SSA-538 Childhood Disability Evaluation Form

Form Approved
OMS. No. 0 9 W 6 R

Social Sacurity Administretion

CHILDHOOD DISABILITY EVALUATION FORM
Level of Detsrminatlon:

Name:

17 Initial
0 Reconsidsratlon 0

CDR
CDR Reconsideration

Other
Is the child engaglng in SGA7
n y a s UNO
Filing Date:

SSH:

Date of Birth:
I. SUMMARY

A. IMPAIRMENTS:

0. DISPOSITION: Check one entry that best describes your findings in this cam. Complete this section la&.
1

.

[7

-

NOT SEVERE No medically determinable Impairment OR impairment or combination of impairments Is a
slight abnormality or a combination of slight abnormalities that results in no more than minimal functional
limitations. (Explain below.)

Explanation:

'

Y

. (Cite complete Listing and subsectionla),

2. [7

MEETSLISTING
including any applicable B criteria for 1 12.00.)

3.

MEDICALLY EQUALS LISTING
. (Cite complete listing and subsectionls),
including any applicable B crlteria for 1 12.00 and explain below.)

)

Explanation:

4.

FUNCTIONALLY EQUALS THE LISTINGS - f h e child's medically determinable impairment or combhation of
impairments results in marked Ilmkations in two domains or an extreme limitation in one domain (Explained In
Section llA&B), OR the impairment or combination of impairmems is one of the examples cited in POMS
(Explained In Saction Ill.)
Dl 25225.080 (20 CFR 416.926elmH, example #

6

IMPAIRMENT OR COMBINATION OF IMPAIRMENTS IS SWERE, BUT DOES NOT MEET, MEDICALLY EQUAL,
OR FUNCTIONALLY EQUAL THE LISTINGS. IExplained in Section(s1 llA&B and, if applicable, HI.)

6.

DOES NOT MEEl THE DURATlON REQUIREMENT -The child's Adlcalty determinable impeirment(s) Is or was
of listing-level severity, but Is not expected t o be, or was not, of listing-level severity for 12 continuous
months, and is not expected to result in death. (Explained In Section(s1 IIA&B and, if applimWe, Ill.)

7.

Other (Specify)

Form #A-638-F8 (1-20011 EF (09-220041 Use Rior Mitbns

(Explained in Section Ill.)
1

C. ASSESSMENT OF FUNCTIONING THROUGHOUT SEQUENTIAL EVALUATION

al affirm, by slgnlng betow, that when I evaluated the ahiM4sfunctioning in dgcidhg:

If there is a seware i w i m m t ~ s ~ ;
If the impairment(s) meets or medic&& equals a bdng (if the listing lncllrdes functioning in its criteria); and
If the impalrment(3 functrbnaIIy eq&s the listings;
I mdckmd the folowlng faatom and widen-.

FACTORS:
1. How the chlld's functioning camper- to that of children the same age wha do not have impairments; i.e., what the child is able
to do, not able to do, or Is llmltd or restricted In dolng.
2. Combined effects of multlpk impairments and the Interactive and cumulative effects of an impairment(s1on the child's
actlvhle9, conridsrlng that any activky may involve the integrated uw of many abilities. So,
A single Ifmitation may be the result of one or m e Irnpalrments, and
A single Impairment m y hove effects in more than one domain.
3. How well the child W o r m s activities with respect to:
Initiating, sustaining, and completing activities independently (range of activities, prompting needed, pace of performance,
effort d e d , and how long the child Is able to sustsin actlvlties);
Extra help needed (e.g., personal, equipment, medications);
Adaptations bag.,assbtive devlces, applia-I;
Structured or supportive settings Ie.g., ham,regular or special classrooml, including comparison of functioning in and
outside of setting, ongolng signs or symptoms despitm w i n g , amount of support needed to function within rwular setting.
4, Child's functioning In unusual settings, (e.g., one-to-one, a CE) vs. routine settings (e.g., home, chlldcare, school).

5. Eady intmentton and school programs (9.g.. school records, comprehensive testing, IEPs, class placement, special education
services, accommdations, attendance, panlcipatlonl.

6. Impact of chronic illness, characterized by episcdes of exacerbation and remission, and how It interferes with the child's
activities over tlme,
7. Effects of treatment, indudlng adverse and beneficla1effects of medlcatlons and other treatments, and ifthey Interfere with the
child's day-to-day functioning.

EVIDENCE:
For all dispositions, wherever appropriate, I have e x p l a i d how I consklered the medical, early intervention, schooUpreschool,
parentlcaregiver, and other relevant evldence that supports my findlnga, how t weighed medical opinion evidence, evaluated
physical and mental symptoms, resolved any material Inconsistencies, and welghed evidence when material inconsistencies in the
file could nor be resolved. 1 have considered and expleined test results in the context of all the other evidence.

The o o n w l m + w i t hoverall reapamdblhy for the RnaUnp in this SSA-638 must complete the first slgrrature Line (Sea
Dl 25230.0011843. If any ditional mmultants provided Input to these flndfng8, they must dao sign b~ the boxes folbwing.
S
'

THESE FINDINGS COMPLEtE THE MEDICAL PORTION OF THE DISABILITY DETERMINATION.

