Current HA-1152

SOCIAL SECURITY ADMINISTRATION
OFFICE OF DISABILITY ADJUDICATION AND REVIEW

Form Approved
OMB No. 0960-0662

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

SOCIAL SECURITY NUMBER

-

-

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 limitations 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 effectively function.
Extreme - There is major limitation in this area. There is no useful ability to function in this area.

IT IS VERY IMPORTANT TO DESCRIBE THE FACTORS THAT SUPPORT YOUR ASSESSMENT.
WE ARE REQUIRED TO CONSIDER THE EXTENT TO WHICH YOUR ASSESSMENT IS SUPPORTED.
(1) Is ability to understand, remember, and carry out instructions affected by the impairment?
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.
None

Mild

Moderate

No

Marked

Yes

Extreme

Understand and remember simple instructions.
Carry out simple instructions.
The ability to make judgments on simple work-related
decisions.
Understand and remember complex instructions.
Carry out complex instructions.
The ability to make judgments on complex
work-related decisions.
Identify the factors (e.g., the particular medical signs, laboratory findings, or other factors described above) that
support your assessment.

Form HA-1152-U3 (06-2006) ef (09-2006)
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(2.) Is ability to interact appropriately with supervisors, co-workers, and and the public, as well
as respond to changes in a routine work setting, affected by the impairment?
If "no," go to question #3. If "yes," please check the appropriate block to describe the individual's
restriction for the following work-related mental activities.
None
Mild
Moderate

No
Marked

Yes
Extreme

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.
Identify 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?

No

Yes

If "yes," please identify the capability and describe how it is affected.

Identify 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 information to form an opinion within a reasonable degree of medical or psychological
probability as to past limitations, on what date were the limitations you found above first present?
(5) If the claimant's impairment(s) include alcohol and/or substance abuse, do these impairments contribute to any of the
claimant's limitations as set forth above? If so, please identify and explain what changes you would make to your
answers if the claimant was totally abstinent from alcohol and/or substance use/abuse.

Form HA-1152-U3 (06-2006) ef (09-2006)
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(6) Can the individual manage benefits in his/her own best interest?

Signature

No

Yes

Date

Print Name, Title and Medical Specialty (Legibly Please)

PRIVACY ACT STATEMET:
The Social Security Administration is authorized to collect the information on this form under sections 205(a), 223(d),
1614(a)(3)(H)(I) and 1631(d)(1) of the Social Security Act. The information on this form is needed by Social Security to
complete processing of the named patient's claim. While giving us the information on this form is voluntary, failure to
provide the requested information may prevent an accurate or timely decision on the named patient's claim. Although the
information you furnish on this form is almost never used for any purpose other than making a determination about
disability, such information may be disclosed by 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 information between
Social Security and another agency.
Explanations about these and other reasons why information about you may be used or given out are available in Social
Security offices. If you want to learn more about this, contact any Social Security office.
PAPERWORK REDUCTIO ACT:
This information collection meets the clearance 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. 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.

Form HA-1152-U3 (06-2006) ef (09-2006)
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