Medical Source Statement of Ability to Do Work-Related Activities

OMB 0960-0662

SSA uses Forms HA-1151 and HA-1152 to collect data that is required to determine the residual functional capacity (RFC) of individuals who are appealing denied claims for benefits based on disability. The RFC of an individual must be determined in cases where SSA cannot make a determination on a claim for benefits based on current work activity or on medical facts alone. The respondents are medical sources paid by SSA to provide reports based either on existing medical evidence or on consultative examinations conducted for the purposes of the report.

The latest form for Medical Source Statement of Ability to Do Work-Related Activities expires 2021-02-28 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form HA-1151-BK Medical Source Statement of Ability To Do Work-Related Activities (Physical) - SSA-1151 Form
Form HA-1152 Medical Source Statement of Ability to Do Work-Related Activities (Mental) - SSA-1152 Form
Supporting Statement - 0662.docx Supporting Statement A
Addendum - 0662.docx Supplementary Document
Medical Source Statement of Ability To Do Work-Related Activities (Physical) - SSA-1151 Form
Medical Source Statement of Ability to Do Work-Related Activities (Mental) - SSA-1152 Form

All Historical Document Collections

202101-0960-006 Approved without change	Revision of a currently approved collection	2021-01-28
201704-0960-009 Approved without change	Revision of a currently approved collection	2017-09-01
201611-0960-004 Approved without change	No material or nonsubstantive change to a currently approved collection	2016-11-29
201406-0960-011 Approved without change	Revision of a currently approved collection	2014-09-24
201109-0960-011 Approved without change	Revision of a currently approved collection	2012-01-13
200810-0960-004 Approved without change	Extension without change of a currently approved collection	2009-04-03
200608-0960-007 Approved without change	No material or nonsubstantive change to a currently approved collection	2006-08-23
200602-0960-006 Approved without change	Reinstatement with change of a previously approved collection	2006-02-10
200409-0960-017 Approved without change	No material or nonsubstantive change to a currently approved collection	2004-09-29
200210-0960-009 Approved with change	Existing collection in use without an OMB Control Number	2002-10-21

OMB Details

Medical Source Statement of Ability To Do Work-Related Activities (Physical)

Federal Enterprise Architecture: Income Security - General Retirement and Disability

Form HA-1151-BK

Medical Source Statement of Ability to Do Work-Related Activities (Physical)

Paper Only

Form

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.