MENTAL RESIDUAL FUNCTIONAL CAPACITY ASSESSMENT
SOCIAL SECURITY NUMBERNAME
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 CONCLUSIONSI.
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 III (Functional Capacity Assessment).
If rating Category 5 is checked for any of the following items, you MUST
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
Significantly AvailableMarkedlyModerately 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 work 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)
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