Disability Report Form Guide (Text Version)

Return To: Introduction | Forms | How To Apply

Go To Section:

1. Information About the Disabled Person
2. Your Illnesses, Injuries or Conditions and How They Affect You
3. Information About Your Work
4. Information About Your Medical Records
5. Medications
6. Tests
7. Education / Training Information
8. Vocational Rehabilitation, Employment, or Other Support Services Information
9. Remarks
   
   Information about Person Completing this Form.

Select Back to top to return to the top of this page.

A. Name, B. Social Security Number

We need your name and Social Security number to identify your medical and work records. If you have used other names, please list those names in Section 4.C. Many doctors and hospitals use Social Security numbers as patient identification numbers. Your number may help them to locate and send us your medical records faster.

Back to top

C. Daytime Telephone Number

We need an area code and phone number where we can reach you or leave a message, because we may need to contact you for additional information. If you do not have a phone, please give us the name and phone number of someone who can get in touch with you quickly. Let them know that we may call them with a message for you.

Back to top

D. Name of a Friend or Relative

We ask you to identify a friend or relative who knows about your illnesses, injuries, or conditions because he or she can often tell us how your medical problems affect you. Reports from doctors and hospitals provide a lot of information we need, but they don't always give us a complete picture of how your illnesses, injuries, or conditions affect you in your daily life. For this reason, we may, with your permission, contact a friend or relative who may be able to help with your claim, help you obtain medical records, or get you to a medical examination. Please give a complete mailing address of your friend or relative.

If you need to give us more than one name, please write the other name(s), phone number, and relationship to you in Section 9 - Remarks.

FREQUENTLY ASKED QUESTIONS:

Can I list my husband or wife or older children?
Yes. In fact, we are very interested in hearing from people who know you best and can tell us about your illnesses, injuries, or conditions and how they affect you.

Should I tell the person that I list that you may be calling him or her?
Yes. You should tell the person that we may call or write him or her for information about your illnesses, injuries, or conditions or your activities.

Back to top

E. Height and F. Weight

We ask you for your height and weight because this information may be important in evaluating your illnesses, injuries, or conditions. Even though your height and weight may be in your medical records, the information you give us can show us if it is the most accurate and up-to-date information.

FREQUENTLY ASKED QUESTIONS:

What if I don't know my height or weight?
If you don't know your height or weight, just write the words "don't know" on the line. However, if you know approximately how tall you are or how much you weigh, you can write the word "about" followed by your height or weight. For example, "about 5 feet, 6 inches."

I haven't been weighed recently and I am not sure if my weight has changed. What should I write?
You can write the last weight that you remember and tell us approximately when you were last weighed. For example, "150 pounds last summer." If you think that you may have gained or lost weight since you were last weighed, you can also mention that in Section 9 - Remarks.

I don't like to tell people how much I weigh. Do I need to tell you?
We certainly understand your feelings. However, the information that you give us is private, and we use it only as part of your medical evaluation. Medical reports don't always include your height or weight, so the information you give us may be very helpful.

Back to top

G. Medical Assistance Card

If you have a Medicaid, Medi-Cal, or other medical assistance card from your State government, your card number can help us obtain your medical records. This may help us complete your claim sooner.

FREQUENTLY ASKED QUESTIONS:
Do you want the number of any health insurance card that I have?
No. We only want your card number if you receive medical assistance from your State government, such as Medicaid or Medi-Cal. This number may help us obtain your medical records more easily. We do not need a number if you have commercial health insurance, such as Blue Cross, Medicare, or an HMO.

What if I don't know my number?
If you know the State office that gave you the card, you can call them for your number. Or, you can call your doctor's office. If you still do not know what your card number is, just write the words "don't know" on the line.

Back to top

H., I., J. Can You Speak, Read, Write, and Understand English?

We need to know if you can speak and understand English for several reasons:

1. If you cannot speak or understand English, we will be able to help you by providing an interpreter, free of charge, when we talk with you about your claim.
2. If you cannot speak, read, or write English, is there someone who does, and will give you messages, if we need to contact you?
3. Many of our booklets and letters are written in languages other than English. If we know that you read another language, we may be able to give you information in a language that you understand.
4. If you are unable to do the type of work you did in the past, we will decide if you can do other types of work. We will consider your age, education, and skill level. Education includes your ability to communicate in English. If you cannot speak, read, or write English, it may be harder for you to do some jobs.

