Fillable Printable Mental Residual Functional Capacity Assessment
Fillable Printable Mental Residual Functional Capacity Assessment
Mental Residual Functional Capacity Assessment
MENTAL RESIDUAL FUNCTIONAL CAPACITY ASSESSMENT
SOCIAL SECURITY NUMBER
NAME
ASSESSMENT IS FOR:
CATEGORIES
(From IB of the PRTF)
12 Months After Onset:
Current Evaluation
(Date)
Date Last
Insured:
(Date)
Other:
to
(Date)
(Date)
SUMMARY CONCLUSIONS
I.
This section is for recording summary conclusions der ived 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 w orkweek, on an ongoing basis. Detailed
explanation of the degree of limitation f or 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 M UST 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
Sign i ficantly AvailableMar kedlyMod erately
Limitation in this
EvidenceLimited Limited Limited Category
UNDERSTANDING AND MEMORY
The ability to remember locations and
work-like procedures.
1.
The ability to understand and remem-
ber very short and simple instructions.
1.
The ability to understand and remem-
ber detailed instructions.
1.
SUSTAINED CONCENTRATION AND PERSISTENCE
The ability to carry out very short and
simple instructions.
1.
The ability to carry out detailed instruc-
1.
tions.
The ability to maintain attention and
concentration for extended periods.
1.
The ability to perform activities within a
schedule, maintain regular attendance.
and be punctual within customary toler-
ances.
1.
The ability to sustain an ordinary routine
without special supervision.
1.
The ability to w ork in coordination with
1.
or proximity to others without being dis-
tracted by them.
The ability to make simple work-related
decisions.
1.
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A.
B.
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3.
4.
5.
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10.
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5.
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5.
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5.
Not Ratable on
No Evidence of
Not
Available
Limitation in this
Mod erately Mar kedlySign i ficantly
Limited EvidenceCategoryLimited Limited
Continued—
SUSTAINED CONCENTRATION
AND PERSISTENCE
The ability to complete a normal work-
day and workweek without interruptions
from psychologically based symptoms
and to perform at a consistent pace
without an unreasonable number and
length of rest periods.
C.
SOCIAL INTERACTION
The ability to interact appropriately w ith
the general public.
The ability to ask simple questions or
request assistance.
The ability to accept instructions and re-
spond appropriately to criticism from
supervisors.
The ability to get along w ith cow orkers
or peers without distracting them or ex-
hibiting behavioral ex tremes.
The ability to maintain socially appropri-
ate behavior and to adhere to basic
standards of neatness and cleanliness.
D.
ADAPTATION
The ability to respond appropriately to
changes in the work setting.
The ability to be aware of normal haz-
ards and take appropriate precautions.
The ability to travel in unfamiliar places
or use public transportation.
The ability to set realistic goals or make
plans independently of others.
REMARKS:
If you checked box 5 for any of the preceding items or it any other documentation deficiencies were identified,
you m u st 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
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II.
Continued on Page 4
Ill.
FUNCTIONAL CAPA CITY 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.
Continued on Page 4
MEDICAL CONSULTANT'S SIGNATURE
DATE
Form
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Continuation Sheet—Indicate section(s) being continued.
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Form
SSA-4734-F4-SUP
(8-85)
*U.S. Government Printing Office: 1989-241-312/80099
