Form Ssa-4734-F4-Sup - Mental Residual Functional Capacity Assessment Page 2
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1
2
3
4No Evidence of
Not Ratable on
Not
Significantly
Moderately
Markedly
Limitation in this
Available
Limited
Limited
Limited
Category
Evidence
SUSTAINED CONCENTRATION
Continued—
AND PERSISTENCE
11.
The ability to complete a normal work-
day and workweek without interruptions
from psychologically based symptoms
1.
2.
3.
4.
5.
and to perform at a consistent pace
without an unreasonable number and
length of rest periods.
C. SOCIAL INTERACTION
12.
The ability to interact appropriately with
1.
2.
3.
4.
5.
the general public.
13.
The ability to ask simple questions or
1.
2.
3.
4.
5.
request assistance.
14.
The ability to accept instructions and re-
1.
2.
3.
4.
5.
spond appropriately to criticism from
supervisors.
15.
The ability to get along with coworkers
or peers without distracting them or ex-
1.
2.
3.
4.
5.
hibiting behavioral extremes.
16.
The ability to maintain socially appropri-
ate behavior and to adhere to basic
1.
2.
3.
4.
5.
standards of neatness and cleanliness.
D. ADAPTATION
17.
The ability to respond appropriately to
1.
2.
3.
4.
5.
changes in the work setting.
18.
The ability to be aware of normal haz-
1.
2.
3.
4.
5.
ards and take appropriate precautions.
19.
The ability to travel in unfamiliar places
1.
2.
3.
4.
5.
or use public transportation.
20.
The ability to set realistic goals or make
1.
2.
3.
4.
5.
plans independently of others.
II.
REMARKS:
If you checked box 5 for any of the preceding items or it any other documentation deficiencies were identified,
you must specify what additional documentation is needed. Cite the item number(s), as well as any other specific deficiency,
and indicate the development to be undertaken.
Continued on Page 3
SSA-4734-F4-SUP
2
Form
(8-85)
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