Fillable Recommended FullyFavorableDecision Checksheet Form Recommended Fully Favorable Decision Checksheet

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Recommended FullyFavorableDecision Checksheet Form Recommended Fully Favorable Decision Checksheet

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Country of origin: US
File type: PDF

U.S.A. forms for Social Security Administration

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Recommended Fully Favorable Decision Checksheet
Claimant Name:
SSN:
DIB Application Date:
Hearing Date:
SSI Application Date:
DWB Application Date:
Date First Insured:
Date Last Insured:
Established Onset Date:
EOD is
AOD
Amended AOD
Current Appl. Date
(SSI Only)
Prior Appl. Date
(SSI Only)
Prior Application
Reopened
Not Reopened
Prior Application Date(s): T2
T16
Reason for Reopening
Within one year
Good cause
Grounds for reopening at any time
Work After Onset
UWA
Not SGA
TWP
Severe Impairment(s) (singly or in combination):
Impairment(s) MEETS Listing #
Impairment(s) EQUALS Listing #
Child is Functionally Equal to Listings
Mrk
Extr
Mrk
Extr
1. Acquiring and Using Information
4. Moving about and Manipulating objects
2. Attending and Completing Tasks
5. Caring for Oneself
3. Interacting with Others
6. Health and Physical Well-being
Mental Impairment Analysis (Part B)
Understanding, Remembering, or Applying
Information
None
Mild
Moderate
Marked
Extreme
Interacting with Others
None
Mild
Moderate
Marked
Extreme
Concentrating, Persisting, or Maintaining
Pace
None
Mild
Moderate
Marked
Extreme
Adapting or Managing Oneself
None
Mild
Moderate
Marked
Extreme
Mental Impairment Analysis (Part C)
12.02, 12.03, 12.04, 12.06, or 12.15 Serious and persistent with at least 2 year duration and
evidence of an ongoing reliance upon medical treatment, mental health therapy, psychosocial
supports, or a highly structured setting
Page 2 of 2
Residual Functional Capacity:
Full range of
Sedentary
Light
Medium
Less than full range of
Sedentary
Light
Medium (describe below)
Nonexertional only (describe below)
Function by Function:
Rationale for Decision (Include Evaluation of Symptoms and Assessment of Medical Opinions):
No PRW PRW but is unable to perform
PRW:
unskilled
skilled/semiskilled but skills do not transfer to other occupations w/in RFC
Claimant “disabled” based on:
Direct application of Medical-Vocational Rule #
Framework of Rule #
based on VE testimony
based on SSR#
Section 204.00 Framework
based on VE testimony
based on SSR#
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Recommended FullyFavorableDecision Checksheet Form Recommended Fully Favorable Decision Checksheet

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Completed 12 May 2020

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