What treatment did you receive?

What doctors do you see at this hospital/clinic on a regular basis?

 FORM SSA-3368-BK (12/98) PAGE 5
SECTION 4 – INFORMATION ABOUT YOUR MEDICAL RECORDS

HOSPITAL/CLINIC
2. HOSPITAL/CLINIC TYPE OF VISIT DATES
NAME INPATIENT STAYS DATE IN DATE OUT

(Stayed at least overnight)

STREET ADDRESS OUTPATIENT VISITS DATE FIRST VISIT DATE LAST VISIT

(Sent home same day)

CITY STATE ZIP EMERGENCY ROOM VISITS DATES OF VISITS

PHONE

Area Code Phone Number

Next appointment Your hospital/clinic number

Reasons for visits

What treatment did you receive?

What doctors do you see at this hospital/clinic on a regular basis?

If you need more space, use Remarks, Section 9

F. Does anyone else have medical records or information about your illnesses, injuries, or
conditions (Workers’ Compensation, insurance companies, prisons, attorneys, welfare), or are you
scheduled to see anyone else?
YES (If “YES,” complete the information below.) NO
NAME DATES

STREET ADDRESS FIRST VISIT

CITY STATE ZIP LAST SEEN

PHONE NEXT APPOINTMENT

Area Code Phone Number

CLAIM NUMBER (If any)

REASONS FOR VISITS?

 If you need more space, use Remarks, Section 9
FORM SSA-3368-BK (12/98) PAGE 6

SECTION 5 – MEDICATIONS
Do you currently take any medications for your illnesses, injuries or conditions? YES NO
If “YES,” please tell us the following: (Look at your medicine bottles, if necessary.)
IF PRESCRIBED, REASON FOR SIDE EFFECTS
NAME OF MEDICINE GIVE NAME OF DOCTOR MEDICINE YOU HAVE

If you need more space, use Remarks, Section 9

SECTION 6 – TESTS

Have you had, or will you have, any medical tests for your illnesses, injuries or conditions?
YES NO If “YES,” please tell us the following: (Give approximate dates, if necessary.)

WHEN DONE, OR
WHEN IT WILL WHO SENT YOU
KIND OF TEST BE DONE? WHERE DONE? FOR THIS TEST?
(Month, day, year) (Name of Facility)
EKG (HEART TEST)

TREADMILL (EXERCISE TEST)

CARDIAC CATHETERIZATION

BIOPSY
Name of body part
HEARING TEST

VISION TEST

IQ TESTING

EEG (BRAIN WAVE TEST)

HIV TEST

BLOOD TEST (NOT HIV)

BREATHING TEST

X-RAY
Name of body part
MRI/CT SCAN
Name of body part

If you have had any other tests, list them in Remarks, Section 9.
FORM SSA-3368-BK (12/98) PAGE 7
 SECTION 7 – EDUCATION/TRAINING INFORMATION

A. Circle the highest grade of school completed.

0 1 2 3 4 5 6 7 8 9 10 11 12 GED College: 1 2 3 4 or more

Approximate date completed:

B. Did you attend special education classes? YES NO If “NO,” go to part C.

NAME OF SCHOOL

ADDRESS
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)

City State ZIP

DATES ATTENDED TO

TYPE OF PROGRAM

C. Have you completed any type of special job training, trade or vocational school? YES NO

If “YES,” what type?

Approximate date completed:

SECTION 8 – VOCATIONAL REHABILITATION INFORMATION

A. Have you received services from Vocational Rehabilitation or any other organization to help you get
back to work? YES NO If “NO,” go to part B.

NAME OF ORGANIZATION

NAME OF COUNSELOR

ADDRESS
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)

City State ZIP

DAYTIME PHONE NUMBER

Area Code Number

DATES SEEN TO

TYPE OF SERVICES OR
TESTS PERFORMED (IQ, vision, physicals, hearing, workshops, etc.)

B. Would you like to receive rehabilitation services that could help you get YES NO
back to work?

FORM SSA-3368-BK (12/98) PAGE 8

 SECTION 9 – REMARKS
Use this section for any added information you did not show in earlier parts of this form.
When you are done with this section (or if you don’t have anything to add), be sure to go to
the next
page and complete the signature block.

FORM SSA-3368-BK (12/98) PAGE 9

 SECTION 9 – REMARKS

ANYONE MAKING A FALSE STATEMENT OR REPRESENTATION OF A MATERIAL FACT FOR

USE IN DETERMINING A RIGHT TO PAYMENT UNDER THE SOCIAL SECURITY ACT
COMMITS A CRIME PUNISHABLE UNDER FEDERAL LAW.

Signature of claimant or person filing on claimant’s behalf (Parent, guardian) Date (Month, day, year)

Witnesses are required ONLY if this statement has been signed by mark (X) above. If signed by mark (X), two
witnesses to the signing who know the person making the statement must sign below giving their full
addresses.

1. Signature of Witness 2. Signature of Witness

Address (number and street, city, state, and ZIP code) Address (number and street, city, state, and ZIP code)

FORM SSA-3368-BK (12/98) PAGE 10

 TO BE COMPLETED BY SSA
NUMBER HOLDER

SOCIAL SECURITY NUMBER

EMPLOYEE/CLAIMANT/BENEFICIARY (If other than Number Holder)

AUTHORIZATION FOR SOURCE TO RELEASE

INFORMATION TO THE SOCIAL SECURITY ADMINISTRATION (SSA)
INFORMATION ABOUT MEDICAL OR OTHER SOURCE-PLEASE PRINT, TYPE, OR WRITE CLEARLY
NAME AND ADDRESS OF SOURCE (Include Zip Code) RELATIONSHIP TO DISABLED PERSON

INFORMATION ABOUT DISABLED PERSON-PLEASE PRINT, TYPE, OR WRITE CLEARLY

NAME AND ADDRESS (If known) AT TIME DISABLED PERSON DATE OF BIRTH DISABLED PERSON’S I.D. NUMBER
HAD CONTACT WITH SOURCE (Include Zip Code) (If known and different than SSN)
(Clinic/Patient No.)

APPROXIMATE DATES OF DISABLED PERSON’S CONTACT WITH SOURCE (e.g. dates of

hospital admission, treatment, discharge, etc.)

TO BE COMPLETED BY DISABLED PERSON OR PERSON AUTHORIZED TO ACT IN HIS/HER BEHALF

GENERAL AND SPECIAL AUTHORIZATION TO RELEASE MEDICAL AND OTHER INFORMATION IN
ACCORDANCE WITH THE PROVISIONS OF THE SOCIAL SECURITY ACT; THE PUBLIC HEALTH SERVICE ACT,
SECTIONS 523 AND 527; AND TITLE 38 U.S.C. VETERANS BENEFITS SECTION 4132.
I hereby authorize the above-named source to release or disclose to the Social Security Administration or State agency the
following information for the period(s) identified above:

1) All medical records or other information regarding my treatment, hospitalization, and/or outpatient care for my
impairment(s), including psychological or psychiatric impairment(s), drug abuse, alcoholism, sickle cell anemia,
or human immunodeficiency virus (HIV) infection (including acquired immunodeficiency syndrome (AIDS) or tests
for HIV), or sexually transmitted diseases;
2) Information about how my impairment(s) affects my ability to complete tasks and activities of daily living;
3) Information about how my impairment(s) affected my ability to work.

I authorize the use of a telefax or photocopy of this form for the release or disclosure of the information described above.

I understand that this authorization, except for action already taken, may be voided by me at anytime. If I do not void this
authorization, it will automatically end when a final decision is made on my claim. If I am already receiving benefits, the
authorization will end when a final decision is made as to whether I can continue to receive benefits.
READ IMPORTANT INFORMATION ON REVERSE BEFORE SIGNING FORM BELOW
SIGNATURE OF DISABLED PERSON OR PERSON RELATIONSHIP TO DISABLED DATE
AUTHORIZED TO ACT IN HIS/HER BEHALF PERSON (if other than self)

STREET ADDRESS TELEPHONE NUMBER (Area Code)

CITY STATE ZIP CODE

The signature and address of a person who either knows the person signing this form or is satisfied as to that person’s identity is requested below. This is not
required by the Social Security Administration, but without it the source may not honor this authorization.
SIGNATURE OF WITNESS STREET ADDRESS

CITY STATE ZIP CODE

Form SSA-827 (1-97) Use Prior Editions (OVER)

 Explanation of Form SSA-827, Authorization For Source to
Release Information to the Social Security Administration (SSA)

We are requesting that you authorize the release of information about your impairment to us.
Sources usually require this authorization before releasing information to us. Also, the law requires
this authorization for release of information about certain conditions.

