Mental Residual Functional Capacity Assessment

CURRENT
MENTAL RESIDUAL FUNCTIONAL CAPACITY ASSESSMENT
NAME

SOCIAL SECURITY NUMBER

CATEGORIES (From IB of the PRTF)

ASSESSMENT IS FOR:
12 Months After Onset:

Current Evaluation

(Date)

Date Last
Insured:
(Date)

Other:

to
(Date)

(Date)

I.

SUMMARY CONCLUSIONS
This section is for recording summary conclusions derived from the evidence in file. Each mental activity is to be evaluated within
the context of the individual's capacity to sustain that activity over a normal workday and workweek, on an ongoing basis. Detailed
explanation of the degree of limitation for each category (A through D), as well as any other assessment information you deem
appropriate, is to be recorded in Section III (Functional Capacity Assessment).
If rating Category 5 is checked for any of the following items, you MUST specify in Section II the evidence that is needed to make
the assessment. If you conclude that the record is so inadequately documented that no accurate functional capacity assessment
can be made, indicate in Section II what development is necessary. but DO NOT COMPLETE SECTION III.
Not
Significantly
Limited

Moderately
Limited

Markedly
Limited

No Evidence of
Limitation in this
Category

Not Ratable on
Available
Evidence

A. UNDERSTANDING AND MEMORY
1. The ability to remember locations and

1.

2.

3.

4.

5.

2. The ability to understand and remember very short and simple instructions.

1.

2.

3.

4.

5.

3. The ability to understand and remember detailed instructions.

1.

2.

3.

4.

5.

work-like procedures.

B. SUSTAINED CONCENTRATION AND PERSISTENCE

Form

4. The ability to carry out very short and
simple instructions.

1.

2.

3.

4.

5.

5. The ability to carry out detailed instructions.

1.

2.

3.

4.

5.

6. The ability to maintain attention and
concentration for extended periods.

1.

2.

3.

4.

5.

7. The ability to perform activities within a
schedule, maintain regular attendance.
and be punctual within customary tolerances.

1.

2.

3.

4.

5.

8. The ability to sustain an ordinary routine
without special supervision.

1.

2.

3.

4.

5.

9. The ability to work in coordination with
or proximity to others without being distracted by them.

1.

2.

3.

4.

5.

10. The ability to make simple work-related
decisions.

1.

2.

3.

4.

5.

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Not

Significantly
Limited

Moderately
Limited

Markedly
Limited

No Evidence of
Limitation in this
Category

Not Ratable on
Available
Evidence

Continued—SUSTAINED CONCENTRATION

AND PERSISTENCE
11. The ability to complete a normal workday and workweek without interruptions
from psychologically based symptoms
and to perform at a consistent pace
without an unreasonable number and
length of rest periods.

1.

2.

3.

4.

5.

12. The ability to interact appropriately with
the general public.

1.

2.

3.

4.

5.

13. The ability to ask simple questions or
request assistance.

1.

2.

3.

4.

5.

14. The ability to accept instructions and respond appropriately to criticism from
supervisors.

1.

2.

3.

4.

5.

15. The ability to get along with coworkers
or peers without distracting them or exhibiting behavioral extremes.

1.

2.

3.

4.

5.

16. The ability to maintain socially appropriate behavior and to adhere to basic
standards of neatness and cleanliness.

1.

2.

3.

4.

5.

17. The ability to respond appropriately to
changes in the work setting.

1.

2.

3.

4.

5.

18. The ability to be aware of normal hazards and take appropriate precautions.

1.

2.

3.

4.

5.

19. The ability to travel in unfamiliar places
or use public transportation.

1.

2.

3.

4.

5.

20. The ability to set realistic goals or make
plans independently of others.

1.

2.

3.

4.

5.

C. SOCIAL INTERACTION

D. ADAPTATION

II.

REMARKS: If you checked box 5 for any of the preceding items or it any other documentation deficiencies were identified,
you must specify what additional documentation is needed. Cite the item number(s), as well as any other specific deficiency,
and indicate the development to be undertaken.

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Continued on Page 4
Ill. FUNCTIONAL CAPACITY ASSESSMENT
Record in this section the elaborations on the preceding capacities. Complete this section ONLY after the SUMMARY
CONCLUSIONS section has been completed. Explain your summary conclusions in narrative form. Include any information
which clarifies limitation or function. Be especially careful to explain conclusions that differ from those of treating medical sources
or from the individual's allegations.

Continued on Page 4
MEDICAL CONSULTANT'S SIGNATURE

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DATE

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Continuation Sheet—Indicate section(s) being continued.

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*U.S. Government Printing Office: 1989-241-312/80099