MORE INFORMATION:

• Publications in Non-English Languages
• Interpreter Services

Back to top

Section 2 - Your Illnesses, Injuries, or Conditions and How They Affect You

General Information About Section 2

We will consider all the facts, including medical evidence from your doctors, hospitals, and clinics where you have been treated in deciding if you are disabled. Please describe your illnesses, injuries, or conditions, when they began, and how they limit your activities. If you give us a full description of your illnesses, injuries, or conditions, it will help us decide your case quicker.

We will consider all your illnesses, injuries, and conditions, whether or not you have been receiving treatment for them.

It is important that you give the date you became unable to work. If you are disabled, the date you became unable to work may affect when you can begin receiving benefits and the amount of your benefits. We also ask about any work you have done after the date your condition first interfered with your ability to work because this helps us decide the earliest date that your disability began.

Back to top

A. What are the illnesses, injuries, or conditions that limit your ability to work?

It is important that you list all of your illnesses, injuries, or conditions that affect your ability to work, including any mental and emotional illnesses. We will consider all your illnesses, injuries, or conditions, whether or not you have been receiving treatment for them. Use your own words if you don't know the medical names.

If you need more room to write, use the space in Section 9 - Remarks.

Back to top

B. How do your illnesses, injuries, or conditions limit your ability to work?

To help us decide if you are disabled you should describe how your illnesses, injuries, or conditions limit your ability to do work-related activities, such as walking, sitting, lifting and carrying, or remembering instructions. See Section 2.C., for information about how symptoms, such as pain, shortness of breath, or fatigue may affect your ability to function. If you need more room to write, use the space in Section 9 - Remarks.

Back to top

C. Do your illnesses, injuries, or conditions cause you pain or other symptoms?

We consider the effects of symptoms, such as pain, shortness of breath, or fatigue on your ability to function. Symptoms may restrict your ability to do daily activities, such as personal care (bathing, hair care, and dressing), food preparation, household maintenance, and recreational activities. They may also limit your ability to do work-related activities, such as walking, sitting, lifting, carrying, or remembering instructions. You should tell us in Section 2.B how your symptoms affect your ability to work.

Back to top

D. When did your illnesses, injuries, or conditions first interfere with your ability to work?
Some illnesses, injuries, or conditions may start suddenly or get worse over time. To evaluate your illnesses, injuries, or conditions and decide when your disability began, we will consider the date you list here and in Section 2.E., and Section 2.I. For illnesses, injuries, or conditions that occur suddenly, such as a stroke or heart attack, the dates in Section 2.D., Section 2.E. and Section 2.I. may be the same.

Back to top

E. When did you become unable to work because of your illnesses, injuries, or conditions?

Disability under our rules is based on your inability to work because of your illnesses, injuries, or conditions, even if you have never worked. As closely as possible, you should give the date that your illnesses, injuries, or conditions caused you to become unable to work. This date may or may not be the same as the date in Section 2.D.

To determine the beginning date of your disability, we will look at the date you list here (even if you have never worked), the dates in Section 2.D., and Section 2.I., and evidence from your medical records.

Back to top

F. Have you ever worked?

We need to know if you have ever worked because you may have done work that is not shown in our records. We will look at your age, education, past work experience, and any work skills that you may have in deciding your claim. If you have worked, we will need more information about your work in Section 3.

Back to top

G. Did you work at any time after the date your illnesses, injuries, or conditions first interfered with your ability to work?

If we find that you are disabled, we will decide the earliest date that your disability began. You must be unable to work because of your illnesses, injuries, or conditions to qualify for disability under Social Security rules. However, some people keep working after their illnesses, injuries, or conditions first started. To determine the earliest date that you became disabled, we need to know if you tried to work after the date you wrote in Section 2.D. We also need to understand how your illnesses, injuries, or conditions affected your ability to work.

Back to top

H. If you did work after the date your illnesses, injuries, or conditions first interfered with your ability to work, did they cause you to work fewer hours, change your job duties, or make any other job-related changes?

If you worked after your illnesses, injuries, or conditions first interfered with your ability to work, you may have made changes in your job, such as working fewer hours, doing lighter job duties, or receiving extra help from your employer. Please explain any changes in the way you did your job because of your illnesses, injuries, or conditions.

