Last Update: 2/12/09 (Transmittal I-2-73)
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CLAIMANT'S NAME (Last, First) |
SSN |
REQUESTOR/SOURCE |
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REQUESTOR'S ADDRESS |
REQUESTOR'S TELEPHONE NO. |
RELATION TO CLAIMANT DATE OF REQUEST |
HOW WAS CRITICAL REQUEST RECEIVED?
Written statement submitted. [Letter or statement attached.]
Telephone contact received by _______________________ (employee). [RC attached.]
Other: _________________________________________________________
ALLEGED CRITICAL SITUATION (Check any and all that apply):
___ Terminal Illness [TERI]—FLAG with Form SSA-2200.
___ Military Service Casualty Case [MSCC]—FLAG with MSCC flag found in I-2-1-96
___ Compassionate Allowance [CAL]—FLAG with Critical Case flag found in I-2-1-94, with clear designation that case involves CAL.
___ Without and unable to obtain food, medicine, or shelter [DIRE NEED]
Lack of food/shelter
Lack of necessary medical care/medications
Foreclosure or eviction
Other: _____________________________________________________________
___ Verified with servicing Field Office (FO) or other source:
Income of any kind/source? Yes/No __________________________________
Receiving any aid from the state or federal government? (Workers' comp, TANF, food stamps, WIC, Medicare, Medicaid, veterans' benefits, etc.)? Yes/No ______________________________________________
Dependents: __________
Obligations/Expenses/Debts: __________________________________________________________________________________________________________________________________
___ Suicidal or ___ Homicidal [SUICIDAL/HOMICIDAL]. See I-2-1-37. .
DESIGNATOR: _________________________ [HOCALJ, HOD, GS, ALJ] (Circle one)
DATE: _________________
ENTERED INTO HO DATA SYSTEM (date of designation, type of critical case)
CLAIM FILE FLAGGED AS CRITICAL CASE