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

Form HA-1152 (01-2017) UF
Discontinue Prior Editions
Social Security Administration
Office of Disability Adjudication and Review

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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 -

Able to function in this area independently, appropriately, effectively, and on a sustained basis.

Mild -

Functioning in this area independently, appropriately, effectively, and on a sustained basis
is slightly limited.
Moderate - Functioning in this area independently, appropriately, effectively, and on a sustained basis is fair.
Marked -

Functioning in this area independently, appropriately, effectively, and on a sustained basis
is seriously limited.

Extreme -

Unable to function in this area independently, appropriately, effectively, and on a sustained basis.

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.

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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 (such as the ability to concentrate, persist, or maintain pace
and the ability to adapt or manage oneself) 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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No

(6) Can the individual manage benefits in his/her own best interest?

Signature

Yes

Date

Print Name, Title, and Medical Specialty (Legibly Please)

PRIVACY ACT STATEMENT

See Revised 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 1-800-772-1213 (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.