FREQUENTLY ASKED QUESTIONS:

Why do you want to know about changes in my work patterns caused by my illnesses, injuries, or conditions?
We ask you questions about changes in your work patterns caused by your illnesses, injuries, or conditions because it helps us decide the beginning date of your disability.

What do you mean by extra help from my employer?
Some examples include extra supervision, help lifting or carrying, or extra rest breaks. If you worked under special conditions during a period that you say you were disabled, we will ask you to tell us about those special conditions.

Back to top

I. Are you working now? If No, when was the last day you worked?

Because your work activity is important in determining whether you are disabled, we must know if you are working now. If you stopped working, you should enter the date you stopped working. This may or may not be the same as the date in Section 2.E. If you are working now, we will be asking you for more information about your work.

Back to top

J. Why did you stop working?

If you stopped working for medical reasons, enter your illnesses, injuries, or conditions here.

If you stopped work for any reason other than your disability, such as retirement, plant closure, layoff, or you quit, please explain.

If we find you disabled under our rules, we need to know the date you became unable to work because of your illnesses, injuries, or conditions. The date that we find you disabled is your established onset date. This date may affect when your benefits will start and the amount of your benefits.

MORE INFORMATION - HOW THE ONSET DATE MAY AFFECT YOUR BENEFITS:

If you are applying for Social Security Disability Insurance benefits, your benefits may be paid beginning with the sixth full month after your disability began. You may also receive up to 12 months of prior payments, depending on when your disability began and when you filed your claim.

If you are applying for Supplemental Security Income, your benefits will begin the first month after…. either the date your disability began or the date you filed your application, whichever is later.

Back to top

Section 3 - Information About Your Work

General Information About Section 3

We need to find out about your past work to decide if you can still do it. To make this decision, we need to know how you did your job. We also need to know if you learned skills on your job.

We need this information to see if there are other jobs that you have done other than your usual work. If you cannot do your usual work, we will decide if you can do another job that you did in the last 15 years. Remember that you are not disabled according to our rules unless your illnesses, injuries, or conditions prevent you from doing any job. Because people lose job skills if they do not use them for a long time, we do not consider them and you do not need to include jobs you did more than 15 years before you became disabled. If you need more room to list your jobs, use the space in Section 9 - Remarks.

FREQUENTLY ASKED QUESTIONS:

Can't you get this information from my Social Security records?
The information about the kind of job that you did and the skills that you needed to do that job is not in our records. Our records only show who paid you and how much they paid you in a given year.

Back to top

A. List all the jobs that you had in the 15 years before you became unable to work because of your illnesses, injuries, or conditions.

Please list all your jobs in the 15 years before you became unable to work because of your illnesses, injuries, or conditions, starting with your most recent job and working back. For each job, list the title of the job (for example, waitress, truck driver, bank teller), the type of business where you worked (fast food, laundry, bank, etc.), the dates you worked there (month and year are enough), the number of hours a day you worked, the number of days per week, and your most recent pay rate.

Back to top

B. Which job did you do the longest?

Back to top

C. Describe this job. What did you do all day? (If you need more space, write in Section 9- Remarks.)

This information is very important because we need to decide if your illnesses, injuries, or conditions prevent you from doing your past work. Please tell us about your job duties. This is your chance to tell us what you actually did on the job. We need this information so we can understand what your job was like. If you need more room, you can use Section 9 - Remarks to continue your description, or you may add additional sheets of paper.

FREQUENTLY ASKED QUESTIONS:

Why can't I just list the job I did the longest without describing it?
We need more information than that. There are jobs with the same name but very different job duties. There are also jobs that have the same job duties but have different names. That is why a job title is not enough to describe your work.

Please try to describe what you did on the job so that someone who has never done it will understand how you did it. We need this information to decide if you can do your past work.

How much information do you want about my job(s)?
Tell us what you did on the job that you held the longest. We need enough information to get a good picture of what you did in a normal workday. Remember that most people have no idea what it takes to do your job.

What if I had more than one major job in the 15 years before I became unable to work because of my illnesses, injuries, or conditions?
If we need more information about these jobs, we will send you another form with enough room to describe all of your jobs.

