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pdfDisability Case Selection
May 13, 2009
1
Select Case Level
May 13, 2009
2
Confirm Case Creation
May 13, 2009
3
Form Selection
May 13, 2009
4
Link Folder
May 13, 2009
5
CDR Information, Part 1 of 2
User has indicated claimant used other names, but has not entered any
May 13, 2009
6
CDR Information, Part 2 of 2
Other Names = Yes, but no other names entered
May 13, 2009
7
Other Names Used
May 13, 2009
8
CDR Information, Part 2 of 2
Other Names = Yes, with another name entered
May 13, 2009
9
CDR Representatives
Appointed Representative = No
May 13, 2009
10
CDR Representatives, Part 1 of 2
Appointed Representative = Yes
May 13, 2009
11
CDR Representatives, Part 2 of 2
Appointed Representative = Yes
May 13, 2009
12
CDR Claims
May 13, 2009
13
Contacts, Part 1 of 3
May 13, 2009
14
Contacts, Part 2 of 3
Person Completing Report = Claimant
May 13, 2009
15
Contacts, Part 3 of 3
Person Completing Report = Someone Else
May 13, 2009
16
Medical Conditions, Part 1 of 2
Medical Conditions Propagated from mainframe, no new conditions entered
May 13, 2009
17
Medical Conditions, Part 2 of 2
Medical Conditions Propagated from mainframe, no new conditions entered
May 13, 2009
18
Medical Conditions, Part 1 of 2
Medical Conditions Propagated from mainframe, plus one new conditions entered
User has indicated claimant uses an assistive device
May 13, 2009
19
Medical Conditions, Part 2 of 2
Medical Conditions Propagated from mainframe, plus one new conditions entered
User has indicated claimant uses an assistive device
May 13, 2009
20
Medical Sources
Initial view
May 13, 2009
21
Medical Sources
User has indicated claimant has medical sources, but has not entered any
May 13, 2009
22
Doctor/Therapist Information, Part 1 of 2
May 13, 2009
23
Doctor/Therapist Information, Part 2 of 2
May 13, 2009
24
Medical Sources
User has indicated claimant has medical sources and entered a doctor
May 13, 2009
25
Hospital/Clinic Information, Part 1 of 3
May 13, 2009
26
Add Hospital/Clinic, Part 2 of 3
May 13, 2009
27
Add Hospital/Clinic, Part 3 of 3
May 13, 2009
28
Tests Summary
May 13, 2009
29
Test Information
No body part involved or other explanation needed
May 13, 2009
30
Test Information
Body part involved
May 13, 2009
31
Physical and Mental Condition Information – Plan A
Claimant adds physical or mental condition while adding test
May 13, 2009
32
Physical and Mental Condition Information – Plan B
Claimant adds physical or mental condition while adding test
May 13, 2009
33
Medicines Summary
May 13, 2009
34
Medicine Information
May 13, 2009
35
Other Medical Information
Initial View
May 13, 2009
36
Other Medical Information
User has indicated claimant has other medical source, but has not entered any
May 13, 2009
37
Other Medical Information
May 13, 2009
38
Other Medical Information
User has entered an other medical source
May 13, 2009
39
Education and Training
Initial View
May 13, 2009
40
Education and Training, Part 1 of 2
User has indicated claimant received education and training
May 13, 2009
41
Education and Training, Part 2 of 2
User has indicated claimant received training
May 13, 2009
42
Vocational Rehabilitation, Employment, or Other Support Services
Initial View
May 13, 2009
43
Vocational Rehabilitation
User has indicated claimant received vocational rehabilitation, but has not entered any
May 13, 2009
44
Vocational Rehabilitation, Employment, or Other Support Services Information,
Part 1 of 2
May 13, 2009
45
Vocational Rehabilitation, Employment, or Other Support Services Information,
Part 2 of 2
May 13, 2009
46
Daily Activities
Initial View
May 13, 2009
47
Daily Activities
User has indicated claimant has hobbies or interests
May 13, 2009
48
Daily Activities, continued, Part 1 of 2
Initial View
May 13, 2009
49
Daily Activities, continued, Part 2 of 2
Initial View
May 13, 2009
50
Daily Activities, continued
User has indicated claimant has difficulty bathing
May 13, 2009
51
Work
May 13, 2009
52
Daily Activities, cont 2, Part 1 of 2
Initial View
May 13, 2009
53
Daily Activities, cont 2, Part 2 of 2
Initial View
May 13, 2009
54
Remarks
May 13, 2009
55
SSA will insert the following revised Privacy Act Statement into the form at its
next scheduled reprinting:
Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 223(d), and 1631(e)(1) of the Social Security Act, as amended, authorize us to
collect this information. We will use the information you provide to make a decision on the
named claimant’s claim. Furnishing us this information is voluntary. However, failing to
provide us with all or part of the information could prevent an accurate or timely decision on the
named claimant’s claim.
We rarely use the information you supply for any purpose other than to make a decision on the
named claimant’s claim. However, we may use the information for the administration of our
programs including sharing information:
1. To comply with Federal laws requiring the release of information from our records
(e.g., to the Government Accountability Office and Department of Veterans Affairs);
2. To facilitate statistical research, audit, or investigative activities necessary to assure the
integrity and improvement of our programs. (e.g., to the Bureau of Census and to
private entities under contract with us).
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notices entitled, Supplemental Security Income
Record and Special Veterans Benefits (60-0103), Claims Folders System (60-0089), Master
Beneficiary Record (60-0090), and Electronic Disability Claim File (60-0320). Additional
information about this and other system of records notices and our programs are available from
our Internet website at www.socialsecurity.gov or at your local Social Security office.
We may share the information you provide to other health agencies through computer matching
programs. Matching programs compare our records with records kept by other Federal, State, or
local government agencies. We use the information from these programs to establish or verify a
person’s eligibility for federally funded or administered benefit programs and for repayment of
incorrect payments or delinquent debts under these programs.
SSA will insert the following revised PRA Statement into the form at its
next scheduled reprinting:
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 (OMB) control number. We estimate that it will take about
60 minutes to read the instructions, gather the facts, and answer the questions. Send only
comments relating to our time estimate above to: SSA, 6401 Security Blvd, Baltimore,
MD 21235-0001.
| File Type | application/pdf |
| File Title | Slide 1 |
| Author | 414761 |
| File Modified | 2013-09-05 |
| File Created | 2009-07-16 |