You can provide this authorization by signing a Form SSA-827, Authorization For Source to Release
Information to the Social Security Administration (SSA), for each source identified during your
disability interview or during the processing of your claim. We must inform you that because of
various Federal disclosure laws, SSA cannot give an absolute pledge of confidentiality regarding information
submitted in connection with your claim.

PRIVACY ACT NOTICE

The Social Security Administration is authorized to collect the information on this form under
sections 205(a), 223(d) and 1631(e)(1) of the Social Security Act. The information on this form is
needed by Social Security to make a decision on your claim. While giving us the information on this
form is voluntary, failure to provide all or part of the requested information could prevent an
accurate or timely decision on your claim and could result in the loss of benefits. Although the
information you furnish on this form is almost never used for any purpose other than making a determination
on your disability claim, such information may be disclosed by the Social Security Administration as
follows:

(1) To enable a third party or agency to assist Social Security in establishing rights to Social
Security benefits and/or coverage;

(2) To comply with Federal laws requiring the release of information from Social Security
records (e.g., to the General Accounting Office and the Department of Veterans Affairs);

(3) To facilitate statistical research and audit 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 the information you give us when we match records by computer. Matching
programs compare our records with those of other Federal, State, or local government 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 information you provide us 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.
Form SSA-827 (1-97) Use Prior Editions *U.S. GPO: 1997-424-970
 WORK HISTORY REPORT - Form SSA-3369-BK

READ ALL OF THIS INFORMATION BEFORE

YOU BEGIN COMPLETING THIS FORM

IF YOU NEED HELP

If you need help with this form, complete as much of it as you can, and your interviewer
will help you finish it.

HOW TO COMPLETE THIS FORM

The information that you give us on this form will be used by the office that makes the

Work History Report - Form SSA-3369-BK

disability decision on your disability claim. You can help them by completing as much of
the form as you can.

• Print or type.
• When a question refers to “you,” “your,” or “the Disabled Person,” it refers to the
person who is applying for disability benefits. If you are filling out the form for
someone else, provide information about him or her.
• Be sure to explain an answer if the question asks for an explanation, or if you
think you need to explain an answer.
• If more space is needed to answer any questions, use the “REMARKS” section on
Page 8, and show the number of the question being answered.

WHY THIS INFORMATION IS IMPORTANT

The information we ask for on this form will help us understand how your illnesses or
injuries or conditions might affect any work you are qualified to do. The information tells
us about the kinds of work you did, including the types of skills you need and the physical
and mental requirements of each job. In Section 2, be sure to give us all of the different
kinds of work you have done in the last 15 years before you stopped working. There is a
separate page to describe each different job.

REMEMBER TO SIGN THE FORM IN THE SIGNATURE SPACES ON PAGE 8.

 The Privacy and Paperwork Reduction Acts

The Social Security Administration is authorized to collect the information on this form under
sections 205(a), 223(d) and 1631(e)(1) of the Social Security Act. The information on this form
is needed by Social Security to make a decision on the named claimant’s claim. While giving us
the information on this form is voluntary, failure to provide all or part of the requested informa-
tion could prevent an accurate or timely decision on the named claimant’s claim. Although the
information you furnish is almost never used for any purpose other than making a determination
about the claimant’s disability, such information may be disclosed by the Social Security
Administration as follows: (1) to enable a third party or agency to assist Social Security in estab-
lishing rights to Social Security benefits and/or coverage; (2) to comply with Federal Laws
requiring the release of information from Social Security records (e.g., to the General Accounting
Office and the Department of Veteran 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 the information you give us when we match records by computer. Matching
programs compare our records with those of other Federal, State, or local government 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 information you provide us may be used or
given out are available in Social Security offices.

The Paperwork Reduction Act of 1995 requires us to notify you that this information
collection is in accordance with the clearance requirements of Section 3507 of the Paperwork
Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to,
a collection of information unless it displays a valid OMB control number. We estimate that it
will take you about 30 minutes to complete this form. This includes the time it will take to read
the instructions, gather the necessary facts, and fill out the form.

PLEASE REMOVE THIS SHEET BEFORE RETURNING THE COMPLETED FORM.

 Form Approved
SOCIAL SECURITY ADMINISTRATION OMB No. 0960-0578

WORK HISTORY REPORT

SECTION 1 – INFORMATION ABOUT THE DISABLED PERSON

A. NAME (First, Middle Initial, Last) B. SOCIAL SECURITY NUMBER

C. DAYTIME TELEPHONE NUMBER (If you have no number where you can be reached, give us a
daytime number where we can leave a message for you.)

Work History Report - Form SSA-3369-BK

Your Number Message Number None
Area Code Number

SECTION 2 – INFORMATION ABOUT YOUR WORK

List the kinds of jobs that you have had in the last 15 years that you worked.

Job Title Type of Business Dates Worked

(Example: Cook) (Example: Restaurant) (Month & Year)

FROM TO

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

FORM SSA-3369-BK (7/98) DESTROY ALL PRIOR EDITIONS PAGE 1

 Give us more information about Job No. 1 listed on Page 1. Estimate hours and pay, if you need to.

JOB TITLE NO. 1

Rate of Pay $ Per (Circle One) Hours per day Days per week
Hour Week Month Year

In this job, did you: Use machines, tools, or equipment? Yes (explain below) No

Use technical knowledge or skills? Yes (explain below) No

Write reports or complete forms? Yes (explain below) No

Describe this job. What did you do all day? (If you need more space, write in the “Remarks” section.)

In this job, how many total hours each day did you:

Walk? Kneel? (Bend legs to rest on knees.)

Stand? Crouch? (Bend legs and back down & forward.)
Sit? Crawl? (Move on hands & knees.)
Climb? Handle, grab or grasp big objects?
Stoop? (Bend down and forward at waist.) Write, type or handle small objects?

Lifting and Carrying (Explain what you lifted, how far you carried it, and how often you did this.)

Check heaviest weight you lifted:

Less than 10 lbs. 10 lbs. 20 lbs. 50 lbs. 100 lbs. or more Other

Check weight you frequently lifted: (By frequently, we mean from 1/3 to 2/3 of the workday.)

Less than 10 lbs. 10 lbs. 25 lbs. 50 lbs. or more Other

Did you supervise other people in this job? Yes (Complete items below.) No (Skip to next page.)

How many people did you supervise?

What part of your time was spent supervising people?

Did you hire and fire employees? Yes No

Were you a lead worker? Yes No

FORM SSA-3369 - BK (7/98) PAGE 2

 Give us more information about Job No. 2 listed on Page 1. Estimate hours and pay, if you need to.

JOB TITLE NO. 2

Rate of Pay $ Per (Circle One) Hours per day Days per week
Hour Week Month Year

In this job, did you: Use machines, tools, or equipment? Yes (explain below) No

Use technical knowledge or skills? Yes (explain below) No

Write reports or complete forms? Yes (explain below) No

Describe this job. What did you do all day? (If you need more space, write in the “Remarks” section.)

In this job, how many total hours each day did you:

Walk? Kneel? (Bend legs to rest on knees.)

Stand? Crouch? (Bend legs and back down & forward.)
Sit? Crawl? (Move on hands & knees.)
Climb? Handle, grab or grasp big objects?
Stoop? (Bend down and forward at waist.) Write, type or handle small objects?

Lifting and Carrying (Explain what you lifted, how far you carried it, and how often you did this.)

Check heaviest weight you lifted:

Less than 10 lbs. 10 lbs. 20 lbs. 50 lbs. 100 lbs. or more Other

Check weight you frequently lifted: (By frequently, we mean from 1/3 to 2/3 of the workday.)

Less than 10 lbs. 10 lbs. 25 lbs. 50 lbs. or more Other

Did you supervise other people in this job? Yes (Complete items below.) No (Skip to next page.)

How many people did you supervise?

What part of your time was spent supervising people?

Did you hire and fire employees? Yes No

Were you a lead worker? Yes No

FORM SSA-3369-BK (7/98) PAGE 3

 Give us more information about Job No. 3 listed on Page 1. Estimate hours and pay, if you need to.

JOB TITLE NO. 3

Rate of Pay $ Per (Circle One) Hours per day Days per week
Hour Week Month Year

In this job, did you: Use machines, tools, or equipment? Yes (explain below) No

Use technical knowledge or skills? Yes (explain below) No

Write reports or complete forms? Yes (explain below) No

Describe this job. What did you do all day? (If you need more space, write in the “Remarks” section.)