Back to top

THE FOLLOWING QUESTIONS ASK FOR INFORMATION ABOUT THE JOB YOU DID THE LONGEST IN THE 15 YEARS BEFORE YOU BECAME UNABLE TO WORK BECAUSE OF YOUR ILLNESSES, INJURIES, OR CONDITIONS, THAT YOU DESCRIBED IN Section 3.C.

D. In this job (the one you described in 3.C), did you use machines, tools, or equipment? Use technical knowledge or skills? Do any writing, complete reports, or perform any duties like this?

This checklist asks you about your job skills. Check "YES" or "NO" for each of the items listed.

FREQUENTLY ASKED QUESTIONS:

What do you mean by machines, tools, and equipment?
We are trying to understand what you did on the job. For example, if you were a carpenter, did you only use hand tools like hammers and saws? For another example, if you were a secretary, did you use a computer for word processing?

What do you mean by technical knowledge?
We mean special skills you learned on the job. For example, an electrician learns about the basic laws of electricity, the electrical codes and how to use special tools.

What do you mean by writing and completing reports?
This question asks you if you did any writing or if you had to complete reports as part of your job. For example, a bookkeeper completes accounting reports as part of his or her job duties.

Back to top

E. In this job (the one you described in 3.C) , how many total hours each day did you: walk, stand, sit, climb, stoop, kneel, crouch, crawl, handle, grab, or grasp big objects, write, type, or handle small objects?

This item asks you for the number of hours that you usually did certain physical activities in a normal day on your job. If the list does not really describe what you did on your job, then be sure to explain it in Section 9 - Remarks. In a normal workday, most people would have to do some of the activities listed. Please try to tell us how long you did the activities in a normal workday. For example, a security guard might sit for 4 hours and walk for 4 hours in an 8-hour workday.

FREQUENTLY ASKED QUESTIONS:

Why are standing and walking separated?
Some jobs may require standing in one place for long periods of time and other jobs require mostly walking or a combination of walking and standing. We need this information to understand the physical requirements of your job.

Back to top

F. Lifting and Carrying (Explain what you lifted, how far you carried it, and how often you did this)

This item asks you what lifting and carrying you had to do on your job (the one you described in 3.C) . Be sure to tell us how often and for how long you had to lift and carry things on your job. We use the information in deciding how your illnesses, injuries, or conditions affect your ability to work.

Back to top

G. Check heaviest weight lifted.

This item asks you to check the heaviest weight you had to lift on the job (the one you described in 3.C) every day. We need this information to decide if you can still do this job.

Back to top

H. Check weight frequently lifted (By frequently, we mean from 1/3 to 2/3 of the workday).

This item asks you how much weight you had to lift frequently on your job (the one you described in 3.C). We realize that it is difficult to know exactly how much certain items weigh, but you may give us an estimate about how much you think they weigh.

For example, a gallon of milk weighs about 8 pounds, and bags of sugar, flour, dry dog food, and kitty litter have their weights listed on the package. You can compare those weights to the weights you had to lift frequently on the job.

Back to top

I. Did you supervise other people in this job?

Check “Yes” or “No”. If “No” go to question J. If “Yes”, tell us how many people you supervised, how much of your day was spent supervising the work of others, and whether you hired and fired employees in your job.

Back to top

J. Were you a lead worker?

What we mean by “lead worker” is someone who performs some kind of non-supervisory work but who may have additional responsibility for setting the pace of work or for ensuring the completion of work.

All of the information we ask you to provide about your job gives us a good idea about the physical requirements of your job. We will use this information to decide if your illnesses, injuries, or conditions prevent you from doing your past work.

Back to top

Section 4 - Information About Your Medical Records

General Information About Section 4

If you have received treatment, we will ask for your medical records. We use your medical records and other information to decide if you are disabled under our rules.

We need information about your medical treatment for any illnesses, injuries, or conditions that limit your ability to work. If you already have copies of your medical records in your possession from your doctors, hospitals, clinics, and other medical sources, we will not have to request them. This will allow us to decide your claim faster. Do not wait to file your claim if you do not have these records. With your permission, we will ask the medical sources you list to send them to us. If you have not received treatment, or we do not get enough information about your illnesses, injuries, or conditions, we may ask you to have a special examination or test.

We need this information because we use your medical records and other information to decide if you are disabled. We will contact the medical sources that have treated you for illnesses, injuries, or conditions and ask them to send us copies of your medical records.

