Fillable MEDICAL SOURCE STATEMENT OF ABILITY TO DO WORK-RELATED

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MEDICAL SOURCE STATEMENT OF ABILITY TO DO WORK-RELATED

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SOCIAL SECURITY ADMINISTRATION Form Approved
OFFICE OF DISABILITY ADJUDICATION AND REVIEW 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 - 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 Yes
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 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.
________________________________________________________________________________________________________
FORM HA-1152-U3 (06-2006) ef (09-2006)
Destroy Old Stock
(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 Yes
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 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 affected by the impairment?
No Yes
If “yes,” please identify the capability and describe how it is affected.
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 your 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.
________________________________________________________________________________________________________
FORM HA-1152- U3 (06-2006) ef (09-2006)
Destroy Old Stock
(6) Can the individual manage benefits in his/her own best interest?
No Yes
Signature
Date
Print Name, Title and Medical Specialty (Legibly Please)
PRIVACY ACT STATEMENT:
The Social Security Administration is authorized to collect the information on this form under sections 205(a), 223(d),
1614(a)(3)(H)(I) and 1631(d)(1) of the Social Security Act. The information on this form is needed by Social Security to
complete processing of the named patient’s claim. While giving us the information on this form is voluntary, failure to provide
the requested information may prevent an accurate or timely decision on the named patient’s claim. Although the information
you furnish on this form is almost never used for any purpose other than making a determination about disability, such
information may be disclosed by the Social Security Administration to another person or governmental agency only with respect
to Social Security programs and to comply with federal laws requiring the exchange information between Social Security and
another agency.
Explanations about these and other reasons why information about you may be used or given out are available in Social Security
offices. If you want to learn more about this, contact any Social Security office.
PAPERWORK REDUCTION ACT:
This information collection meets the clearance 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 you about 15 minutes to read the instructions, gather the necessary facts, and
answer the questions. You may send comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimorem MD 21234-
6401. Send only
comments relating to our time estimate to this address, not the completed form.
________________________________________________________________________________________________________
FORM HA-1152-U3 (06-2006) ef (09-2006)
Destroy Old Stock
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MEDICAL SOURCE STATEMENT OF ABILITY TO DO WORK-RELATED

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Completed 1 August 2021

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