In this job, how many total hours each day did you:

Walk? Kneel? (Bend legs to rest on knees.)

Stand? Crouch? (Bend legs and back down & forward.)
Sit? Crawl? (Move on hands & knees.)
Climb? Handle, grab or grasp big objects?
Stoop? (Bend down and forward at waist.) Write, type or handle small objects?

Lifting and Carrying (Explain what you lifted, how far you carried it, and how often you did this.)

Check heaviest weight you lifted:

Less than 10 lbs. 10 lbs. 20 lbs. 50 lbs. 100 lbs. or more Other

Check weight you frequently lifted: (By frequently, we mean from 1/3 to 2/3 of the workday.)

Less than 10 lbs. 10 lbs. 25 lbs. 50 lbs. or more Other

Did you supervise other people in this job? Yes (Complete items below.) No (Skip to next page.)

How many people did you supervise?

What part of your time was spent supervising people?

Did you hire and fire employees? Yes No

Were you a lead worker? Yes No

FORM SSA-3369-BK (7/98) PAGE 4

 Give us more information about Job No. 4 listed on Page 1. Estimate hours and pay, if you need to.

JOB TITLE NO. 4

Rate of Pay $ Per (Circle One) Hours per day Days per week
Hour Week Month Year

In this job, did you: Use machines, tools, or equipment? Yes (explain below) No

Use technical knowledge or skills? Yes (explain below) No

Write reports or complete forms? Yes (explain below) No

Describe this job. What did you do all day? (If you need more space, write in the “Remarks” section.)

In this job, how many total hours each day did you:

Walk? Kneel? (Bend legs to rest on knees.)

Stand? Crouch? (Bend legs and back down & forward.)
Sit? Crawl? (Move on hands & knees.)
Climb? Handle, grab or grasp big objects?
Stoop? (Bend down and forward at waist.) Write, type or handle small objects?

Lifting and Carrying (Explain what you lifted, how far you carried it, and how often you did this.)

Check heaviest weight you lifted:

Less than 10 lbs. 10 lbs. 20 lbs. 50 lbs. 100 lbs. or more Other

Check weight you frequently lifted: (By frequently, we mean from 1/3 to 2/3 of the workday.)

Less than 10 lbs. 10 lbs. 25 lbs. 50 lbs. or more Other

Did you supervise other people in this job? Yes (Complete items below.) No (Skip to next page.)

How many people did you supervise?

What part of your time was spent supervising people?

Did you hire and fire employees? Yes No

Were you a lead worker? Yes No

FORM SSA-3369-BK (7/98) PAGE 5

 Give us more information about Job No. 5 listed on Page 1. Estimate hours and pay, if you need to.

JOB TITLE NO. 5

Rate of Pay $ Per (Circle One) Hours per day Days per week
Hour Week Month Year

In this job, did you: Use machines, tools, or equipment? Yes (explain below) No

Use technical knowledge or skills? Yes (explain below) No

Write reports or complete forms? Yes (explain below) No

Describe this job. What did you do all day? (If you need more space, write in the “Remarks” section.)

In this job, how many total hours each day did you:

Walk? Kneel? (Bend legs to rest on knees.)

Stand? Crouch? (Bend legs and back down & forward.)
Sit? Crawl? (Move on hands & knees.)
Climb? Handle, grab or grasp big objects?
Stoop? (Bend down and forward at waist.) Write, type or handle small objects?

Lifting and Carrying (Explain what you lifted, how far you carried it, and how often you did this.)

Check heaviest weight you lifted:

Less than 10 lbs. 10 lbs. 20 lbs. 50 lbs. 100 lbs. or more Other

Check weight you frequently lifted: (By frequently, we mean from 1/3 to 2/3 of the workday.)

Less than 10 lbs. 10 lbs. 25 lbs. 50 lbs. or more Other

Did you supervise other people in this job? Yes (Complete items below.) No (Skip to next page.)

How many people did you supervise?

What part of your time was spent supervising people?

Did you hire and fire employees? Yes No

Were you a lead worker? Yes No

FORM SSA-3369-BK (7/98) PAGE 6

 Give us more information about Job No. 6 listed on Page 1. Estimate hours and pay, if you need to.

JOB TITLE NO. 6

Rate of Pay $ Per (Circle One) Hours per day Days per week
Hour Week Month Year

In this job, did you: Use machines, tools, or equipment? Yes (explain below) No

Use technical knowledge or skills? Yes (explain below) No

Write reports or complete forms? Yes (explain below) No

Describe this job. What did you do all day? (If you need more space, write in the “Remarks” section.)

In this job, how many total hours each day did you:

Walk? Kneel? (Bend legs to rest on knees.)

Stand? Crouch? (Bend legs and back down & forward.)
Sit? Crawl? (Move on hands & knees.)
Climb? Handle, grab or grasp big objects?
Stoop? (Bend down and forward at waist.) Write, type or handle small objects?

Lifting and Carrying (Explain what you lifted, how far you carried it, and how often you did this.)

Check heaviest weight you lifted:

Less than 10 lbs. 10 lbs. 20 lbs. 50 lbs. 100 lbs. or more Other

Check weight you frequently lifted: (By frequently, we mean from 1/3 to 2/3 of the workday.)

Less than 10 lbs. 10 lbs. 25 lbs. 50 lbs. or more Other

Did you supervise other people in this job? Yes (Complete items below.) No (Skip to next page.)

How many people did you supervise?

What part of your time was spent supervising people?

Did you hire and fire employees? Yes No

Were you a lead worker? Yes No

FORM SSA-3369-BK (7/98) PAGE 7

 SECTION 3 – REMARKS
Use this section for any added information you did not show in earlier parts of this form.

ANYONE MAKING A FALSE STATEMENT OR REPRESENTATION OF A MATERIAL FACT FOR USE IN

DETERMINING A RIGHT TO PAYMENT UNDER THE SOCIAL SECURITY ACT COMMITS A CRIME
PUNISHABLE UNDER FEDERAL LAW.
Signature of claimant or person filing on claimant’s behalf (Parent, guardian) Date (Month, day, year)

Witnesses are required ONLY if this statement has been signed by mark (X) above. If signed by mark (X), two
witnesses to the signing who know the person making the statement must sign below giving their full addresses.
1. Signature of Witness 2. Signature of Witness

Address (number and street, city, state, and ZIP code) Address (number and street, city, state, and ZIP code)

FORM SSA-3369-BK (7/98) PAGE 8

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 Form Approved
OMB NO.0960-0431

PHYSICAL RESIDUAL FUNCTIONAL CAPACITY ASSESSMENT

Claimant: SSN:000-00-0000

Number Holder(If CDB Claim):

Primary Diagnosis: RFC Assessment Is For:

Secondary Diagnosis: Current Evaluation
Other Alleged Impairments: Date Last Insured:
Date 12 Months After Onset:
Other(Specify):

PRIVACY ACT/PAPERWORK ACT NOTICE: The information requested on this form is authorized by Section 223 and Section 1633 of
the Social Security Act. The information provided will be used in making a decision on this claim. Failure to complete this form may result
in a delay in processing the claim Information furnished on this form may be disclosed by the Social Security Administration to another
person or governmental agency on]y with respect to Social Security progrants and to comply with federal laws S requiring the exchange of
information between Social Security and other agencies.
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance
requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to
respond to, a collection of information unless it displays a valid 0MB control number.
TIME IT TAKES TO COMPLETE THIS FORM: We estimate that it will take you about 20 minutes to complete this form. This includes
the time it will take to read the instructions. gather the necessary facts and fill out the form. If you have comments or suggestions on this
estimate, write to the Social Security Administration, ATTN: Reports Clearance Officer. I -A-2 I Operations Bldg., Baltimore, MD 21235-
0001 Send only comments relating to our "time it takes" estimate to the office listed above All requests for Social Security cards and other
claims-related information should be sent to your local Social Security office, whose address is listed under Social Security Administration in
the U.S. Government section of your telephone directory.

I. LIMITATIONS:
For Each Section A - F
⇒ Base your conclusions on all evidence in file (clinical and laboratory findings; symptoms; observations; lay evidence;
reports of daily activities; etc.).
⇒ Check the blocks which reflect your reasoned judgment.
⇒ Describe how the evidence substantiates your conclusions (Cite specific clinical and laboratory findings, observations,
lay evidence, etc.
⇒ Ensure that you have requested:
• Appropriate treating and examining source statements regarding the individual's capacities (DI 22505.OOOff.
and DI 22510.OOOff.) and that you have given appropriate weight to treating source conclusions. (See
Section III.)
• Considered and responded to any alleged limitations imposed by symptoms (pain, fatigue, etc.) attributable, in
your judgment, to a medically determinable impairment. Discuss your assessment of symptom- related
limitations in the explanation for your conclusions in A - F below. (See also Section II.)
• Responded to all allegations of physical limitations or factors which can cause physical limitations.
⇒ Frequently means occurring one-third to two-thirds of an 8-hour workday (cumulative, not continuous). Occasionally
means occurring from very little up to one-third of an 8-hour workday (cumulative, not continuous).