We also ask for information such as:

• What are your illnesses, injuries, or conditions?
• When did they begin?
• How do they limit your activities?
• What did medical tests show?
• What treatment did you receive?

In addition, we ask for information about your ability to do work-related activities, such as walking, sitting, lifting, carrying, and understanding and remembering instructions.

We do NOT ask your doctors to decide if you are disabled. Rather, we decide if you are disabled under our rules.

Back to top

A. Have you been seen by a doctor/hospital/clinic or anyone else for the illnesses, injuries or conditions that limit your ability to work?

We need to know if you have been treated for any illnesses, injuries, or conditions that limit your ability to work, even if you have not been seen recently.

Back to top

B. Have you been seen by a doctor/hospital/clinic or anyone else for emotional or mental problems that limit your ability to work?

We need to know if you have been treated for any emotional or mental problems that limit your ability to work, even if you have not been seen recently. We need this information because we consider emotional and mental difficulties, in addition to physical problems, when we decide your claim. It's important that we know about treatment for ALL of your illnesses, injuries, and conditions. If you have received treatment, we will ask for your medical records.

Back to top

C. List other names you have used on your medical records.

When we request your medical records, we must know the name you were using at the time you received treatment. This information will help us get your medical records faster. Include your maiden name or previous married name(s), nicknames, or any other names that would appear on your medical records. When completing Section 4.D. through Section 4.F. below, it is also helpful if you give other names your records may be listed under for each doctor, hospital, or other source of treatment.

Back to top

D. List each DOCTOR / HMO / THERAPIST / OTHER.

We need names and addresses for your medical sources so that we can request your medical records. We use these records along with other information to decide if you are disabled under our rules.

List ALL health care professionals you have seen for your illnesses, injuries, or conditions. Include physicians, psychologists, optometrists, nurse-practitioners, physician assistants, therapists, chiropractors, social workers, and counselors. Also include alternative medicine professionals, such as acupuncturists.

It is important that you provide the full name of the doctor or other medical source, and the complete mailing address. For example, do not simply list "Dr. Smith on Taylor Rd in Clarksville." We may not be able to obtain your records with an incomplete address. You can check the phone book, your appointment card, your billing statement, or call the doctor's office to get the mailing address. Some doctors have more than one office, so give us the address for the location where you are treated or where your medical records are kept. We also need a phone number because we may need to call their office.

Your dates of treatment tell us how long you have been seen, and when your next appointment will be. If you can't remember the exact dates, try to give us the approximate dates. For example, you can write "about 2 years ago," "last year," or "6 months ago." Information about the reasons for your visits and the treatment received will help us decide which records to request. If you know your patient identification number, it may help us get your medical records faster.

If you need more room to list additional health care professionals, use the space in Section 9 - Remarks. Remember that we need to know about all of your treatment.

FREQUENTLY ASKED QUESTIONS:

How far back should I go when listing my medical treatment?
We need to know about your medical treatment since at least the time you became unable to work. If you were treated for your illnesses, injuries, or conditions before then, we also need to know about that treatment. In addition to deciding if you are disabled under our rules now, we must also decide when you first became disabled. We also use your medical records to see how your illnesses, injuries, or conditions have changed over time.

If I have an appointment scheduled with a new doctor I haven't seen before, should I list this? What about future hospital and clinic appointments?
Yes, you should list these appointments and give us the appointment dates. We always need your most current treatment records.

What if I don't know my patient identification number or hospital/clinic number?
We can still get your records without this number, but sometimes the medical source can find your records quicker if they have this information. This number is usually available on your medical records or bills.

What happens if I don't know the complete addresses for the places where I have been treated?
If you do not give us complete addresses, or if you give us the wrong addresses, we may be delayed in getting your medical records. Therefore, it is important that you try to find the complete address by checking the phone book, appointment cards, billing statements, or calling the office for the address.

Back to top

E. List each HOSPITAL / CLINIC.

We need the names and addresses of hospitals and clinics that have treated you for your illnesses, injuries, or conditions so that we can request your medical records. We use these records along with other information to see if you are disabled under our rules.

Be sure to include the complete name, address, and phone number of the hospital or clinic where you were treated. Some hospitals and clinics have more than one location, so providing the exact address is important. You can check the phone book, your appointment card, your billing statement, or call the hospital or clinic to get the mailing address for requesting your medical records. If you have already listed a clinic or clinic doctor in Section 4.D., you do not need to list them again here.

