Childhood Disability Evaluation Form

FMm Approved
OMB. No.

Sodal Security Adrnlnlslralon

CHILDHOOD DISABILITY EVALUATION FORM

1 Levd of detminatkn:

Name:

lnitlal

COR

Reconsideration

CDR Reconsideration

Is this child waging in SGA7

Date of Blrth:

Other
Yes

No

Filing Date:

I.SUMMARY
A. IMPAIRMENTS:

B, DISPOSITION: Check one enlq that best describes your flndlngs in thls case.Complete thls section last,
1-

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NOT SEVERE No medically detemtnabte impairment OR Impairment or combination of Impairments
is a slight abnormality w a comblnatlon of slight abnormallfles that results In no more than mlnimal functional
limitations. (Emlain below.)

Explanation:

.

(Cite complete Llsting and w bsection(s),

2-

MEETS USTING
induding any applicable 6 crlterla for 112.00.)

3.

M E D l W Y EQUALS LISTING
, ( C b complete Listing and
subsection(s), induding any applicable B wlterla for 112.00 and explaln below.)
Explanation:

4.

FUNCTIONALLY EQUALS THE LISTINGS -The chlld's Wically determinable impairment or canbination
of impairments results in marked limitations In two domains ar an e x t r m limitation in one domain (Explained in
W o n II M B ) , OR the Impairment or combinaUon of Impairmentsis one of the examples cited in POMS

(Explained in Sedlon Ill.)

Dl 25225.060 (20 CFR 416.928a(m)), example #
5,

IMPAIRMENT OR COMBINATION OF IMPAIRMENTS IS SEVERE, BUT DOES NOT MEET, MEDICALLY
EQUAL, OR FUNCTIONALLY EQUAL THE LISTINGS. (Explained in Section@) I1 A&B and, if applicable, Ill.)

6.

DOES NOT MEET THE DURATION REQUIREMENT f he chlld's mdicall debminable lmpalmaent(s) is at w&s
of lidlwp-leve
swerily,
l
but Is not expected to be, or was not, of listinglevdsevedtyfor 12 continuous months.
and is not expected to result In death. (Explained In Section(s) I I M B and, #applicable, Ill.)

7.

other (SW)

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Form 88ASSBa6 (I-MOI ) ef (162004)
Use Priw Edltbns

(Explained in Section Ill.)

C. ASSESSMENT OF FUNCTIONINGTHROUGHOUT SEQUENTIAL EVALUATION
t a r m . by slgnlng below, that when Ievaluated the chlld'r functbnlng In decldlng:
Ifthere is a sewn imp&mnt(s);
If the impairment($)meets or medically muds a lidkg (if the listing Includes functioning in its criteria); and
If the impairment(s) funclio&ly equals the listiqs;
I considered the fdlowlng factors and evidence.

FACTORS:

1. Haw ttre child's functioning compares to that of children the same age who do not have Impairments; La.,what the
chid is able to do, not able to do, or Is limlted or restricted In dolng,
2. Combined
of m a p i e impairments and the interactive and cumulative effects of an impairment@)on bhe
child's activities, considering that any acthrliy may iwoh the lntegratd use of many abilities. So,
A singte limitatation may be the result of one or more impairments, and
A single impairment may have effects in more than one domain.

3. How well the child pmforms activltles with respect to:
Initiating, sustaining, and completing activities independently (range of activities, prompting needed, pace of
performance, effort needed, and how long the child is able to sustain activities);
Extra help needed (e.g., personal, equipment, medidoris);
+

Adaptations (e.g., assfdve devices. appliances);
Structured or supportive M n g s (e.g., home, regdar or special dassroom), including comparison of functioning
In and outside of setting. omgoing signs or symptoms despite setting. amount of support needed to functlon
within regular setting.

4. ChlBd's fundonlng in unusual settings, (e.g., one-to-one, a CE) vs. routine settings (e.g., home, childcare, school).
5. Early interventionand s c h d programs (e-g., school records. comprehensivetesting, IEPs, class placement,
special education sewices, aocomn%xiations.attendance. participation).

8. Impact of chronic illness, charactetlzedby episodes of exacehation and remission, and how it interfereswith the
child's activities over time.
7. Effects of treatment, induding adverse and beneficial effectsof rnedikatians and other treatments, and if they
interfere with the child's day-today functioning.

EVIDENCE:
For all dispositions, wherever appropriate. I have explained how I considered the medical, early Intervention,
schoollpre-school, parenthregiver, and other relevant evidmx that s u m my findings, how Iweighed medical
opinion evidence, evaluated physical and mental symptwns, resolved any material incondstencles, and welghed
evidence when material inconsistenciesin the file could not be resolved. I have considered and explairwd test
results in the context of all the other widen-.
The consultant wlth overall responsibility for the findings In thls SSA-538 must complete the flmt signature
line (See Dl 25230.00104). If any addtttonal consultants provided Input to h s e findings, t h y must also sign
in the boxes following.

Consultant with overall responsiblllty (Sign, print name and specialty)

1 Date

Sign
Additional consultant signature (Sign, print name and specialty)

Sign

1 Date

~ext

Additional consultant signature (Sign, prlnt name and specialty)

Form SSA-5SF6 (1-2001) J (10-2004)

2

Date

II. FUNCTIONAL EQUIVALENCE
Consider functional equivalence when the chlld's medically determinable Impalrment(s) Is "severe"but does not meet or
medically equal a Ilsting. An Impalrment(s) functionally equals the IlsClngs If It results in "marked and severe functional
limitations,"i.e., the irnpalrment(s)causes "marked"Ilmltatlms In two domalns or an "extreme"llmlbtion In one domain.
FOR DEFINITIONS OF "MARKED" AND "EXTREME"see page 5.