Form SSA-4734BK (1-89) 1

(Formerly SSA-4734-U8 Use prior editions)
A. EXERTIONAL LIMITATIONS

None established. (Proceed to section B.)

1. Occasionally lift and/or carry (including upward pulling) (maximum)-when less than one-third of the time or less than
10 pounds, explain the amount (time/pounds) in item 6.

less than 10 pounds

10 pounds
20 pounds
50 pounds
100 pounds or more

2. Frequently lift and/or carry (including upward pulling) (maximum)-when less than two-thirds of the time or less than
10 pounds, explain the amount (time/pounds) in item 6.

less than 10 pounds

10 pounds
25 pounds
50 pounds or more

3. Stand and/or walk (with normal breaks) for a total of:

less than 2 hours in an 8-hour workday
at least 2 hours in an 8-hour workday
about 6 hours in an 8-hour workday

medically required hand-held assistive device is necessary for ambulation

4. Sit (with normal breaks) for a total of

less than about 6 hours in an 8-hour workday
about 6 hours in an 8-hour workday

must periodically alternate sitting and standing to relieve pain or discomfort. (If checked, explain in 6.)

5. Push and/or pull (including operation of hand and/or foot controls)-

unlimited, other than as shown for lift and/or carry
limited in upper extremities (describe nature and degree)
limited in lower extremities (describe nature and degree)

6. Explain how and why the evidence supports your conclusions in item 1 through 5. Cite the specific facts upon
which your conclusions are based.

Form SSA-4734BK (1-89) 2

(Formerly SSA-4734-U8 Use prior editions)
 6. Continue (note: make additional comments in section IV)

B. POSTURAL LIMITATIONS

None established. (Proceed to section C.)

Frequently Occasionally Never

1. Climbing-ramp/stairs ladder/rope/scaffolds
2. Balancing
3. Stooping
4. Kneeling
5. Crouching
6. Crawling
7. When less than two-thirds of the time for frequently or less than one-third for occasionally, fully describe and explain.
Also explain how and why the evidence supports your conclusions in items 1 through 6. Cite the specific facts upon
which your conclusions are based.

Form SSA-4734BK (1-89) 3

(Formerly SSA-4734-U8 Use prior editions)
C. MANIPULATIVE LIMITATIONS

None established. (Proceed to section D.)

LIMITED UNLIMITED
1. Reaching all directions (including overhead)
2. Handling (gross manipulation)
3. Fingering (fine manipulation)
4. Feeling (skin receptors)
5. Describe how the activities checked "limited" are impaired. Also, explain how and why the evidence supports your
conclusions in item 1 through 4. Cite the specific facts upon which your conclusions are based.

D. VISUAL LIMITATIONS
None established. (Proceed to section E.)

LIMITED UNLIMITED
1. Near acuity
2. Far acuity
3. Depth perception
4. Accommodation
5. Color vision
6. Field of vision
7. Describe how the faculties checked "limited" are impaired. Also explain how and why the evidence supports your
conclusions in item 1 through 6. Cite the specific facts upon which your conclusions are based.

Form SSA-4734BK (1-89) 4

(Formerly SSA-4734-U8 Use prior editions)
E. COMMUNICATIVE LIMITATIONS

None established. (Proceed to section F.)

LIMITED UNLIMITED
1. Hearing
2. Speaking
3. Describe how the faculties checked "limited" are impaired. Also, explain how and why the evidence supports your
conclusions in items 1 and 2. Cite the specific facts upon which your conclusions are based.

F. ENVIRONMENTAL LIMITATIONS

None established. (Proceed to section II.)

UNLIMITED AVOID AVOID EVEN AVOID ALL

CONCENTRATED MODERATE EXPOSURE
EXPOSURE EXPOSURE
1. Extreme cold
2. Extreme heat
3. Wetness
4. Humidity
5. Noise
6. Vibration
7. Fumes, odors, dusts, gases,
poor ventilation, etc.
8. Hazards(machinery,
heights, etc.)
9. Describe how these environmental factors impair activities and identify hazards to be avoided. Also, explain how and
why the evidence supports your conclusions in items 1 though 8. Cite the specific facts upon which your conclusions
are based.

Form SSA-4734BK (1-89) 5

(Formerly SSA-4734-U8 Use prior editions)
 9. Continue (note: make additional comments in section IV)

II. SYMPTOMS

For symptoms alleged by the claimant to produce physical limitations, and for which the following have not previously
been addressed in section I, discuss whether:

A. The symptom(s) is attributable, in your judgment, to a medically determinable impairment.

B. The severity or duration of the symptom(s), in your judgment, is disproportionate to the expected severity or
expected duration on the basis of the claimant's medically determinable impairment(s).

C. The severity of the symptom(s) and its alleged effect on function is consistent, in your judgment, with the total
medical and nonmedical evidence, including statements by the claimant and others, observations regarding activities of
daily living, and alterations of usual behavior or habits.

Form SSA-4734BK (1-89) 6

(Formerly SSA-4734-U8 Use prior editions)
III. TREATING OR EXAMINING SOURCE STATEMENT(S)

A. Is a treating or examining source statement(s) regarding the claimant's physical capacities in file?
Yes

No (Includes situations in which there was no source or when the source(s) did not provide a statement regarding the
claimant's physical capacities.)

B. If yes, are there treating/examining source conclusions about the claimant's limitations or restrictions which are
significantly different from your findings?

Yes

No

C. If yes, explain why those conclusions are not supported by the evidence in file. (Cite the source's name and the
statement date.)

IV. ADDITIONAL COMMENTS:

These findings complete the medical portion of the disability determination.

MEDICAL CONSULTANT'S SIGNATURE: MEDICAL CONSULTANT’S CODE: DATE:

Form SSA-4734BK (1-89) 7

(Formerly SSA-4734-U8 Use prior editions)
 Form Approved
0MB No 0960-0431

MENTAL RESIDUAL FUNCTIONAL CAPACITY ASSESSMENT

Name: SSN:000-00-0000

Categories(From 1B of the PRFT) Assessment Is For:

Current Evaluation
Date Last Insured: / /
Date 12 Months After Onset: / /
Other(Specify):

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.
Not Moderately Markedly No Evidence Not Ratable
Significantly Limited Limited of Limitation on
Limited in this Available
Category Evidence
A. UNDERSTANDING AND MEMORY
1. The ability to remember locations and
work-like procedures
2. The ability to understand and remember
very short and simple instructions
3. The ability to understand and remember
detailed instructions.
B. SUSTAINED CONCENTRATION AND
PERSISTENCE
4. The ability to carry out very short and
simple instructions
5. The ability to carry out detailed
instructions.
6. The ability to maintain attention and
concentration for extended periods.
7. The ability to perform activities within a
schedule, maintain regular attendance,
and be punctual within customary toler-
ances
8. The ability to sustain an ordinary routine
without special supervision
9. The ability to work in coordination with or
proximity to others without being dis-
tracted by them
10. The ability to make simple work-related
decisions.

1
Form SSA-4734-BK-SUP(8/85)
Formerly SSA-4734-F4-SUP1
11. 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.

Not Moderately Markedly No Evidence Not Ratable

Significantly Limited Limited of Limitation on
Limited in this Available
Category Evidence
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.
D. ADAPTATION
17. The ability to respond appropriately to
changes in the work setting.
18. The ability to be aware of normal hazards
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

II. REMARKS: 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.

III. 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.

These findings complete the medical portion of the disability determination.

