Form Ssa-4734-F4-Sup - Mental Residual Functional Capacity Assessment
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4MENTAL RESIDUAL FUNCTIONAL CAPACITY ASSESSMENT
NAME
SOCIAL SECURITY NUMBER
CATEGORIES (From IB of the PRTF)
ASSESSMENT IS FOR:
12 Months After Onset:
Current Evaluation
(Date)
Date Last
Insured:
(Date)
Other:
to
(Date)
(Date)
I.
SUMMARY CONCLUSIONS
This section is for recording summary conclusions derived from the evidence in file. Each mental activity is to be evaluated within
the context of the individual's capacity to sustain that activity over a normal workday and workweek, on an ongoing basis. Detailed
explanation of the degree of limitation for each category (A through D), as well as any other assessment information you deem
appropriate, is to be recorded in Section III (Functional Capacity Assessment).
If rating Category 5 is checked for any of the following items, you MUST specify in Section II the evidence that is needed to make
the assessment. If you conclude that the record is so inadequately documented that no accurate functional capacity assessment
can be made, indicate in Section II what development is necessary. but DO NOT COMPLETE SECTION III.
Not
No Evidence of
Not Ratable on
Significantly
Moderately
Markedly
Limitation in this
Available
Limited
Limited
Limited
Category
Evidence
A.
UNDERSTANDING AND MEMORY
The ability to remember locations and
1.
1.
2.
3.
4.
5.
work-like procedures.
2.
The ability to understand and remem-
1.
2.
3.
4.
5.
ber very short and simple instructions.
3.
The ability to understand and remem-
1.
2.
3.
4.
5.
ber detailed instructions.
B.
SUSTAINED CONCENTRATION AND PERSISTENCE
4.
The ability to carry out very short and
1.
2.
3.
4.
5.
simple instructions.
5.
The ability to carry out detailed instruc-
1.
2.
3.
4.
5.
tions.
6.
The ability to maintain attention and
1.
2.
3.
4.
5.
concentration for extended periods.
7.
The ability to perform activities within a
schedule, maintain regular attendance.
1.
2.
3.
4.
5.
and be punctual within customary toler-
ances.
8.
The ability to sustain an ordinary routine
1.
2.
3.
4.
5.
without special supervision.
9.
The ability to work in coordination with
1.
2.
3.
4.
5.
or proximity to others without being dis-
tracted by them.
10.
The ability to make simple work-related
1.
2.
3.
4.
5.
decisions.
SSA-4734-F4-SUP
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