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)
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.
Form
SSA-4734-F4-SUP
(8-85)
1
A.
B.
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10.
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