MEDICAL CONSULTANT'S SIGNATURE DATE

Paperwork/Privacy Act Notice: The information requested on this form is authorized by Section 223 and Section 1633 of the
Social Security Act. The information provided will be used in making a decision on this claim. Failure to complete this form
2
Form SSA-4734-BK-SUP(8/85)
Formerly SSA-4734-F4-SUP2
may result in a delay in processing the claim. Information furnished on this form maybe disclosed by the Social Security
Administration to another person or governmental agency only with respect to Social Security programs and to comply with
federal laws requiring the exchange information between Social Security and other agencies.
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the
clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are
not required to respond to, a collection of information unless it displays a valid 0MB control number.
Time It Takes To Complete This Form: We estimate that it will take you about 20 minutes to complete this form. This includes
the time it will take to read the instructions, gather the necessary facts and fill out the form. If you have comments or
suggestions on this estimate, write to the Social Security Administration, ATTN: Reports Clearance Officer, 1-A-21 Operations
Bldg., Baltimore, MD 21235-0001. Send only comments relating to our "time it takes" estimate to the office listed above. All
requests for Social Security cards and other claims-related information should be sent to your local Social Security office,
whose address is listed under Social Security Administration in the U.S. Government section of your telephone directory.

3
Form SSA-4734-BK-SUP(8/85)
Formerly SSA-4734-F4-SUP3
 Form Approved
OMB No. 0960-0413

PSYCHIATRIC REVIEW TECHNIQUE

Name SSN

NH (If different from above) SSN

I. MEDICAL SUMMARY

A. Assessment is from: to

B. Medical Disposition(s):

1. No Medically Determinable Impairment

2. Impairment(s) Not Severe
3. Impairment Severe But Not Expected to Last 12 Months
4. Meets Listing (Cite Listing)
5. Equals Listing (Cite Listing)
6. RFC Assessment Necessary

7. Coexisting Nonmental Impairment(s) that Requires Referral to Another Medical Specialty

8. Insufficient Evidence

C. Category(ies) Upon Which the Medical Disposition(s) is Based:

1. 12.02 Organic Mental Disorders

2. 12.03 Schizophrenic, Paranoid and other Psychotic Disorders
3. 12.04 Affective Disorders
4. 12.05 Mental Retardation
5. 12.06 Anxiety-Related Disorders
6. 12.07 Somatoform Disorders
7. 12.08 Personality Disorders
8. 12.09 Substance Addiction Disorders
9. 12.10 Autism and Other Pervasive Developmental Disorders

These findings complete the medical portion of the disability determination.

MC/PC’s Signature Date

Form SSA-2506-BK (9-2000) (1)

 Form Approved
OMB No. 0960-0413
MC/PC’s Printed Name Code

II.
DOCUMENTATION OF FACTORS THAT EVIDENCE THE DISORDER

A. 12.02 Organic Mental Disorders

Psychological or behavioral abnormalities associated with a dysfunction of the brain . . . as evidenced by at least
one of the following:

1. Disorientation to time and place

2. Memory impairment
3. Perceptual or thinking disturbances
4. Change in personality
5. Disturbance in mood
6. Emotional lability and impairment in impulse control
7. Loss of measured intellectual ability of at least 15 I.Q. points from premorbid levels or overall
impairment index clearly within the severely impaired range on neuropsychological testing, e.g.,
the Luria-Nebraska, Halstead-Reitan, etc.
A medically determinable impairment is present that does not precisely satisfy the diagnostic criteria above.

Disorder

Pertinent symptoms, signs, and laboratory findings that substantiate the presence of the impairment:

Form SSA-2506-BK (9-2000) (2)

 Insufficient evidence to substantiate the presence of the disorder (explain in Part IV, Consultant’s Notes.)

B. 12.03 Schizophrenic , Paranoid and other Psychotic Disorders

Psychotic features and deterioration that are persistent (continuous or intermittent), as evidenced by at
least one of the following:

1. Delusions or hallucinations
2. Catatonic or other grossly disorganized behavior
3. Incoherence, loosening of associations, illogical thinking, or poverty of content of speech if associated
with one of the following:
a. Blunt affect, or
b. Flat affect, or
c. Inappropriate affect
4. Emotional withdrawal and/or isolation

A medically determinable impairment is present that does not precisely satisfy the diagnostic criteria above.

Disorder

Pertinent symptoms, signs, and laboratory findings that substantiate the presence of the impairment:

Form SSA-2506-BK (9-2000) (3)

 Insufficient evidence to substantiate the presence of the disorder (explain in Part IV, Consultant’s Notes.)

C. 12.04 Affective Disorders

Disturbance of mood, accompanied by a full or partial manic or depressive syndrome, as evidenced by at least one
of the following:

1. Depressive syndrome characterized by at least four of the following:

a. Anhedonia or pervasive loss of interest in almost all activities, or

b. Appetite disturbance with change in weight, or
c. Sleep disturbance, or
d. Psychomotor agitation or retardation, or
e. Decreased energy, or
f. Feelings of guilt or worthlessness, or
g. Difficulty concentrating or thinking, or
h. Thoughts of suicide, or
i. Hallucinations, delusions or paranoid thinking
2. Manic syndrome characterized by at least three of the following:
a. Hyperactivity, or
b. Pressures of speech, or
c. Flight of ideas, or
d. Inflated self-esteem, or
e. Decreased need for sleep, or
f. Easy distractability, or
g. Involvement in activities that have a high probability of painful consequences which are
not recognized, or
h. Hallucinations, delusions or paranoid thinking

3. Bipolar syndrome with a history of episodic periods manifested by the full symptomatic picture of both
manic and depressive syndromes (and currently characterized by either or both syndromes)

A medically determinable impairment is present that does not precisely satisfy the diagnostic criteria above.

Disorder

Pertinent symptoms, signs, and laboratory findings that substantiate the presence of the impairment
(explain in Part IV, Consultant’s Notes, if necessary):

Form SSA-2506-BK (9-2000) (4)

 Insufficient evidence to substantiate the presence of the disorder (explain in Part IV, Consultant’s Notes.)

D. 12.05 Mental Retardation

Significantly subaverage general intellectual functioning with deficits in adaptive behavior initially manifested
during the developmental period; i.e., the evidence demonstrates or supports onset of the impairment before age
22, with one of the following:

1. Mental incapacity evidenced by dependence upon others for personal needs (e.g., toileting, eating,
dressing or bathing) and inability to follow directions, such that the use of standardized measures of
intellectual functioning is precluded*
2. A valid verbal, performance, or full scale I.Q. of 59 or less*
3. A valid verbal, performance, or full scale I.Q. of 60 through 70 and a physical or other mental impairment
imposing additional and significant work-related limitation of function*
4. A valid verbal, performance, or full scale I.Q. of 60 through 70*

A medically determinable impairment is present that does not precisely satisfy the diagnostic criteria above.

Disorder

Pertinent symptoms, signs, and laboratory findings that substantiate the presence of the impairment:

Form SSA-2506-BK (9-2000) (5)

 Insufficient evidence to substantiate the presence of the disorder (explain in Part IV, Consultant’s Notes.)

*NOTE: Items 1, 2, 3, and 4 correspond to listings 12.05A, 12.05B. 12.05C. and 12.05D, respectively.
E. 12.06 Anxiety Related Disorders

Anxiety as the predominant disturbance or anxiety experienced in the attempt to master symptoms, as evidenced
by at least one of the following:

1. Generalized persistent anxiety accompanied by three of the following:

a. Motor tension, or

b. Autonomic hyperactivity, or
c. Apprehensive expectation, or
d. Vigilance and scanning

2. A persistent irrational fear of a specific object, activity or situation which results in a compelling desire
to avoid the dreaded object, activity, or situation
3. Recurrent severe panic attacks manifested by a sudden unpredictable onset of intense apprehension,
fear, terror, and a sense of impending doom occurring on the average of at least once a week
4. Recurrent obsessions or compulsions which are a source of marked distress

5. Recurrent and intrusive recollections of a traumatic experience, which are a source of marked distress

A medically determinable impairment is present that does not precisely satisfy the diagnostic criteria above.

Disorder

Pertinent symptoms, signs, and laboratory findings that substantiate the presence of the impairment
(explain in Part IV, Consultant’s Notes, if necessary):

Form SSA-2506-BK (9-2000) (6)

 Insufficient evidence to substantiate the presence of the disorder (explain in Part IV, Consultant’s Notes.)

F. 12.07 Somatoform Disorders

Physical symptoms for which there are no demonstrable organic findings or known physiological mechanisms, as
evidenced by at least one of the following:

1. A history of multiple physical symptoms of several years duration beginning before age 30 that have
caused the individual to take medicine frequently, see a physician often and alter life patterns
significantly

2. Persistent nonorganic disturbance of one of the following:

a. Vision, or
b. Speech, or
c. Hearing, or
d. Use of a limb, or
e. Movement and its control (e.g., coordination of disturbances, psychogenic seizures, akinesia,
dyskinesia), or
f. Sensation (e.g., diminished or heightened)

3. Unrealistic interpretation of physical signs or sensations associated with the preoccupation or belief that
one has a serious disease or injury

A medically determinable impairment is present that does not precisely satisfy the diagnostic criteria above.

