SSA-4734-F4-SUP Mental Residual Functional Capacity Assessment

FORM APPROVED
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MENTAL RESIDUAL FUNCTIONAL CAPACITY ASSESSMENT
BOClAL SECURITY NUMBER

NAME

CATEGORIES (From I C of the PRTF)

-

ASSESSMENT IS FOR:

12 Months After Onset:

Current Evaluation
Date Last
Insured:
(Dab)

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 Ill (Functional Capacity
Assessment).
If rating category 5 is checked for any of the following items, you MUST specdy 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 Ill.
Not
Significantly
Limited
'

Moderately
Limited

Markedly
Limited

No Evidence Not Ratable
of Limitation in on Available
this Category Evidence

A. UNnFRSTANDlNG AND MEMORY
1. The ability to remember locations and
work-like procedures.

1.

2. The ability to understand and remember very short and simple instructions.

1.

3. The ability to understand and remember detailed instructions.

1.

B. SUSTAINED CONCENTRATION AND PFRSISTFNE
4. The ability to cany out very short and
simple instructions.

1.

2-

5. The ability to carry out detailed instructions.

1.

2.

6. The ability to maintain attention and
concentration for extended periods.

1.

7. The ability to perform activities within a

schedule, maintain regular attendance,
and be punctual within customary tolerances.

1.

8. The ability to sustain an ordinary routine
without special supervision.
1.

9. The ability to work in coordination with
or proximity to others without being distracted by them.
10.The ability to make simple work-related
decisions.
Form SSA4734-FCSUP (10-2004) ef (10-2004)
Use Prior Editions

I.

2.

1.
1

3.

4.

5.

Continued

-

-SUSTAINFD CONCFNTRATION

Not
Significantly
Limited

11. The ability to complete a normal workday and workweek without interruptions
from psychologically based symptoms
and to perform at a consistent pace
without an unreasonable number and
length of rest periods.

Moderately
Limited

No Evidence
Markedly of Limitation in
Limited
this Category

Not Ratable
on Available
Evidence

1.

C. SOCIAL INTERACTION
12. The ability to interact appropriately with
the general public.

1.

13. The ability to ask simple questions or
request assistance.
14. The a b i l i to accept instructions and
respond appropriately to criticism from
supervisors.
15. The ability to get along with coworkers

or peers without distracting them or
exhibiting behavioral extremes.
16. The ability to maintain socially appropriate behavior and to adhere to basic
standards of neatness and cleanliness.

1.

D. ADAPTATION

17.The ability to respond appropriately to
changes in the work setting.

1.

18.The ability to be aware of normal hazards and take appropriate precautions. 1.
19.The ability to travel in unfamiliar
places or use public transportation.

20.The ability to set realistic goals or make
plans independently of others.

C]

1.
1.

II. REMARKS: Ifyou checked box 5 for any of the preceding items or if 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
Form SSA-4734-FCSUP (10-2004) ef (10-2004)

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Continued on Page 4

((1.

FUNCTIONAL CAPACITY ASSESSMENT
Record the elaborations on the preceding capacities in thls section. 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

THESE FINDINGS COMPLETE THE MEDICAL PORTION OF THE DISABILITY DETERMINATION.
DATE:

MEDICAL CONSULTANT'S SIGNATURE
I

Form SSA-4734-F4-SUP (10-2004) ef ( 10-2004)

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Continuation Sheet - Indicate sedion(s) being continued.

Privacy Act Notice: The information requested on this form is authorized by Section 223 and Section 1633 of the Social Security
Act. The information provided will be used in making a decision on this claim. Failure to complete this form may result in a &lay in
processing the claim. Information furnished on this form may be disclosed by the Social Security Administration to another person
or governmental agency only with respect to Social Security programs and to comply with federal laws requiring the exchange of
infonnation between Social Security and other agencies.

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Thefollowing revised PRA Statement will be inserted into the form at its
next scheduled reprinting:
Paperwork Reduction Act Statement - This information collection meets the
requirements of 44 U.S.C. 8 3507, as amended by section 2 of the Paperwork Reduction
Act of 1995. You do not need to answer these questions unless we display a valid Office
of Management and Budget control number. We estimate that it will take about 20
minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. The office is listed under U. S. Government agencies in your telephone
directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778).
You may send comments on our time estimate above to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401. Send & comments relating to our time estimate to this
address, not the completed form.