We need your dates of treatment and the date of your next appointment. If you can't remember the exact dates, try to give us the approximate dates. For example, you can write "about 2 years ago," "last year," or "6 months ago." Hospitals and clinics often need these dates to give us your medical records. Also include your hospital or clinic number if you know it.

Your type of visit should be shown as:

• Inpatient Stays (Stayed at least overnight)
• Outpatient Visits (Sent home the same day)
• Emergency Room (ER) Visits (Seen in ER and sent home after treatment)

Make sure you list ALL hospitals, clinics, and treatment centers where you received treatment for your illnesses, injuries, or conditions. If you do not have enough room, use the space in Section 9 - Remarks.

Include as much information as possible about the reasons for your visits, the types of treatment you received, and the names of the doctors or other health care professionals that treated you. This information allows us to ask for the specific records we need from your doctors.

Back to top

F. Does anyone else have medical records or information about your illnesses, injuries or conditions?

We need information about anyone else who would have medical records or information about your illnesses, injuries, or conditions. Sometimes sources other than the doctors, hospitals, and clinics you listed in items 4.D. and 4.E. will have copies of your medical records, and they may give them to us more quickly.

These sources may include State workers' compensation, insurance companies, prisons, attorneys, public welfare offices, and others. If you have any of your medical records, you should give them to us with the Disability Report.

Be sure to provide all information, including the complete name and address. We need a phone number because we may have to call these sources about your medical records. Your dates of visits, next appointment, claim number, and reasons for visits help us ask for the information we need. If you do not have enough room, please use the space in Section 9 - Remarks.

Back to top

Section 5 - Medications

General Information About Section 5

This section tells us a little more about you and how you are being treated for your illnesses, injuries, or conditions. We need to know about the medicines your doctor(s) prescribed and any "over-the-counter" medicines you take, such as aspirin or Tylenol. It is very important that you list ALL of the medicines you take, even if they are not for the current illnesses, injuries, or conditions for which you are filing a disability claim.

The kinds of medication, how often you take them, and how they affect you can help us learn more about you so that we can make a better decision on your claim. If you are using any other types of medicines, such as herbs or home remedies, we also need to know this because it may tell us about other medical problems that may affect your current illnesses, injuries, or conditions. We will look at all other illnesses, injuries, or conditions you may have when we make a decision on your claim.

FREQUENTLY ASKED QUESTIONS:

Why don't you get this information from my doctor?
We not only need the medicines that are prescribed by a doctor, but also any over-the-counter medicines or herbal remedies you may be taking. These other types of medicines might not be listed in your doctor’s records. Also, a doctor's records don't always show how the medicine "makes you feel."

Back to top

Name of Medicine

For prescription medicine, you will be able to get this information from the container. If you do not have the container, you can give us the common name or the type of medicine (such as heart medicine or arthritis medicine).

For non-prescription (over-the-counter) or herbal medicines, give us the name of the medicine.

Back to top

If Prescribed, Give Name of Doctor

We need the name of the doctor who prescribed the medicine you are taking. This does not have to be your current doctor. It may be a doctor you have seen before for another illness, injury, or condition. If you cannot remember the doctor's name, please write "unknown" in the space.

Reminder: If you have not already listed the name of this doctor, please enter the information in Section 4. If there is not enough room to list this doctor in Section 4, list the doctor in Section 9 - Remarks. Be sure to include all the information that Section 4 asks for.

If you give us complete information, we will be able to get a better picture of you and how your illnesses, injuries, or conditions affect your ability to work. When we review your claim, we look at your entire physical and mental medical history to decide if you are disabled under our rules. By giving us complete information, you will help us decide your claim quicker.

If the medicine you are taking was not prescribed by a doctor, just write "over-the-counter" or what other type of medication it may be (like "herbal" or "home remedy").

Back to top

Reason for Medicine

What we need for you to write here is why you are taking the medicine. Examples of this would be "to slow down my heart rate," "for high blood pressure," "to help me sleep at night," "for pain relief," "for headaches," or "for depression." This is important because some medicines can be prescribed for different reasons.