Disorder

Pertinent symptoms, signs, and laboratory findings that substantiate the presence of the impairment
(explain in Part IV, Consultant’s Notes, if necessary):

Form SSA-2506-BK (9-2000) (7)

 Insufficient evidence to substantiate the presence of the disorder (explain in Part IV, Consultant’s Notes.)

G. 12.08 Personality Disorders

Inflexible and maladaptive personality traits which cause either significant impairment in social or occupational
functioning or subjective distress, as evidenced by at least one of the following:

1. Seclusiveness or autistic thinking

2. Pathologically inappropriate suspiciousness or hostility
3. Oddities of thought, perception, speech and behavior
4. Persistent disturbances of mood or affect
5. Pathological dependence, passivity, or aggressivity
6. Intense and unstable interpersonal relationships and impulsive and damaging behavior

A medically determinable impairment is present that does not precisely satisfy the diagnostic criteria above.

Disorder

Pertinent symptoms, signs, and laboratory findings that substantiate the presence of the impairment
(explain in Part IV, Consultant’s Notes, if necessary):

Form SSA-2506-BK (9-2000) (8)

 Insufficient evidence to substantiate the presence of the disorder (explain in Part IV, Consultant’s Notes.)

H. 12.09 Substance Addiction Disorders

Behavioral changes or physical changes associated with the regular use of substances that affect the central
nervous system.

If present evaluate under one or more of the most closely applicable listings:
1. Listing 12.02--Organic mental disorders*
2. Listing 12.04--Affective disorders*
3. Listing 12.06--Anxiety disorders*
4. Listing 12.08--Personality disorders*
5. Listing 11.14--Peripheral neuropathies*
6. Listing 5.05--Liver damage*
7. Listing 5.04--Gastritis*
8. Listing 5.08--Pancreatitis*
9. Listing 11.02 or 11 .03--Seizures*

A medically determinable impairment is present that does not precisely satisfy the diagnostic criteria above.

Disorder

Pertinent symptoms, signs, and laboratory findings that substantiate the presence of the impairment
(explain in Part IV, Consultant’s Notes, if necessary):

Form SSA-2506-BK (9-2000) (9)

 Insufficient evidence to substantiate the presence of the disorder (explain in Part IV, Consultant’s Notes.)

*NOTE: Items 1, 2, 3, 4, 5, 6, 7, 8, and 9 correspond to Listings 12.09A, 12.09B, 12.09C, 12.09D, 12.09E, 12.09F, 12.09G,
12.09H, and 12.09I, respectively. If items 1, 2, 3, or 4 are checked, only the numbered items in subsections IIIA, IIIC, IIIE. or IIIG
of the form need be checked. The first two blocks under the disorder heading in those subsections need not be checked.

I. 12.10 Autistic Disorder and Other Pervasive Developmental Disorders

Form SSA-2506-BK (9-2000) (10)

 Qualitative deficits in the development of reciprocal social interaction, in the development of verbal and nonverbal
communication skills, and in imaginative activity. Often there is a markedly restricted repertoire of activities and
interests, which frequently are stereotyped and repetitive.

1. Autistic disorder, with medically documented findings in all of the following:

a. Qualitative deficits in reciprocal social interaction
b. Qualitative deficits in verbal and nonverbal communication and in imaginative activity
c. Markedly restricted repertoire of activities and interests
2. Other pervasive developmental disorders, with medically documented findings of both of the following:
a. Qualitative deficits in reciprocal social interaction
b. Qualitative deficits in verbal and nonverbal communication and in imaginative activity

A medically determinable impairment is present that does not precisely satisfy the diagnostic criteria above.

Disorder

Pertinent symptoms, signs, and laboratory findings that substantiate the presence of the impairment
(explain in Part IV, Consultant’s Notes, if necessary):

Insufficient evidence to substantiate the presence of the disorder (explain in Part IV, Consultant’s Notes.)

Form SSA-2506-BK (9-2000) (11)

III. RATING OF FUNCTIONAL LIMITATIONS
A. "B" Criteria of the Listings

Indicate to what degree the following functional limitations (which are found in paragraph B of listings 12.02-12.04,
12.06-12.08 and 12.10 and paragraph D of 12.05) exist as a result of the individual's mental disorder(s).

NOTE: Item 4 below is more than measures of frequency. See 12.00C4 and also read carefully the instructions for this
section.

Specify the listing(s) (i.e., 12.02 through 12.09) under which the items below are being rated:

FUNCTIONAL
LIMITATION DEGREE OF LIMITATION

Insufficient
1. Restriction of. Activities None Slight Moderate Marked* Extreme* Evidence
of Daily Living

Insufficient
2. Difficulties in None Slight Moderate Marked* Extreme* Evidence
Maintaining Social
Functioning

Insufficient
3. Deficiencies in Never Seldom Often Frequent* Extreme* Evidence
Maintaining
Concentration,
Persistence or Pace

One Four
4. Repeated Episodes of or or Insufficient
Deterioration. Each of Never Two Three* More Evidence
Extended Duration

*Degree of limitation that satisfies the functional

criteria

Form SSA-2506-BK (9-2000) (12)

 B. "C" Criteria of the Listings

1. Complete this section if 12.02 (Organic Mental), 12.03 (Schizophrenic, etc.), or 12.04 (affective) applies
and the requirements in paragraph B of the appropriate listing are not satisfied.

NOTE: Item 1. below is more than a measure of frequency and duration. See 12.00C4 and also read
carefully the instructions for this section

Medically documented history of a chronic organic (12.02), schizophrenic, etc. (12.03), or affective
(12.04) disorder of at least 2 years duration that has caused more than a minimal limitation of ability to do
any basic work activity, with symptoms or signs currently attenuated by medication or psychosocial
support, and one of the following:

1. Repeated episodes of decompensation, each of extended duration

2. A residual disease that has resulted in such marginal adjustment that even a minimal increase in
mental demands or change in the environment would be predicted to cause the individual to
decompensate

3. Current history of 1 or more years inability to function outside a highly supportive living
arrangement with an indication of continued need for such an arrangement.

Evidence does not establish the presence of the “C” criteria.

Insufficient evidence to establish the presence of the “C” criteria (explain in Part IV, Consultant’s
Notes).

2. Complete this section if 12.06 (Anxiety Related) applies and the requirements in paragraph B of listing
12.06 are not satisfied.

Complete inability to function independently outside the area of one’s home

Evidence does not establish the presence of the “C” criteria.

Insufficient evidence to establish the presence of the “C” criteria (explain in Part IV, Consultant’s
Notes)

Form SSA-2506-BK (9-2000) (13)

IV. CONSULTANT’S NOTES

Form SSA-2506-BK (9-2000) (14)

Section 223 and section 1633 of the Social Security Act authorize the information requested on this form. The
information provided will be used in making a decision on this claim. Completion of this form is mandatory in
disability claims involving mental impairments. Failure to complete this form may result in a delay in processing the
claim. Information furnished on this form may be disclosed by the Social Security Administration to another
person or governmental agency only with respect to Social Security programs and to comply with federal laws
requiring the exchange of information between Social Security and another agency.

We may also use the information you give us when we match records by computer. Matching programs compare
our records with those of other Federal, State or local government 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 information about you may be used and given out are available in
Social Security offices. If you want to learn more about this, contact any Social Security office.

PAPERWORK REDUCTION ACT STATEMENT: The Paperwork Reduction Act of 1995 requires us to
notify you that this information collection is in accordance with the clearance requirements to section 3507 of the
Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a
collection of information unless it displays a valid OMB control number. We estimate that it will take you about 15
minutes to complete this form. This includes the time it will take to read the instructions, gather the necessary
facts and fill out the form.

Form SSA-2506-BK (9-2000) (15)

 DISABILITY REPORT – CHILD - Form-SSA-3820-BK

READ ALL OF THIS INFORMATION

BEFORE YOU BEGIN COMPLETING THIS FORM

IF YOU NEED HELP

If you need help with this form, complete as much of it as you can, and your interviewer
will help you finish it.

HOW TO COMPLETE THIS FORM

The information that you give us on this form will be used by the office that makes the
disability decision on your disability claim. You can help them by completing as much of
the form as you can.

• Fill out this form before your interview appointment.

