Form SSA-4734-F4-SUP Mental Residual Functional Capacity Assessment

Form SSA-4734-F4-SUP is a U.S. Social Security Administration form also known as the "Mental Residual Functional Capacity Assessment". The latest edition of the form was released in August 1, 1985 and is available for digital filing.

Download a PDF version of the Form SSA-4734-F4-SUP down below or find it on U.S. Social Security Administration Forms website.

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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
No Evidence of
Not Ratable on
Significantly
Moderately
Markedly
Limitation in this
Available
Limited
Limited
Limited
Category
Evidence
A.
UNDERSTANDING AND MEMORY
The ability to remember locations and
1.
1.
2.
3.
4.
5.
work-like procedures.
2.
The ability to understand and remem-
1.
2.
3.
4.
5.
ber very short and simple instructions.
3.
The ability to understand and remem-
1.
2.
3.
4.
5.
ber detailed instructions.
B.
SUSTAINED CONCENTRATION AND PERSISTENCE
4.
The ability to carry out very short and
1.
2.
3.
4.
5.
simple instructions.
5.
The ability to carry out detailed instruc-
1.
2.
3.
4.
5.
tions.
6.
The ability to maintain attention and
1.
2.
3.
4.
5.
concentration for extended periods.
7.
The ability to perform activities within a
schedule, maintain regular attendance.
1.
2.
3.
4.
5.
and be punctual within customary toler-
ances.
8.
The ability to sustain an ordinary routine
1.
2.
3.
4.
5.
without special supervision.
9.
The ability to work in coordination with
1.
2.
3.
4.
5.
or proximity to others without being dis-
tracted by them.
10.
The ability to make simple work-related
1.
2.
3.
4.
5.
decisions.
SSA-4734-F4-SUP
1
Form
(8-85)
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
No Evidence of
Not Ratable on
Significantly
Moderately
Markedly
Limitation in this
Available
Limited
Limited
Limited
Category
Evidence
A.
UNDERSTANDING AND MEMORY
The ability to remember locations and
1.
1.
2.
3.
4.
5.
work-like procedures.
2.
The ability to understand and remem-
1.
2.
3.
4.
5.
ber very short and simple instructions.
3.
The ability to understand and remem-
1.
2.
3.
4.
5.
ber detailed instructions.
B.
SUSTAINED CONCENTRATION AND PERSISTENCE
4.
The ability to carry out very short and
1.
2.
3.
4.
5.
simple instructions.
5.
The ability to carry out detailed instruc-
1.
2.
3.
4.
5.
tions.
6.
The ability to maintain attention and
1.
2.
3.
4.
5.
concentration for extended periods.
7.
The ability to perform activities within a
schedule, maintain regular attendance.
1.
2.
3.
4.
5.
and be punctual within customary toler-
ances.
8.
The ability to sustain an ordinary routine
1.
2.
3.
4.
5.
without special supervision.
9.
The ability to work in coordination with
1.
2.
3.
4.
5.
or proximity to others without being dis-
tracted by them.
10.
The ability to make simple work-related
1.
2.
3.
4.
5.
decisions.
SSA-4734-F4-SUP
1
Form
(8-85)
No Evidence of
Not Ratable on
Not
Significantly
Moderately
Markedly
Limitation in this
Available
Limited
Limited
Limited
Category
Evidence
SUSTAINED CONCENTRATION
Continued—
AND PERSISTENCE
11.
The ability to complete a normal work-
day and workweek without interruptions
from psychologically based symptoms
1.
2.
3.
4.
5.
and to perform at a consistent pace
without an unreasonable number and
length of rest periods.
C. SOCIAL INTERACTION
12.
The ability to interact appropriately with
1.
2.
3.
4.
5.
the general public.
13.
The ability to ask simple questions or
1.
2.
3.
4.
5.
request assistance.
14.
The ability to accept instructions and re-
1.
2.
3.
4.
5.
spond appropriately to criticism from
supervisors.
15.
The ability to get along with coworkers
or peers without distracting them or ex-
1.
2.
3.
4.
5.
hibiting behavioral extremes.
16.
The ability to maintain socially appropri-
ate behavior and to adhere to basic
1.
2.
3.
4.
5.
standards of neatness and cleanliness.
D. ADAPTATION
17.
The ability to respond appropriately to
1.
2.
3.
4.
5.
changes in the work setting.
18.
The ability to be aware of normal haz-
1.
2.
3.
4.
5.
ards and take appropriate precautions.
19.
The ability to travel in unfamiliar places
1.
2.
3.
4.
5.
or use public transportation.
20.
The ability to set realistic goals or make
1.
2.
3.
4.
5.
plans independently of others.
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.
Continued on Page 3
SSA-4734-F4-SUP
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Form
(8-85)
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
DATE
SSA-4734-F4-SUP
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Form
(8-85)
Continuation Sheet—Indicate section(s) being continued.
SSA-4734-F4-SUP
4
*U.S. Government Printing Office: 1989-241-312/80099
Form
(8-85)

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