Form SSA-1205-BK Disability Hearing Officer's Report of Disability Hearin

Form Approved
OMB NO. 0960-0440

DHU Code Number

DISABILITY HEARING OFFICER'S REPORT OF DISABILITY HEARING

Paperwork/Privacy Act Notice: The Social Security Administration is authorized to collect the information on this form under Section 205(a), 1631 (e)(1)(A) and (B),
and 1872 of the Social Security Act, as amended (42 U.S.C. 405, 1383, and 1395ii). Giving us this information is mandatory.
The information on this form will aid Disability Hearings Officers in conducting hearings and in preparing disability decisions. It will be made a part of the claims folder
and be subject to its rules concerning disclosure.
We may also use the information you give us when we match records by computer. Matching programs compare our records with those of other Federal, State, or local
government agencies. Many agencies may use matching programs to find or prove that a person qualifies for benefits paid by the Federal government. The law allows us
to do this even if you do not agree to it. Explanations about these and other reasons why information you provide us may be used or given out are available in Social
Security offices. If you want to learn more about this, contact any Social Security office.

See Revised PRA, Attached

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by Section 2 of the Paperwork Reduction
Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take about
60 minutes to read the instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL
SECURITY OFFICE. To find the nearest office, call 1-800-772-1213. Send only comments on our time estimate above to: SSA, 6401 Security Blvd., Baltimore, MD
21235-6401.

1.

I. IDENTIFYING INFORMATION
CLAIMANT'S NAME (Enter any changes in address/telephone number)

2.

NUMBER HOLDER'S NAME (If different from claimant)

3. NUMBER HOLDER'S SOCIAL SECURITY NUMBER

-

II. BACKGROUND INFORMATION
Yes
1. FILE REVIEWED BY CLAIMANT/REPRESENTATIVE

-

No

(If no, explain)
2.

HEARING PLACE

3.

HEARING DATE/TIME HEARING BEGAN

4.

PRESENT AT HEARING WERE:

5.

MONTH/YEAR OF CESSATION

6.

REASON FOR DETERMINATION UNDER APPEAL

8.

BASIS FOR CPD

7.

DATE OF COMPARISON POINT
DECISION (CPD)

9.

CLAIMANT'S BIRTHDATE

10. TYPE OF CLAIM(S)
TITLE II
DIB

AGE

DWB

HEIGHT

WEIGHT

TITLE XVI

CDB

Disability

Yes

11. ABILITY TO READ/WRITE/SPEAK/UNDERSTAND ENGLISH

EDUCATION

Blind

No (If no, explain)

III. ISSUES
The basic issue to be determined is whether the claimant is disabled/blind under the definition of disability/blindness contained in
sections 223 (d) and 1614 (a) of the Social Security Act, taking into account, when applicable, the standard of review for termination of
disability benefits contained in sections 223 (f) and 1614 (a)(4) of the Social Security Act.

1.

Other issues (new claim, EPE, 301 etc.):

2.

Additional evidence submitted:

Form SSA-1205-BK (6-1992) ef (05-2006)
Destroy prior editions

1.

(over)

3.

Identify CPD impairment(s) and describe any changes, including new impairments:

Form SSA-1205-BK (6-1992) ef (05-2006)

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4.

Impairment(s) which prevents claimant from working. Describe limitations:

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CLAIMANT'S STATEMENTS OF MEDICAL INFORMATION
(Review sources/treatment/impairment with claimant)

5.

Claimant's comments on previously submitted medical evidence:

6. List any other doctors' reports, hospitalizations, and surgeries (performed and/or recommended) not contained in
the claims file and which relate to the claimant's alleged disability; include claimant's explanation (if any) of why
this evidence indicates no improvement and/or current disability:

7. Claimant's medication (type, prescribed dosage, reason for usage, frequency of use): Explain any changes in
medication since the CPD: Effects/results of medication (including side effects, if any):

8.

Other prescribed treatments/restrictions (therapy, inhalants, diet, elastic stockings, bed rest, bypass surgery,
prosthesis, etc.) since the CPD: Effects/results of other treatments (including side effects, if any):

Form SSA-1205-BK (6-1992) ef (05-2006)

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CLAIMANT'S STATEMENT OF PAIN OR OTHER SYMPTOMS
(complete only if symptoms are an issue)

9. Describe location of pain; activity causing pain; type (sharp, dull); day/night; frequency and duration; radiation;
relieved by. Explain any changes relating to pain or other symptoms since the CPD:

CLAIMANT'S STATEMENT OF DAILY ACTIVITIES
10. Describe living arrangements (i.e., lives alone, type of housing, etc.)
Describe any changes since the CPD:

11. How does the claimant spend his/ her time during a typical day/week (household responsibilities, hobbies, social
activities, exercises, etc.)? Describe any changes since the CPD.