Disability Report – Child – Form SSA-3820-BK

• Print or type.
• Do Not Leave Answers Blank. If you do not know the answers or the answer
is “none” or “does not apply,” write: “don’t know,” or “none,” or “does not
apply.”
• IN SECTION 4, PUT INFORMATION ON ONLY ONE DOCTOR/HOSPITAL/
CLINIC IN EACH SPACE.
• Each address should include a ZIP code. Each telephone number should
include an area code.
• DO NOT ASK A DOCTOR OR HOSPITAL TO COMPLETE THE FORM.
However, you can get help from a friend or family member.
• If your appointment is for an interview by telephone, have the form ready to
discuss with us when we call you.
• If your appointment is for an interview in our office, bring the completed form
with you or mail it ahead of time, if you were told to do so.
• Be sure to explain an answer if the question asks for an explanation or if you
want to give additional information.
• If you need more space to answer any questions or want to tell us more about
an answer, please use the “REMARKS” section on Pages 10 and 11, and show
the number of the question being answered.

ABOUT THE CHILD’S MEDICAL AND OTHER RECORDS

If you have any of the following records for the child at home, send them to our office
with your completed forms or bring them with you to the interview. If you need the
records back, tell us and we will photocopy them and return them to you.

• The child’s medical records.

• Copies of the child’s prescriptions.
• The child’s Individualized Education Program
• The child’s Individualized Family Service Plan

YOU DO NOT NEED TO ASK DOCTORS OR HOSPITALS FOR ANY MEDICAL

RECORDS THAT YOU DO NOT ALREADY HAVE. With your permission, we will do
that for you. The information we ask for on this form tells us from whom to request
medical and other records. If you cannot remember the names and addresses of any of the
doctors or hospitals, or the dates of treatment, perhaps you can get this information from
the telephone book, or from medical bills, prescriptions and prescription bottles.

The Privacy and Paperwork Reduction Acts

The Social Security Administration is authorized to collect the information on this form under
sections 205(a), 223(d) and 1631(e)(1) of the Social Security Act. The information on this form
is needed by Social Security to make a decision on the named claimant’s claim. While giving us
the information on this form is voluntary, failure to provide all or part of the requested informa-
tion could prevent an accurate or timely decision on the named claimant’s claim. Although the
information you furnish is almost never used for any purpose other than making a determination
about the claimant’s disability, such information may be disclosed by the Social Security
Administration as follows: (1) to enable a third party or agency to assist Social Security in estab-
lishing rights to Social Security benefits and/or coverage; (2) to comply with Federal Laws
requiring the release of information from Social Security records (e.g., to the General Accounting
Office and the Department of Veteran 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 the information you give us when we match records by computer. Matching
programs compare our records with those of other Federal, State, or local government 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 information you provide us may be used or given
out are available in Social Security offices.

The Paperwork Reduction Act of 1995 requires us to notify you that this information
collection is in accordance with the clearance requirements of Section 3507 of the Paperwork
Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a
collection of information unless it displays a valid OMB control number. We estimate that it
will take you about 40 minutes to complete this form. This includes the time it will take to read the
instructions, gather the necessary facts, and fill out the form.

REMOVE THIS SHEET BEFORE RETURNING THE COMPLETED FORM.

 Form Approved
SOCIAL SECURITY ADMINISTRATION OMB No. 0960-0577

DISABILITY REPORT - CHILD

SECTION 1 – INFORMATION ABOUT THE CHILD

A. CHILD’S NAME (First, Middle Initial, Last) B. CHILD’S SOCIAL SECURITY NUMBER

C. YOUR NAME (If agency, provide name of agency and contact person)

YOUR MAILING ADDRESS (Number and Street, Apt. No. (if any), P.O. Box, or Rural Route)

CITY STATE ZIP CODE

Disability Report – Child – Form SSA-3820-BK

D. YOUR DAYTIME PHONE NUMBER (If you have no phone number, give us a daytime number
where we can leave a message for you.)

Area Code Number Your Number Message Number None

E. What is your relationship to the child?

F. Can you speak English ? YES NO If “NO,” what languages can you speak?

If you cannot speak English, give us the name of someone we may contact who speaks English and will
give you messages.

NAME RELATIONSHIP TO CHILD

ADDRESS
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)

DAYTIME
City State ZIP PHONE Area Code Phone Number

Can you read English? YES NO

G. Does the child live with you? YES NO If “NO,” with whom does the child live?

NAME RELATIONSHIP TO CHILD

ADDRESS
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)

DAYTIME
City State ZIP PHONE Area Code Phone Number

Can this person speak English? YES NO

If “NO,” what languages can this person speak?

Can this person read English ? YES NO

FORM SSA-3820-BK (12/98) 7/98 EDITION(S) MAY BE USED UNTIL EXHAUSTED PAGE 1
 SECTION 1 – INFORMATION ABOUT THE CHILD

H. Can the child speak English? YES NO

If “NO,” what languages can the child speak?

I. What is child’s height (without shoes) ? What is child’s weight (without shoes)?

J. Does the child have a medical assistance card? (for example, Medicaid, Medi-Cal)

YES NO

If “YES,” show the number here:

SECTION 2 – CONTACT INFORMATION

Give the name of a person that we can contact (other than the child’s doctors, such as legal guardian) who
knows about the child’s illnesses, injuries, or conditions and can help you with his/her claim.

NAME OF CONTACT

ADDRESS
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)

City State ZIP

DAYTIME PHONE NUMBER

Area Code Number

RELATIONSHIP TO CHILD

SECTION 3 – THE CHILD’S ILLNESSES, INJURIES OR

CONDITIONS AND HOW THEY AFFECT HIM/HER

A. What are the child’s disabling illnesses, injuries, or conditions?

B. How do the child’s illnesses, injuries or conditions limit his/her daily activities?

Month Day Year

C. When did the child become disabled?

D. Do the child’s illnesses, injuries or conditions cause pain? YES NO

FORM SSA-3820-BK (12/98) PAGE 2

 SECTION 4 – INFORMATION ABOUT THE CHILD’S MEDICAL RECORDS

A. Has the child been seen by a doctor/hospital/clinic or anyone else for the illnesses, injuries or conditions?

YES NO

B. Has the child been seen by a doctor/hospital/clinic or anyone else for emotional or mental problems?

YES NO

Tell us who may have medical records or other

information about the child’s illnesses, injuries or conditions.

C. List each DOCTOR/HMO/THERAPIST. Include the child’s next appointment.

1. NAME DATES

STREET ADDRESS FIRST VISIT

CITY STATE ZIP LAST SEEN

PHONE CHART/HMO # NEXT APPOINTMENT

Area Code Phone Number

REASONS FOR VISITS

WHAT TREATMENT WAS RECEIVED?

2. NAME DATES

STREET ADDRESS FIRST VISIT

CITY STATE ZIP LAST SEEN

PHONE CHART/HMO # NEXT APPOINTMENT

Area Code Phone Number

REASONS FOR VISITS

WHAT TREATMENT WAS RECEIVED?

FORM SSA-3820-BK (12/98) PAGE 3

 SECTION 4 – INFORMATION ABOUT THE CHILD’S MEDICAL RECORDS

DOCTOR/HMO/THERAPIST
3. NAME DATES

STREET ADDRESS FIRST VISIT

CITY STATE ZIP LAST SEEN

PHONE CHART/HMO # NEXT APPOINTMENT

Area Code Phone Number

REASONS FOR VISITS

WHAT TREATMENT WAS RECEIVED?

If you need more space, use Remarks, Section 10

D. List each HOSPITAL/CLINIC. Include child’s next appointment.
1. HOSPITAL/CLINIC TYPE OF VISIT DATES
NAME INPATIENT STAYS DATE IN DATE OUT

(Stayed at least overnight)

STREET ADDRESS OUTPATIENT VISITS DATE FIRST VISIT DATE LAST VISIT

(Sent home same day)

CITY STATE ZIP EMERGENCY ROOM VISITS DATES OF VISITS

PHONE

Area Code Phone Number

Next appointment The child’s hospital/clinic number

Reasons for visits

What treatment did the child receive?

What doctors does the child see at this hospital/clinic on a regular basis?

FORM SSA-3820-BK (12/98) PAGE 4

 SECTION 4 – INFORMATION ABOUT THE CHILD’S MEDICAL RECORDS

HOSPITAL/CLINIC
2. HOSPITAL/CLINIC TYPE OF VISIT DATES
NAME INPATIENT STAYS DATE IN DATE OUT

(Stayed at least overnight)

STREET ADDRESS OUTPATIENT VISITS DATE FIRST VISIT DATE LAST VISIT

(Sent home same day)

CITY STATE ZIP EMERGENCY ROOM VISITS DATES OF VISITS

PHONE

Area Code Phone Number

Next appointment The child’s hospital/clinic number

Reasons for visits

What treatment did the child receive?

