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

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)
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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?
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.
None

Mild

Moderate

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.

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FORM HA-1152-U3 (04-2009) ef (04-2009)
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(2) Is ability to interact appropriately with supervision, co-workers, and the public, as well
as respond to changes in the routine work setting, affected by impairments?
No
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
Marked
Interact appropriately with the public.

Yes

Extreme

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?
If “yes,” please identify the capability and describe how it is affected.

No

Yes

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.

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FORM HA-1152-U3 (04-2009) ef (04-2009)
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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)

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FORM HA-1152-U3 (04-2009) ef (04-2009)
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Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 223(d), 1614(a)(3)(H)(I) and 1631(d)(1) of the Social Security Act, as amended,
authorize us to collect this information. The information you provide will be used to complete
processing of the named patient’s claim.
The information you furnish on this form is voluntary. However, failure to provide the requested
information may prevent an accurate or timely decision on the named patient’s claim.
We rarely use the information you supply for any purpose other than for determining eligibility
for benefits. 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:
1. 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
or delinquent debts under these programs.
Additional information regarding this form, routine uses of information, and our programs and
systems, is available on-line at www.ssa.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. The office is listed under U. S.
Government agencies in your telephone directory or you may call Social Security at 1-800772-1213 (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.
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FORM HA-1152-U3 (04-2009) ef (04-2009)
Destroy Old Stock