This person can be the representative payee, appointed representative, a relative, friend, or any person willing to assist the disabled individual. This section also collects information about the person completing the report for the disabled individual. This section Items 4A — 4G collects information about the treating sources, types of treatment received, and medical tests performed within the last 12 months. The complete names, addresses including zip code , and telephone numbers of the treating sources are necessary.
If the disabled person has more than five treating sources, add the additional information to Section — 11 Remarks. This section collects the names of prescription and non-prescription medicines within the last 12 months, prescribing physicians if any , and reasons for the medicines the disabled person is taking.
This section Items 7A -7E collects information about any additional education or training the disabled person has received since the CPD. This section also collects information regarding if the disabled person can read and write in any language. If the disabled individual is participating in a vocational rehabilitation program, see DI The DDS needs this information to evaluate medical improvement and to determine whether an exception to medical improvement applies.
If the applicant does not remember their job title, add a generic title that describes the tasks performed. Type of business: Enter the name or type of business. Hours per day, days per week, and rate of pay. If the applicant had only one job in the last 15 years, answer the rest of the questions in Section 6.
If the applicant had more than one job in the last 15 years before he or she became unable to work, do not answer the rest of the questions in Section 6 and go to Section 7. List all brand name or generic medicines the applicant is taking, including those prescribed by a doctor and any over-the-counter medicines, to treat his or her physical and mental conditions. Provide the name of the medicine, the prescribing physician, and the reason for the medicine i.
If possible, collect this information from the prescription s or prescription bottles. If the applicant has been prescribed medication, but is inconsistent in taking it due to symptoms of his or her illness, poor memory, or limited funds, add the medications to section 7 and provide details in the remarks section about the reasons the applicant is not consistently taking the medicine s.
Include all medical sources that have examined or treated the applicant for physical or mental conditions, even if they are not recent.
It is important to provide comprehensive information in this section, as DDS uses this information to obtain and evaluate medical evidence for the application. Medical treatment sources can include hospitals, clinics, substance use treatment, and evaluation by other health professionals.
Jails and prisons may also be a source of medical records. If the applicant underwent evaluations or treatment while incarcerated, you can add this information to either section 8 or 9.
Contact information: mailing address, fax and phone numbers, treating physician, and patient number. Conditions evaluated: list all mental and physical health conditions evaluated or treated by the provider. If the person completing the report is the same person listed in 2. The name of the person completing the form, if someone other than the claimant or the person listed in 2. Or indicate that, no additional third party contact is available.
Enter information about the claimant's condition s that restricts his or her ability to work. If outside of the USA, you may document the height in centimeters. If outside of the USA, you may document the weight in kilograms.
Use the claimant's allegations, and document the claimant's own perception of when he or she became unable to work because of his or her physical or mental condition s. We refer to this as the alleged onset date AOD. This is the AOD for a claimant who has never worked. Then go to Section 5. Generally, this is the AOD for a claimant who has stopped working. Check the appropriate box for why the claimant stopped working:. Because of other reasons. If the claimant answers:.
Then go to 4. NOTE: The date documented in item 4. Since the date in 4. Do not count sick leave, vacation, or disability pay. For example, changes in job duties or hours worked. This is the AOD for a claimant who is currently working.
For more information about completing work activity reports, see DI Check the box corresponding to the highest grade of school completed by the claimant. If the claimant completed education equivalent to high school from another country, check " Check the box corresponding to whether the claimant received special education "Yes" or "No".
If the claimant answers "No," then go to 5. Check the box corresponding to whether the claimant completed any type of specialized job training, trade, or vocational school "Yes" or "No". List additional education or training under Section 11 — Remarks. Identify the written language the claimant uses every day in most situations at home, work, school, in community, etc. With respect to the language identified in 5. For the evaluation and development of employment and documenting employment cases, see DI List the jobs up to 5 that the claimant has had in the 15 years before he or she became unable to work because of the physical or mental conditions.
List the most recent job first and do not exclude jobs from the list just because earnings are under SGA. Consider listing jobs other than the most recent if the claimant requests a specific job be added. For example, the claimant may have worked more than 5 jobs in the past 3 years, but had a steady job for the previous 10 years.
If the claimant did not work at all in the 15 years before he or she became unable to work, check the box and go to Section 7 — Medicines. Job title: Enter the type of job performed, not the name of the employer.
Even common jobs are performed quite differently from employer to employer. If the job duties and physical and mental requirements were the same, one entry in Section 6. A is sufficient. The information provided on this site is not legal advice, does not constitute a lawyer referral service, and no attorney-client or confidential relationship is or will be formed by use of the site. The attorney listings on this site are paid attorney advertising. In some states, the information on this website may be considered a lawyer referral service.
Please reference the Terms of Use and the Supplemental Terms for specific information related to your state. Call us at 1 Learn about the disability report, a key part of your Social Security disability application.
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