What doctors does the child see at this hospital/clinic on a regular basis?

If you need more space, use Remarks, Section 10

E. Does anyone else have medical records or information about the child’s illnesses, injuries or
conditions (Workers’ Compensation, insurance companies, counselors, detention centers,
attorneys, and/or tutors) or is the child scheduled to see anyone else?
YES (If “YES,” complete the information below.) NO
NAME DATES

ADDRESS FIRST VISIT

CITY STATE ZIP LAST SEEN

PHONE NEXT APPOINTMENT

Area Code Phone Number

CLAIM NUMBER (If any)

REASONS FOR VISITS?

If you need more space, use Remarks, Section 10

FORM SSA-3820-BK (12/98) PAGE 5

 SECTION 5 – MEDICATIONS

Does the child currently take any medications for the illnesses, injuries or conditions? YES NO
If “YES,” tell us the following. (Look at the child’s medicine bottles, if necessary.)

IF PRESCRIBED, GIVE REASON FOR SIDE EFFECTS

NAME OF MEDICINE
NAME OF DOCTOR MEDICINE THE CHILD HAS

If you need more space, use Remarks, Section 10

SECTION 6 – TESTS
Has the child had, or will he/she have, any medical tests for the illnesses, injuries or conditions?
YES NO If “YES,” please tell us the following: (give approximate dates, if necessary).
WHEN DONE, WHO SENT
OR WHEN IT WILL WHERE DONE
KIND OF TEST THE CHILD FOR
BE DONE (Name of Facility)
THIS TEST
(Month, day, year)
EKG (HEART TEST)

TREADMILL (EXERCISE TEST)

CARDIAC CATHETERIZATION

BIOPSY
Name of body part
SPEECH/ LANGUAGE

HEARING TEST

VISION TEST

IQ TESTING

EEG (BRAIN WAVE TEST)

HIV TEST

BLOOD TEST (NOT HIV)

BREATHING TEST

X-RAY
Name of body part
MRI/CAT SCAN
Name of body part

If the child has had other tests, list them in Remarks, Section 10.
FORM SSA-3820-BK (12/98) PAGE 6
 SECTION 7 – ADDITIONAL INFORMATION

A. Has the child been tested or examined by any of the following?

1. Headstart (Title V) YES NO

2. Public or Community Health Department YES NO
3. Child Welfare or Social Service Agency YES NO
4. Women, Infant and Children (WIC) Program YES NO
5. Program for Children with Special Health
Care Needs YES NO
6. Mental Health/Mental Retardation Center YES NO
7. Vocational Rehabilitation YES NO
If “NO” to 7 above and the child is over age 15, do you
want the child to be referred to Vocational Rehabilitation? YES NO

If you answered “YES” to any of the above, complete B below.

B. 1. NAME OF AGENCY

ADDRESS
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)

City State ZIP

PHONE NUMBER
Area Code Number

TYPE OF TEST WHEN DONE

TYPE OF TEST WHEN DONE

FILE OR RECORD NUMBER

2. NAME OF AGENCY

ADDRESS
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)

City State ZIP

PHONE NUMBER
Area Code Number

TYPE OF TEST WHEN DONE

TYPE OF TEST WHEN DONE

FILE OR RECORD NUMBER

If there are any other agencies, show them in Remarks, Section 10.

FORM SSA-3820-BK (12/98) PAGE 7

 SECTION 8 – EDUCATION

A. What is the child’s current grade in school or the highest grade completed?

B. Is the child currently attending school (other than summer school)? YES NO

If “NO” explain why the child is not attending school.

C. List the name of the school the child is currently attending and give dates attended. If the child is no
longer in school, list the name of the last school attended and give dates attended.

NAME OF SCHOOL

ADDRESS
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)

City County State ZIP

PHONE NUMBER
Area Code Number

DATES ATTENDED

TEACHER’S NAME

Has the child been tested for behavioral or learning problems? YES NO
If “YES,” complete the following:

TYPE OF TEST WHEN DONE

TYPE OF TEST WHEN DONE

Is the child in special education? YES NO

If “YES,” and the teacher’s name is different from above, give:

NAME OF SPECIAL EDUCATION TEACHER

Is the child in speech therapy? YES NO

If “YES,” and the therapist’s name is different from above, give:

NAME OF SPEECH THERAPIST

FORM SSA-3820-BK (12/98) PAGE 8

 SECTION 8 – EDUCATION

D. List the names of all other schools attended in the last 12 months and give dates attended.

NAME OF SCHOOL

ADDRESS
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)

City County State ZIP

PHONE NUMBER
Area Code Number

DATES ATTENDED

TEACHER’S NAME

Was the child tested for behavioral or learning problems? YES NO

If “YES,” complete the following:

TYPE OF TEST WHEN DONE

TYPE OF TEST WHEN DONE

Was the child in special education? YES NO

If “YES,” and the teacher’s name is different from above, give:

NAME OF SPECIAL EDUCATION TEACHER

Was the child in speech therapy? YES NO

If “YES,” and the therapist’s name is different from above, give:

NAME OF SPEECH THERAPIST

If there are other schools, show them in Remarks, Section 10.

E. Is the child attending Daycare/Preschool? YES NO

If “YES,” complete the following:

NAME OF DAYCARE/
PRESCHOOL/CAREGIVER

ADDRESS
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)

City County State ZIP

PHONE NUMBER
Area Code Number

DATES ATTENDED

TEACHER’S/CAREGIVER’S NAME

FORM SSA-3820-BK (12/98) PAGE 9

 SECTION 9 – WORK HISTORY

A. Has the child ever worked (including sheltered work)? YES NO

If “YES”, complete the following:

DATES WORKED

NAME OF EMPLOYER

ADDRESS
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)

City State ZIP

PHONE NUMBER
Area Code Number

NAME OF SUPERVISOR

B. List the job title, and briefly describe the work and any problems the child may have had doing the job.

SECTION 10 – REMARKS

Use this section for any added information you did not show in the earlier parts of this form. When
you are done with this section (or if you don’t have anything to add), be sure to go to the next
page and complete the signature block.

FORM SSA-3820-BK (12/98) PAGE 10

 SECTION 10 – REMARKS

ANYONE MAKING A FALSE STATEMENT OR REPRESENTATION OF A MATERIAL FACT FOR USE IN

DETERMINING A RIGHT TO PAYMENT UNDER THE SOCIAL SECURITY ACT COMMITS A CRIME
PUNISHABLE UNDER FEDERAL LAW.

Signature of claimant or person filing on claimant’s behalf (parent, guardian) Date (Month, day, year)

Witnesses are required ONLY if this statement has been signed by mark (X) above. If signed by mark (X),
two witnesses to the signing who know the person making the statement must sign below giving their full
addresses.
1. Signature of Witness 2. Signature of Witness

Address (number and street, city, state, and ZIP code) Address (number and street, city, state, and ZIP code)

FORM SSA-3820-BK (12/98) PAGE 11

 Form Approved
Social Security Administration OMB No. 0960-0568

CHILDHOOD DISABILITY EVALUATION FORM

Name: Level of Determination:
Initial CDR
Reconsideration CDR Reconsideration
SSN: Other_________
Is this child engaging in SGA?
Yes No
Date of birth: Filing Date:______________

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
IIA&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) IIA&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) Destroy Prior Editions 1
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
25230.001B4). 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.

Consultant with overall responsibility (Sign, print name and specialty) Date

Additional consultant signature (Sign, print name and specialty) Date

Additional consultant signature (Sign, print name and specialty) Date

Form SSA-538-F6 (1/2001) 2

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)-(l)). 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

1. Acquiring and Using Information no limitation less than marked marked extreme

Continued in section III

2. Attending and Completing Tasks no limitation less than marked marked extreme

Continued in section III

3. Interacting and Relating With Others no limitation less than marked marked extreme

Continued in section III

Form SSA-538-F6 (1/2001) 3
A. DOMAIN EVALUATIONS (continued)

4. Moving About and Manipulating Objects no limitation less than marked marked extreme

Continued in section III

5. Caring For Yourself no limitation less than marked marked extreme

Continued in section III

6. Health and Physical Well-Being (Reminder—see additional definitions of marked and/extreme for this domain on page 5)
no limitation less than marked marked extreme

Continued in section III

Form SSA-538-F6 (1/2001) 4
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) 5

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 clearance requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You are not
required 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, on
average, to complete this form. This includes the time it will take to read the instructions and complete the appropriate sections.

Form SSA-538-F6 (1/2001) 6