Form SSA-4734-BK Physical Residual Functional Capacity Assessment

FORM
- . ....APPROVED
.- . .
OMB NO. 0960.0431
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PHYSICAL RESIDUAL FUNCTIONAL CAPACITY ASSESSMENT
CLAIMANT:

OClAL SECURITY NUMBER:

NUMBERHOLDER (IF CDB CLAIM):

-

-

I RFC ASSESSMENT IS FOR:

PRIMARY DIAGNOSIS:

Current Evaluation

Date
12 Months After Onset:

SECONDARY DIAGNOSIS:
Date Last
Insured:
OTHER ALLEGED IMPAIRMENTS:

(Date)

(oatel

Other (Specify):
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 of this claim. Failure to complete this form may
result in a delay in processing the claim. Information furnished on this form may be disclosed by the Social Security
Administration to another person or govenunental agency only with respect to Social Security programs and to comply with

Federal laws requiring the exchange of information between Social Security and other agencies,

I. LIMITATIONS:

-

For Each Section A F
Base your conclusions on all evidence in file (clinical and laboratory findings; symptoms; observations,
lay evidence; reports of daily activities; etc.).
I
)
Check the blocks which reflect your reasonedjudgement.

Describe how the evidence substantiates your conclusions (Cite specific clinical and laboratory
findings, observations, lay evidence, etc.).
I
)
Ensure that you have:

Requested appropriate treating and examining source statements regarding the individual's capacities
(Dl 22505.000ff. and Dl 22510.000ff.) and that you have given appropriate weloht to treating source
conclusions (See Section Ill.).
Considered and responded to any alleged limitations imposed by symptoms (pain, fatigue, etc.)
attributable, in your judgement, to a medically determinable impairment. Discuss your assessment of
symptom-related limitations in the explanation for your conclusions in A F below (See also Section 11.).

-

Responded to all allegations of physical limitations or factors which can cause physical limitations.
Frequently means occurring one-third to two-thirds of an 8-hour workday (cumulative, not continuous).
Occasionally means occurring from very little up to one-third of an &hour workday (cumulative, not
continuous).

[1Continued on Page 2
Form SSA-4734-BK (12-2004) ef (12-2004)
(Formerly SSA4734-U8 Use prior editions)

Page 1

A. EXERTIONAL LIMITATIONS
None established. (Proceed to section B.)
1. Occasionally lift andlor carry (including upward pulling)
(maximum) when less than one-third of the time or less than 10 pounds, explain the amount (timelpounds) in item 6.

-

less than 10 pounds
10 pounds
20 pounds
50 pounds

100 pounds or more
2. Frequently lift and/or carry (including upward pulling)
(maximum) - when less than two-thirds of the time or less than 10 pounds, explain the amount (timelpounds) in item 6.
less than 10 pounds
10 pounds
25 pounds

50 pounds or more

3. Stand andlor walk (with normal breaks) for a total of

-

less than 2 hours in an 8-hour workday
at least 2 hours in an 8-hour workday
about 6 hours in an &hour workday

[3 medically required hand-held assistive device is necessary for ambulation
4. Sit (with normal breaks) for a total of -

0 less than about 6 hours in an &hour workday
about 6 hours in an &hour workday
must periodically alternate sitting and standing to relieve pain or discomfort. (If checked, explain in 6.)
5. Push andlor pull (including operation of hand andlor foot controls)

-

unlimited, other than as shown for lift andlor cany
limited in upper extremities (describe nature and degree)
limited in lower extremities (describe nature and degree)
6. Explain how and why the evidence supports your conclusions in item 1 through 5.

Cite the specific facts upon which your conclusions are based.

Continued on Page 3
Form SSA473CBK (12-2004) ef (12-2004)

Page 2

6. Continue (NOTE: MAKE ADDITIONAL COMMENTS IN SECTION IV)

B. POSTURAL LIMITATIONS

None established. (Proceed to section C.)
Frequently
1. Climbing - rampistairs

Occasionally

Never

b

- ladder/rope/scaffolds
2. Balancing

b

3. Stooping

b

4. Kneeling

b

5. Crouching

b

6. Crawling

b

7. When less than two-thirds of the time for frequently or less than one-third for occasionally, fully describe and
explain. Also explain how and why the evidence supports your conclusions in items 1 through 8. Cite the
specific facts upon which your conclusions are based.