This helps us find out how you are being treated for your illnesses, injuries, or conditions and how well that treatment is working for you. We will use this information to help us, as we decide how your illnesses, injuries, or conditions affect your ability to work.

Back to top

Side Effects You Have

This section describes how the medicine you take affects you either physically or mentally. Examples here would be "It just makes me so tired that I can't do anything but sleep," or "I can't go anywhere because I get diarrhea when I take my medicine," "or "It makes me sick to my stomach." You should also list any allergic reactions you have to the medicines you are taking.

Your reaction to the medicine you take may affect your ability to work. We need to know this information since the ability to work is an important part of how we decide whether or not you are disabled.

Back to top

Section 6- Tests

General Information About Section 6

We need the results of your medical tests to better understand the nature of your illnesses, injuries, or conditions. We are interested in tests that are planned for you in the future and also tests that have been completed. We use the results of some kinds of tests to confirm the presence of a medical problem. For example, an x-ray can show the presence of a bone fracture. We use the results of other kinds of tests to find out the extent of physical limitations caused by an illness, injury, or condition. For example, a breathing test can show limitations caused by a lung condition. We will use this information and other evidence to decide what you can still do.

NOTE: Select the name of any test (on page 7) for more information.

FREQUENTLY ASKED QUESTIONS:

Why can't you get this information from my doctor?
You may have tests scheduled in the future, and your doctor will not have the results of those tests. You may also have had tests done as an outpatient or as an emergency room patient, and your doctor may not have the results from such testing. Or, you may have been tested while you were in the hospital, and the hospital did not include the results in your records. We will try to get your test results, but we have to know what tests you had and when and where you had them done so that we can get all the information that tells us about your illnesses, injuries, or conditions.

What information do I put in this section of the form?
A number of tests are listed in this section. If you had or are going to have any of these tests, please give us the dates, location and who asked you to have the test(s). If you had or are going to have a test performed that is not listed in this section, you can give us the information in Section 9 - Remarks on page 10. Be sure to tell us the name of the doctor who sent you for testing so we can obtain these records.

Back to top

EKG (Heart Test)

In this test the patient sits, stands, or lies down while wires are placed on the skin. A machine attached to the other ends of the wires prints out wavy lines on a chart that shows the electrical activity of the heart.

Back to top

Treadmill (Exercise Test)

This is a heart test done while the patient exercises. There are different kinds of exercise methods but the most common is the treadmill test in which the patient has an EKG recorded as he or she walks on a treadmill.

Back to top

Cardiac Catheterization

This is a test of the blood circulation in the heart. In this test the doctor passes a thin wire into the heart through an artery (usually through the groin area). With this test, a doctor can see pictures of the inside of the heart.

Back to top

Biopsy

Name of body part-This is a test in which the doctor removes tissue from a part of the body to see if disease is present. You should enter the name of the body part on the line.

Back to top

Hearing Test

This a test in which a specialist plays different tones through earphones to detect any hearing loss.

Back to top

Speech-Language Test

This is a test that helps a speech-language pathologist to evaluate your ability to use speech and language to communicate with others.

Back to top

Vision Test

This is an eye test that may require reading letters from a chart. It may also require reading letters through a machine with adjustable lenses, or it may check side vision with dots of light.

Back to top

IQ Testing

This is a test that measures a person's ability to understand information and solve problems. This test is made up of a series of short tasks that require either a written or spoken response.

Back to top

EEG (Brain Wave Test)

This test involves placing wires on the scalp. These wires lead to a machine that measures and records brain wave activity. This test can detect seizure activity and other problems in the brain.

Back to top

HIV Test

This is a blood test that detects the presence of the human immunodeficiency virus (HIV).

Back to top

Blood Test (Not HIV)

In this test, a technician draws blood that is tested for abnormalities in a laboratory.

Back to top

Breathing Test

In this test, the patient exhales as hard and as long as possible into a machine that measures the breathing capacity of the lungs.

Back to top

X-Ray

This is a test in which a large machine takes pictures of body parts. You should enter the name of the body part on the line.

Back to top

MRI / CT Scan

These testing methods are like x-rays, but use different methods in making images of the body parts. Both methods show soft tissue far better than x-ray. A CT scan is also called a CAT scan. You should enter the name of the body part on the line.

Back to top

Section 7- Education / Training Information

General Information About Section 7

Information about your education and training are very important to us. If you cannot do your past job, we look at your age, education, training, and job skills to see if you can do other kinds of work.

