Disability Report-Adult-Form Ssa-3368-Bk Read All of This Information Before You Begin Completing This Form If You Need Help
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.
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.
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.
“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 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.
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.)
NAME RELATIONSHIP
ADDRESS
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)
DAYTIME
City State ZIP PHONE Area Code Phone Number
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?
E. When did you become unable to work because of Month Day Year
your illnesses, injuries or conditions?
H. If “YES,” did your illnesses, injuries or conditions cause you to: (Check all that apply,)
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?)
E. Lifting and Carrying (Explain what you lifted, how far you carried it, and how often you did this.)
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.)
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
1. NAME DATES
2. NAME DATES
DOCTOR/HMO/THERAPIST
3. NAME DATES
STREET ADDRESS OUTPATIENT VISITS DATE FIRST VISIT DATE LAST VISIT
PHONE
HOSPITAL/CLINIC
2. HOSPITAL/CLINIC TYPE OF VISIT DATES
NAME INPATIENT STAYS DATE IN DATE OUT
STREET ADDRESS OUTPATIENT VISITS DATE FIRST VISIT DATE LAST VISIT
PHONE
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
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
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)
CARDIAC CATHETERIZATION
BIOPSY
Name of body part
HEARING TEST
VISION TEST
IQ TESTING
HIV TEST
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
NAME OF SCHOOL
ADDRESS
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)
DATES ATTENDED TO
TYPE OF PROGRAM
C. Have you completed any type of special job training, trade or vocational school? YES NO
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)
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?
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.
Address (number and street, city, state, and ZIP code) Address (number and street, city, state, and ZIP code)
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)
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
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.
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
If you need help with this form, complete as much of it as you can, and your interviewer
will help you finish it.
The information that you give us on this form will be used by the office that makes the
• 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.
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.
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.
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.)
List the kinds of jobs that you have had in the last 15 years that you worked.
FROM TO
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
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
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:
Lifting and Carrying (Explain what you lifted, how far you carried it, and how often you did this.)
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.)
Did you supervise other people in this job? Yes (Complete items below.) No (Skip to next page.)
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
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:
Lifting and Carrying (Explain what you lifted, how far you carried it, and how often you did this.)
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.)
Did you supervise other people in this job? Yes (Complete items below.) No (Skip to next page.)
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
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:
Lifting and Carrying (Explain what you lifted, how far you carried it, and how often you did this.)
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.)
Did you supervise other people in this job? Yes (Complete items below.) No (Skip to next page.)
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
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:
Lifting and Carrying (Explain what you lifted, how far you carried it, and how often you did this.)
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.)
Did you supervise other people in this job? Yes (Complete items below.) No (Skip to next page.)
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
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:
Lifting and Carrying (Explain what you lifted, how far you carried it, and how often you did this.)
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.)
Did you supervise other people in this job? Yes (Complete items below.) No (Skip to next page.)
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
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:
Lifting and Carrying (Explain what you lifted, how far you carried it, and how often you did this.)
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.)
Did you supervise other people in this job? Yes (Complete items below.) No (Skip to next page.)
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)
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Claimant: SSN:000-00-0000
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).
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.
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.
must periodically alternate sitting and standing to relieve pain or discomfort. (If checked, explain in 6.)
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.
B. POSTURAL LIMITATIONS
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.
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
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:
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.
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.)
Name: SSN:000-00-0000
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.
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.
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.
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
Name SSN
I. MEDICAL SUMMARY
A. Assessment is from: to
B. Medical Disposition(s):
8. Insufficient Evidence
II.
DOCUMENTATION OF FACTORS THAT EVIDENCE THE DISORDER
Disorder
Pertinent symptoms, signs, and laboratory findings that substantiate the presence of the impairment:
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:
Disturbance of mood, accompanied by a full or partial manic or depressive syndrome, as evidenced by at least one
of the following:
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):
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:
*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:
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):
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
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):
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:
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):
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):
*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.
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.)
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
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:
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.
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.
Insufficient evidence to establish the presence of the “C” criteria (explain in Part IV, Consultant’s
Notes)
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.
If you need help with this form, complete as much of it as you can, and your interviewer
will help you finish it.
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.
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 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.
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)
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.
ADDRESS
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)
DAYTIME
City State ZIP PHONE Area Code Phone Number
G. Does the child live with you? YES NO If “NO,” with whom does the child live?
ADDRESS
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)
DAYTIME
City State ZIP PHONE Area Code Phone Number
FORM SSA-3820-BK (12/98) 7/98 EDITION(S) MAY BE USED UNTIL EXHAUSTED PAGE 1
SECTION 1 – INFORMATION ABOUT THE CHILD
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
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)
RELATIONSHIP TO CHILD
B. How do the child’s illnesses, injuries or conditions limit his/her daily activities?
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
1. NAME DATES
2. NAME DATES
DOCTOR/HMO/THERAPIST
3. NAME DATES
STREET ADDRESS OUTPATIENT VISITS DATE FIRST VISIT DATE LAST VISIT
PHONE
What doctors does the child see at this hospital/clinic on a regular basis?
HOSPITAL/CLINIC
2. HOSPITAL/CLINIC TYPE OF VISIT DATES
NAME INPATIENT STAYS DATE IN DATE OUT
STREET ADDRESS OUTPATIENT VISITS DATE FIRST VISIT DATE LAST VISIT
PHONE
What doctors does the child see at this hospital/clinic on a regular basis?
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
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.)
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)
CARDIAC CATHETERIZATION
BIOPSY
Name of body part
SPEECH/ LANGUAGE
HEARING TEST
VISION TEST
IQ TESTING
HIV TEST
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
B. 1. NAME OF AGENCY
ADDRESS
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)
PHONE NUMBER
Area Code Number
2. NAME OF AGENCY
ADDRESS
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)
PHONE NUMBER
Area Code Number
If there are any other agencies, show them in Remarks, Section 10.
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
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)
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:
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)
PHONE NUMBER
Area Code Number
DATES ATTENDED
TEACHER’S NAME
NAME OF DAYCARE/
PRESCHOOL/CAREGIVER
ADDRESS
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)
PHONE NUMBER
Area Code Number
DATES ATTENDED
TEACHER’S/CAREGIVER’S NAME
DATES WORKED
NAME OF EMPLOYER
ADDRESS
(Number, Street, Apt. No. (if any), P.O. Box, or Rural Route)
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.
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)
I. SUMMARY
A. IMPAIRMENTS:
B. DISPOSITION: Check one entry that best describes your findings in this case. Complete this section last.
Explanation:
3. MEDICALLY EQUALS LISTING__________________________. (Cite complete Listing and subsection(s), including any
applicable B criteria for 112.00 and explain below.)
Explanation:
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.)
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.
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.
Consultant with overall responsibility (Sign, print name and specialty) Date
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
4. Moving About and Manipulating Objects no limitation less than marked marked extreme
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.
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.
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.