Form Ssa-4734-Bk - Physical Residual Functional Capacity Assessment
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8FORM APPR0VED
OMB NO. 0960-0431
PHYSICAL RESIDUAL FUNCTIONAL CAPACITY ASSESSMENT
SOCIAL SECURITY NUMBER:
CLAIMANT:
NUMBERHOLDER (IF CDB CLAIM):
-
-
RFC ASSESSMENT IS FOR:
PRIMARY DIAGNOSIS:
Current Evaluation
Date
12 Months After Onset:
SECONDARY DIAGNOSIS:
Date Last
Insured:
(Date)
(Date)
OTHER ALLEGED IMPAIRMENTS:
Other (Specify):
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 of 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 only with respect to Social Security programs and to comply with
Federal laws requiring the exchange of information between Social Security and other agencies.
PAPERWORK REDUCTION ACT: This information collection meets the requirements of 44 U.S.C. § 3507, as amended by
Section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office
of Management and Budget control number. We estimate that it will take about 20 minutes to read the instructions, gather the
facts, and answer the questions. You may send comments on our time estimate above to: SSA, 1338 Annex Building, Baltimore,
MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.
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 judgement.
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 22505.000ff. and DI 22510.000ff.) 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 judgement, 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).
Continued on Page 2
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Form SSA-4734-BK (12-2004) ef (12-2004)
(Formerly SSA-4734-U8 Use prior editions)
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