Consukant with overall responsibility (Sign, print name and spsciakyl

Date

w

Additional consultant slgnatura (Sign, print name and specialty)

Date

Additional wnsukant signature (Sign,print name and specialty)

Date

11. FUNCTIONAL EQUIVALENCE
Consider functional equivalence when the child's medically detenninabie impairmentls) is "severe" but does not meet or medically
equal a listing, An Irnpsfrment(8)functionally equals the liings if it results in "marked and m e r e functional limitations," Le., the
impairment[s) causos "marked" IimItations in two domains or an "extreme" IimItatlon In one domain. FOR DEFINITIONS OF
"MARKED" AND "EXTREME" see page 5.
Describe and evaluate the child's funetionlng in all domains; see POMS Dl 25225.026-,066 (20 CFR 418.92Sa(f)-(l)I.Then discuss
the factors that apply in the child's case and how you evaluated the evidence as described In Section IC above and in
WMS Dl 26210.001ff. (20 CFR 416.924~).Rate the limitatlorn that result from the child's medically determinable impairment(s).
Check one box for each domain to Indicate the degree of limltatlon assessed.
A. DOMAIN EVALUATIONS
1. Aaqdrkrg md'Using hrfomrati&

no llmttstlon

a

less than marked

marked

extreme

continued in section Ill

2. A t t d n g
omple ng Tasks
k
extreme

a

no limitation

Form SSA438Fb ( 1-20011 EF I092004)

19%

than marked

marked

extreme

A. DOMAIN EVALUAROW I d n u d l
4. Moving About m d -thy

Objects

no limitation

a

less than marked

marked

extreme

C] Continued in section I11
6 . Cmrlm For Y

d

no limitation

less than marked

marked

extreme

[3 Con~inuedin sectlon Ill
this domain on page 5 )

no limitation

0

less than marked

marked

extreme

El

Continued in section Ul
F w $SA638+4
~
{ 1-2001) EF (09-2004)

4

D w the impairment or combhation of impairments h d m d l y eqwl the Ihtlngr?
Yes

-- Marked I i ~ l o inn two domains; findlngs expldned fn Section IIA.

Marked limitation See POMS Dl 25225.0208 (20 CFR 416.926a(e)(2)).
The impairment(s1Interferes serlouarly with the child's ablllty to independently initiate, sustain, or complete
domain-related activities, Day-today functioning may be seriously limited when the child's Impairment($) limits only
one activity or when the interactive and cumulative effects of the child's impairrnent(s1limit several activities.
"More than moderate" but "less than extreme* limitation (i.a., the equivalent of functioning we would expect to
find on standardized testing with scores that are at least two, but less than three, standard deviations below the
mean), or
Up to attainment of age 3, functioning at a level that is more than one-half but not more than two-thirds of the
child's chronological age when there are no standard scores from standardized tests in the case record, or
At any age, a valid score that is two standard deviations or more below the mean, but less than three standard
deviations, on a comprehensive standardized test deslgned to measure ability or functioning in that domain, and
the child's day-today functioning in domain-related activities is consistent with that score.
For the "Health and Phys-d Wdl-Mng" domain, we may also find a 'markedn limitation if the child is frequent1y Ill or
has frequent exacerbations that result in significant, documented symptoms or signs. For purposes of this domain,
"frequent" means episodes of illness or exacerbations that occur on an average of 3 times a year, or once every 4
months, each lastlng 2 weeks or more, We may also find a "marked" llmltation if the child has episodes that:
occur more often than 3 times in a year or once every 4 months but do not last for 2 weeks, or
occur less often than an average of 3 times a year or once every 4 months but last longer than 2 weeks,
if the overall effect (based on the length of the eplsodeIs1 or its frequency) is equivalent in severity.

Yes

-- Extrame IirnZtation In one domain; Rnchgr explained in Sectlon IIA.

Extreme limitation See POMS Dl 25225,02013 (20 CFR 418.928a(e)(31).

J)

The impairment($) interferes vary seriously with the child's ability to independently initiate, sustain, or complete
domain-related activities. Day-to-day functioning may be very seriously limited when the child's impsirment(s1 limits
only one activity or when the interactive and cumulative effects of the child's impairment(s1limlt several activities.
"Extreme* describes the worst limitations, but does not necessarily mean a total tack or loss of ability to function.
"More than marked" limitation ke., the equivalent of the functioning we would expect to find on standardized
testing with scores that are at least three standard deviations below the mean), or
t , Qp to attainment of age 3, functioning at a level that is one-half of the child's chronological age or less when there
are no standard scores from standardized tests in the case record, or
At any age, a valid score that is three standard deviations or more below the mean on a comprehensive
standardized test designed to measure ability or functioning in that domain, and the child's day-to-day functioning
in domain-related activities is 'consistent with that score.
For the "Health and Physical Wdl-(3eingmdomain we may also find an "extreme" limitation if the child is ill or has
frequent execerbatlons that result In significant, documented symptoms or signs substantially in excess of the
requirements for showing a "marked" Ilmltation. However, If the chlld has episodes of Illness or exacerbations of the
impairrnent(s1that we would rate as "extremeu under this definition, the Impairmentts) should meet or medically equal

the requirements of a listing in most cases.

J
-!

No

I

- Findings explained In Section IIA.

Form $$A-S38-F8 ( 1-200 1 1 EF (09-20041

6

Ill. EXPIANATION OF FINDINGS

.

Use thi seetion:
To explain any functionat squivalence "~xample"cited in disposition 4;
To expfain disposition 7;
For any continued exptanation of dlsposit9ns 1, 3, 5, and 6 or functional equivalence flndings that do not fit into Section II;
To discuss any relevant hctors and evidence not explained elsewhere; e.g,, how you weighed evidence wtwn matwirl
inconshenclcr~in the- file could not bs resolved;
* At the discretion of the adjudicative t m , to explain dhqmiilon 2; t o make clear other issues particular to individual cases;
to record all of the requlred elements of a rationrho rwher than on m SSA-4268-U4/C4 per POMS Dl 26235.001.

Y

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Act. T b informath
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