Fillable Printable Mental Residual Functional Capacity Assessment
Fillable Printable Mental Residual Functional Capacity Assessment
Mental Residual Functional Capacity Assessment
MENTAL RESIDUALFUNCTIONALCAPACITY ASSESSMENT
SOCIALSECURITY NUMBER
NAME
ASSESSMENT IS FOR:
CATEGORIES
(From IB of the PRTF)
12Months AfterOnset:
Current Evaluation
(Date)
DateLast
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 eachcategory(A through D), as well as any other assessment information you deem
appropriate,is to be recorded in SectionIII (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 developmentis necessary. but
DO NOT COMPLETESECTIONIII
.
Not
No Evidence of
Not Ratable on
Sign i ficantlyAvailableMar kedlyMod erately
Limitation in this
EvidenceLimitedLimitedLimitedCategory
UNDERSTANDINGAND 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.
SUSTAINEDCONCENTRATION 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.
Form
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A.
B.
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Not Ratable on
No Evidence of
Not
Available
Limitation in this
Mod eratelyMar kedlySign i ficantly
LimitedEvidenceCategoryLimitedLimited
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.
SOCIALINTERACTION
The ability to interact appropriately w ith
the general public.
The ability to ask simple questions or
request assistance.
The ability to accept instructionsand 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 realisticgoals or make
plans independently of others.
REMARKS:
If you checkedbox 5 for any of the precedingitems or it any other documentation deficiencies were identified,
you m u stspecify 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 onPage3
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Form
SSA-4734-F4-SUP
(8-85)
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II.
Continued onPage4
Ill.
FUNCTIONALCAPA CITY ASSESSMENT
Recordinthis sectiontheelaborationson theprecedingcapacities.CompletethissectionONLYaftertheSUMMARY
CONCLUSIONS sectionhasbeen completed. Explain yoursummaryconclusionsin narrativeform.Include any information
which clarifies limitation or function. Be especially careful to explain conclusionsthat differ from those of treating medical sources
or from the individual's allegations.
Continued onPage4
MEDICAL CONSULTANT'S SIGNATURE
DATE
Form
SSA-4734-F4-SUP
(8-85)
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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