Continued on Page 4
Form SSA473CBK (12-2004) ef (12-2004)

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C. MANIPULATIVE LIMITATIONS
None established. (Proceed to section D.)

'
LIMITED

1. Reaching all directions (including overhead)

2. Handling (gross manipulation)
3. Fingering (fine manipulation)

UNLIMITED

b
b
b

4. Feeling (skin receptors)
5. Describe how the activities checked "limited" are impaired. Also, explain how and why the evidence supports
your conclusions in item 1 through 4. Cite the specific facts upon which your conclusions are based.

D. VISUAL LIMITATIONS

None established. (Proceed to section E.)
LIMITED
1.
2.
3.
4.
5.
6.

UNLIMITED

Near acuity
b
Far acuity
Depth perception
b
Accommodation
b
Color vision
Field of vision
b
7. Describe how the faculties checked "limited" are impaired. Also explain how and why the evidence supports
your conclusions in items 1 through 6. Cite the specific facts upon which your conclusions are based.

*

Continued on Page 5
Form SSA4734-BK (12-2004) ef (12-2004)

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E. COMMUNICATIVE LIMITATIONS

None established. (Proceed to section F.)
LIMITED

UNLIMITED

0
0

1. Hearing
2. Speaking

3. Describe how the faculties checked "limited" are impaired. Also, explain how and why the evidence supports
your conclusions in items 1 and 2. Cite the specific facts upon which your wndusions are based.

F. ENVIRONMENTAL LIMITATIONS

None established. (Proceed to section 11.)
1. Extreme cold b
2. Extreme heat b

3. Wetness
4. Humidity
5. Noise

'

AVOID
CONCENTRATED
UNLIMITED EXPOSURE

AVOID EVEN
MODERATE
EXPOSURE

AVOID ALL
EXPOSURE

bn

›

6. Vibration
7. Fumes, odors, b
dusts, gases,
poor ventilation,
etc.
8. Hazards
0
(machinery,
heights, etc.)
9. Describe how these environmental factors impair activities and identify hazards to be avoided. Also, explain
how and why the evidence supports your conclusions in items Ithrough 8. Cite the specific facts upon which
your conclusions are based.

Continued on Page 6
Form SSA-4734-BK (12-2004) ef (12-2004)

Page 5

9. Continue (NOTE: MAKE ADDITIONAL COMMENTS IN SECTION IV)

II.SYMPTOMS

For symptoms alleged by the claimant to produce physical limitations, and for which the following have not
previously been addressed in section I, discuss whether:
A. The symptom(s) is attributable, in your judgment, to a medically determinable impairment.
B. The severity or duration of the symptom(s), in your judgment, is disproportionate to the expected severity or

expected duration on the basis of the claimant's medically determinable impairment(s).
C. The severity of the symptom(s) and its alleged effect on function is consistent, in your judgment, with the total
medical and nonmedical evidence, including statements by the claimant and others, observations regarding
activities of daily living, and alterations of usual behavior or habits.

Continued on Page 7
Fom SSA-4734-BK (12-2004) ef (12-2004)

Page 6

Ill.TREATING OR EXAMINING SOURCE STATEMENT(S)

A. Is a treating or examining source statement@)regarding the claimant's physical capacities in file?
Yes

No (Includes situations in
which there was no source
or when the source(s) did
not provide a statement
regarding the claimant's
physical capacities.)

B. If yes, are there treatinglexamining source conclusions about the claimanfs limitations or restrictions which are
significantly different from your findings?
Yes
C. If yes, explain why those conclusions are not supported by the evidence in file. Cite the source's name and the

statement date.

Continued on Page 8

IV. ADDITIONAL COMMENTS:

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

MEDICAL CONSULTANT'S SIGNATURE:

Form SSA473CBK (12-2004) ef (12-2004)

Page 8

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. 5 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&o comments relating to our time estimate to this
address, not the completedform.