Form HA-1152 Medical Source Statement of Ability to Do Work-Related A

SOCIAL SECURITY ADMINISTRATION
OFFICE OF DISABILITY ADJUDICATTON AND REVIEW

Form Approved

OMS No. 0960·0662

MEDICAL SOURCE STATEMENT OF
ABILITY TO DO WORK-RELATED ACTIVITIES (MENTAL)
=========:========================================================================
NAME OF INDIVIDUAL

SOCIAL SECURITY NUMBER
XXX-XX-XXXX

INSTRUCTIONS:

Please assist us in determining this individual's ability to do work-related activities on a sustained basis.

"Sustained basis" means the ability to perform work-related activities eight hours a day for five days a week,

or an equivalent work schedule. (SSR 96-8p). Please give us your professional opinion of what the individual

can still do despite his/her impairment(s). The opinion should be based on your findings with respect to

medical history, clinical and laboratory findings, diagnosis, prescribed treatment and response, and

prognosis.

For each activity shown below, respond to the questions about the individual's ability to perform the activity.

When doing so, use the following definitions for the rating terms:

•
•
•
•
•

None -

Absent or minimal limitations. If! imitations are present they are transient and/or expected

reactions to psychological stresses.

Mild -
There is a slight limitation in this area, but the individual can generally function well.
Moderate - There is more than a slight limitation in this area but the individual is still able to function satisfactorily.
Marked - There is serious limitation in this area. There is a substantial loss in the ability to eflectively function.
Extreme - There is major limitation in this area. There is no useful abil ity to function in this area.

IT IS VERY IMPORTA"T TO DESCRIBE THE FACTORS THAT SUPPORT Y01 JR ASSESSMENT.
WE ARE REQUIRED TO CONSIDER THE EXTENT TO WHICH YOUR ASSESSMENT IS SUPPORTED.

0

(I) Is ability to understand, remember, and carry out instructions affected by the impairment?
No
If"no," go to question #2. If"yes," please check the appropriate block to describe the individual's
restriction for the following work-related mental activities.

Understand and remember simple instructions.
Carry out simple instructions.
The ability to make judgments on
simple work-related decisions.
Understand and remember eomplex instructions.
Carry out complex instructions.
The ability to make judgments on
complex work-related decisions.

0 Yes

"one

Mild

Moderate

Marked

Extrem.:

D
D

D
D

D
D

D
D

D
D

D

D

D

D

D

D
D

D
D

D
D

D
D

D
D

D

D

D

D

0

IdentifY the factors (e.g., the particular medical signs, laboratory findings, or other factors described above) that support
your assessment.

FORM HA-1152-lJ3 (04-2009) ef(04-2009)
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(2) Is abil ity to interact appropriately with supervisor(&), co-workers. and the publ ic, as well
as respond to changes in a routine work setting. affected by the impainnent?
ONo
ff"no." go to question #3. ff"yes," please check the appropriate block to describe the individual's
restriction for tbe following work-related mental activities.

None
Interact appropriately with the public.
Interact appropriately with supervisor(s).
Interact appropriately with co-workers.
Respond appropriately to usual work

situations and to changes in a routine

work setting.

0
0
0

DYes

Mild

Moderate

Marked

Extreme

0
0

0

0

0

D

D

D

0

D

D

D

D

D

D

Identity the factors (e.g., the particular medical signs, laboratory findings, or other factors described above) that support
your assessment.

(3) Are any other capabilities affected by the impairment?
ff"yes:' please identity the capability and describe how it is all'ected.

DNo

DYes

fdentify the factors (e.g" the particular medical signs, laboratory findings, or other factors described above) that support
your assessment.

(4) The limitations above are assumed to be your opinion regarding current limitations only.
However, if you have sufficient infonnation to fonn an opinion within a reasonable degree ofmedical or psychological
probability as to past limitations, on what date were the limitations you found above first present?_ _ _ _ _ __
(5) Ifthe iiu11vidulif'g impairment(s) include alcohol and/or substance abuse, do these impairments contribute to any oflhe
indiVidual:s limitations as set forth above? If so, please identity and explain what changes you would make to your
answers if the .;\lidWll was totally abstinent from alcohol and/or substance use/abuse.

FORM HA-IIS2-lJ3 (04-2009) ef (04-2009)
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(6) Can the individual manage benefits in hislher own best interest?

Signature

Print Name. Title and Medical Specialty (Legibly Please)

FORM HA-1t52-Ul (04-2009) ef (04-2009)

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Date

DNo

DYes

Privacy Act Statement

ended,
lete

equested

e rarely use the i formatio you supp y for any purpose
r benefi s. Howe er, we m y use it fo the adm nistratio
rogram . We rna also disc se infor ation to nother p
ecorda e with a proved r utine use which i elude bu

ther tha for dete mining e igibility
and inte rityof cial Sec rity
son or t another gency i
are not I mited to he folio ing:

agency to assist ocial Se urity in stablishi g rights t

lor cove age;
n from ocial
and De artment

2.

3.

inations for eligi
pro rams at t e Federal state an

hand i orne rna ntenance

4.

t

FORM UA-IIS2-UJ (04-2009)
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er (04-2009)

SSA will insert the following revised Privacy Act Statement into the form at its next scheduled
reprinting:

Medical Source Statement of Ability to Do Work-Related
Activities (Mental)
Sections 205(a), 223(d), 1614(a)(3 )(H)(J) and 163 1(d)( 1) of the Social Security Act, as amended,
authorize us to collect this information. We will use the information you provide to determine
the individual's ability to perform (mental) work-related activities on a sustained basis.
The information you furnish on this form is voluntary. However, failure to provide the requested
information may affect our ability to make an accurate assessment of the individual's mental
ability to perform a work related activity.
We rarely use the information you supply for any purpose other than for the reasons explained
above. However, we may use it for the administration and integrity of Social Security programs.
We may also disclose information to another person or to another agency in accordance with
approved routine uses, which include, but are not limited to the following:
I. To enable a third party or an agency to assist Social Security in establishing rights to
Social Security benefits and/or coverage;
2. To comply with Federal laws requiring the release of information from Social Security
records (e.g., to the Government Accountability Office and Department of Veterans'
Affairs);
3. To make determinations for eligibility in similar health and income maintenance

programs at the Federal, State and local level; and

4. To facilitate statistical research, audit or investigative activities necessary to assure the
integrity of Social Security programs.
We may also use the information you provide in computer matching programs. Matching
programs compare our records with records kept by other Federal, State, or local government
agencies. Information from these matching programs can be used to establish or verify a
person's eligibility for Federally-funded or administered benefit programs and for repayment of
payments of delinquent debts under these programs.
A complete list of routine uses for this information is available in our System of Records Notice
entitled, Completed Determination Record - Continuing Disability Determinations, 60-0050.
This notice, additional information regarding this form, and information regarding our programs
and systems, is available on-line at http://www.socialsecurity.gov or at your local Social Security
office.

Paperwork Reduction Act Statement - This information collection meets the requirements of
44 U.S.c. § 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 15 minutes to read the instructions, gather
the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO
YOUR LOCAL SOCIAL SECURITY OFFICE. You can find your local Social Security
office through SSA's website at www.socialsecurity.gov. Offices are also listed under U. S.
Government agencies in your telephone directory or you may can 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 only comments relating to our time
estimate to this address, not the completed form.