Describe and evaluate the chlld's functlonlng In all domalns; see POMS Dl 25225.025.055 (20 CFR 418.Q26a(f)-(l)).
Then diswss the factors that apply In the child's case and how you evaluated the evidence as described in Section IC
above and in POMS Dl 25210.001ff. (20CFR 416.924a). Rate the Ilmlhtions that result f m the chlld's medically
determinable impaIrrnent(s1.
Check one box for each domain to indicate the degree of limitation assessed.

A.

DOMAIN EVALUATIONS

1. Acqulrlng and Using Information

No Limitation

Less Than Marked

Marked

Extreme

2. Attending and Completing Tasks

1
No Limitation

Less Than Marked

Marked

Extreme

3. Interdng and Relatlmg With Others

a No Limitation

Less Than Marked

- -

Marked

-

- - -

- - -

fl Extreme

Continued in !?dia~
Ill

A. DOMAIN EVALUATIONS (continued)
4. Moving About and Manipulating Objects

No Lirnitatlon

Less Than Marked

13 Marked

Extreme

Continued in Section Ill

5. Caring For Yourself

No Limitation

Less Than Marked

Marked

Extreme

6. Health and Physical Welt-Being
(Reminder - see additional defmitlons of

No Limitation

less Than Marked

Marked

Extreme

marked and extreme for thls domain on page 5 )

Continued in Sectim Ill

Form SSA-53BF6 (1 -20011 ef (10-2004)

4

B. CONCLUSION
Does the impairment or combination of impairments functionally equal the listings?

aYes - Marked limitation In twa domalns; findings explained in Sectlon IIA.
Marked limitation See POMS Dl 25225.020B (20 CFR 416.926a(e)(Z)).

The impairment(s) interferes seriously with the child's ability to independently initiate, sustain, or complete
domain-related activities. Day-to-day functioning may be seriously limited when the child's lmpairment(s) limits only
one activity or when the interactive and cumulative effects of the child's impairment(s) limit several activities.
"More than moderate" but "less than extreme" limitation (i.e., the equivalent of functioning we would expect to find
on standardized testing with scores that are at least two, but less than three, standard deviations below the
mean), or
Up to attainment of age 3, functioning at a level that is more than one-half but not more than two-thirds of the
child's chronological age when there are no standard scores from standardized tests in the case record, or
At any age, a valid score that is two standard deviations or more below the mean, but less than three standard
deviations, on a comprehensive standardized test designed to measure ability or functioning in that domain, and
the child's day-to-day functioning in domain-related activities is consistent with that score.
For the "Health and Physical Well-Being" domain, we may also find a "marked" limitation if the child is frequently ill
or has frequent exacerbations that result in significant, documented symptoms or signs. f o r purposes of this
domain, "frequent" means episodes of illness or exacerbations that occur on an average of 3 times a year, or once
every 4 months, each lasting 2 weeks or more. We may also find a "marked" limitation if the child has episodes that:
occur more often than 3 times in a year or once every 4 months but do not last for 2 weeks, or
occur tess often than an average of 3 times a year or once every 4 months but last longer #an 2 weeks,
ifthe overall effect (based on the length of the episode(s) or its frequency) is equivalent in severity.
Yes

-- Extreme limitation in one domain; findings explalned in Sectlon IIA.

Extreme limitation See POMS Dl 25225.020C (20CFR 416.926a(e)(3)).

The irnpairment(s) interferes very seriously with the child's ability to independently initiate, sustain, or complete
domain-related actlvities. Day-today functioning may be very seriously limited when the child's impairment(s) limits
only one activity or when the interactive and cumulative effects of the child's impairment(s) limit several activities.
"Extreme" describes the worst limitations, but does not necessarily mean a total tack or loss of ability to function.
"More than marked" limitation (i.e., the equivalent of the functioning we would expect to find on standardized
testing with scores that are at least three standard deviations below the mean), or
Up to attainment of age 3, functioning at a level that is one-half of the child's chronological age or less when there
are no standard scores from standardized tests in the case record, or
At any age, a valid score that is three standard deviations or more below the mean on a comprehensive
standardized test designed to measure ability or functioning in that domain, and the child's day-to-day functioning
in domain-related activities is consistent with that score.

For the "Health and Physical WellmBeingW
domain we may also find an "extreme" limitation if the child is ill or has
frequent exacerbations that result in significant, documented symptoms or signs substantially in excess of the
requirements for showing a "marked" limitation. However, if the child has episodes of illness or exacerbations of the
impairment(s) that we would rate as "extreme" under this definition, the impairment(s)should meet or medically equal
the requirements of a listing in most cases.

No

-- Findings explained in Section IIA.

Form SSA-538-F6 (I
-20011 ef (f 0-2004)

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Ill.EXPLANATION OF FINDINGS
Use this section:
To explain any functional equivalence "example" cited in disposition 4;
To explain dlsposltlon 7;
For any continued explanation of dispositions I , 3, 5, and 6, or functional equivalence findings that do not fit Into
Section II;
To discuss any relevant factors and evidence not explained elsewhere; e.g., how you weighed evidence when
material inconsistencies in the file could not be resolved;
At the discretion of the adjudicative team, to explain dlspositlon 2; to make clear other issues particular to individual
cases; to record all of the required elements of a rationale rather than on an SSA4268-U4JC4 per POMS D1
25235.001.

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Form SSA-538-F6 (7-2001) ef 110-2004)

6

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nRld scheduled reprinting:

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