Back to top

A. Check the highest grade of school completed.

If you did not complete the entire school year, check the previous year that you completed. For example, if you started the 10th grade but did not finish the entire school year, check 9 as the highest grade completed.

If you are not sure how many college credits are in a school year, you may list the number of college credits you have completed. We also need for you to list the date you most recently completed your education.

Back to top

B. Did you attend special education classes?

By "special" education classes, we mean any kind of education services that you received other than what is provided for in a regular classroom. Examples of this could be special classes related to a physical, emotional, or learning disability.

If you attended these types of classes, we need information about them because we may need to contact someone at the school to get your records to use in deciding whether or not you are able to do different kinds of work. Please list the name(s) of the school, the address (as close as you can remember it), the dates you attended these classes, and the type of program you attended.

By "type of program," we mean the kind of services you may have received, like special classes or special help for an emotional disability or a learning disability, such as a reading disorder. Other examples include special classes or special help for a physical disability, such as blindness or deafness.

Back to top

C. Have you completed any type of special job training, trade or vocational school?

If you completed any special job training, or trade or vocational school, you should explain the type of training that you received and the approximate date you completed the training. Examples of this could be auto mechanic, electronics, cosmetology, heating and air conditioning, computer repair, data entry or word processing courses. If you need more room, please go to Section 9 - Remarks.

Back to top

Section 8 - Vocational Rehabilitation, Employment, or other Support Services Information

Have you participated, or are you participating in:

• an individual work plan with an employment network under the Ticket to Work Program;


• an individualized plan for employment with a vocational rehabilitation agency or any other organization;


• a Plan to Achieve Self-Support;


• an individualized education program through an educational institution (if a student age 18-21); or


• any program providing vocational rehabilitation, employment services, or other support services to help you go to work?

If “Yes”, provide the name of the organization or school, the name of your counselor or instructor, the address, phone number, dates when you received services, and types of services, tests, or evaluations performed.

Any information from vocational rehabilitation or other support services could help us understand the nature and extent of your disabling illnesses, injuries, or conditions more fully.

"Other support services" could include sheltered workshops, job coaches, or any group that has given you job training, coaching, or evaluation services.

Provide all details to allow us to call or write for your records. If you cannot get the complete address, show whatever information you know. For example, you may not be able to obtain a full street address, but you know, "They were in the tall office building next to the Smith County Courthouse." Or, you may not know the name of the organization, but you know, "They worked with me at the request of my guidance counselor, Ms. Jones, at Boone County Community College." Be sure to show any such information you believe may help us obtain those records.

Once we obtain this information, we will consider what those trained professionals say about your ability to work. We will consider such things as environmental limitations, ability to carry out physical activities, ability to work with others, ability to receive and understand work instructions, etc. We will consider how their findings fit with other medical records to get a complete picture of your medical limitations.

MORE INFORMATION:

• Social Security Employment Support Programs

Back to top

Section 9 - Remarks

Remarks

Use this section for any information you could not fit into the designated space for any question in earlier parts of this form. Be sure to show which section your remarks relate to. For example, if you did not have enough room to list your illnesses, injuries, or conditions in Section 2.A., you should write "Section 2. A," followed by whatever additional information you want us to know.

You may use this section to show any other information you think would be helpful in understanding your work limitations. For example, if you showed in section 3 that you worked as a dishwasher, but the way you performed your job as a dishwasher was different than for most dishwashers, you should explain those differences in this section.

In this section, you can tell us anything else you wish to explain about why you are unable to work.

If you run out of room in this section, please continue to write or type on additional sheets, again referring to the sections of the form about which you are providing additional information.

We will consider any information you give us in this section to gain a complete picture of your illnesses, injuries, or conditions and any limitations you have.

When you are finished with this section (or if you don't have anything to add), be sure to complete the information requested on the bottom of page 10.

Back to top

Name of Person Completing this Form if other than the Disabled Person

The person completing this form should print his or her name, enter his or her address, and the date the form was completed. Providing an e-mail address is optional. If the person completing this form is other than the disabled person or the person identified in Section 1 Item D., be sure to also give the relationship to the disabled person, daytime phone number, and address.

Learn More About Disability Benefits and How We Decide If You Are Disabled