Form SSA-1205-BK (6-1992) ef (05-2006)

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12.

Explain how condition affects claimant's ability to perform household or other activities. Describe any changes
or modifications since the CPD:

13.

Does claimant drive? If so, length and frequency of trips. If not, explain. If claimant uses other means of
transportation, list type and frequency. Describe changes since the CPD:

14.

How often does claimant shop, for what, alone or with help (is help required or just for company)? Describe
and include any changes since the CPD:

15.

Sleeping habits (Describe any changes since the CPD):

Form SSA-1205-BK (6-1992) ef (05-2006)

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CLAIMANT'S STATEMENTS OF LIMITATIONS

16.

Limited in:

YES

NO

YES

Walking

Seeing

Standing

Hearing

Sitting

Speaking

Lifting/Carrying

Climbing

Bending

Balancing

Reaching

Stooping

NO

Kneeling
Feeling or
Manipulation of
Objects

Crouching
Crawling

If any of the above items are checked ''Yes'', describe the limitation(s) below:
Describe any changes since the CPD:

17. Note any problems with surroundings, e.g., dust, fumes, noise, stress inherent to job duties, and describe
changes since the CPD:

CLAIMANT'S STATEMENTS OF MENTAL LIMITATIONS
18. Briefly describe any difficulty understanding, remembering, concentrating, persisting at tasks and/or completing
them timely, following instructions, relating to others, or tolerating increased stress and/or mental demands such
as those which might be expected in a work situation or to complete household or other tasks. Explain any
changes in these capacities since the CPD:

Form SSA-1205-BK (6-1992) ef (05-2006)

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SUPPLEMENTAL VOCATIONAL INFORMATION
19.

Review and verify relevant vocational history and describe any inconsistencies:

20.

Has claimant looked for work since the CPD?

YES

NO

Explain:

21.

Claimant's explanation of why impairment(s) continues to prevent performance of past or other work:

22.

Has claimant had any education, training or involvement with vocational rehabilitation (VR) since the
NO
YES
CPD?
(Include any education, training or VR the claimant received, is receiving, or plans to receive.)
Explain:

Form SSA-1205-BK (6-1992) ef (05-2006)

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WITNESS STATEMENT
23.

A.1. NAME

A.2. RELATIONSHIP TO CLAIMANT

A.3.

Excluded
(check)

A.4.

Why does witness think the claimant hasn't improved since the CPD or can't work? Basis for this
opinion is (personal observation, what claimant has said, etc.):

B.1. NAME

B.2. RELATIONSHIP TO CLAIMANT

B.3.

Excluded
(check)

B.4.

Why does witness think the claimant hasn't improved since the CPD or can't work? Basis for this
opinion is (personal observation, what claimant has said, etc.):

Form SSA-1205-BK (6-1992) ef (05-2006)

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24.

CLOSING STATEMENT (for additional space, use continuation sheet):

25.

DISABILITY HEARING OFFICER'S OBSERVATION OF THE CLAIMANT AND NOTES
Check each item to indicate if any difficulty observed:
YES

YES

NO

Breathing

Reading

Seeing

Comprehending

Speaking

Responding

Hearing

Concentrating

Sitting

Remembering

Walking

Relating to people

Standing

Unusual behavior

Use of hands
or arms

Deformities
Other (specify)

Writing
If any of the above items are checked "yes," describe the exact difficulty involved:

Form SSA-1205-BK (6-1992) ef (05-2006)

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NO

Disability hearing Officer's Notes:
26.

DATE/TIME

DISABILITY HEARING OFFICER'S SIGNATURE

Form SSA-1205-BK (6-1992) ef (05-2006)

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CONTINUATION SHEET

Form SSA-1205-BK (6-1992) ef (05-2006)

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The following revised PRA Statement will be inserted into the form at its
next scheduled reprinting:
Paperwork Reduction Act Statement - This information collection meets the
requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction
Act of 1995. You do not need to answer these questions unless we display a valid Office
of Management and Budget control number. We estimate that it will take about 60
minutes to read the instructions, gather the facts, and answer the questions. SEND OR
BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY
OFFICE. The office is listed under U. S. Government agencies in your telephone
directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778).
Send only comments relating to our time estimate above to: SSA, 6401 Security Blvd,
Baltimore, MD 21235-6401.