Schizophrenia Presumptive Disability Recommendation Form

OMB Control No. 0960-XXXX

Schizophrenia Presumptive Disability Recommendation Form
The claimant named below has filed for a period of disability and/or disability payments due to
schizophrenia or schizoaffective disorder. If you complete this form, the claimant may be able to receive
early payments. (This is not a request for an examination, but for existing medical information.)
Medical Release Information
Form SSA-827, “Authorization to Release Medical Information to the Social Security Administration,”
is attached.
I hereby authorize the medical source named below to release or disclose to the Social Security
Administration or State agency any medical records or other information regarding my treatment for
mental health/chemical dependency.
Claimant Signature (Required only if Form SSA-827 is NOT attached)

Date

Claimant Information
Name (Please Print)

Claimant’s SSN

Phone Number

Address

Date of Birth

Medical Source’s Name

For Presumptive Disability, the claimant’s condition must meet the criteria noted in Section 1 or
Section 2. Please check all applicable boxes.
Section 1 (Must meet criteria in Group A and Group B)
Group A

Group B

Medically documented persistence, either continuous
or intermittent, of one or more of the following:

Resulting in at least two of the following:

Delusions or hallucinations

Marked restriction of activities of daily living

Catatonic or other grossly disorganized behavior

Marked difficulties in maintaining social
functioning
Marked difficulties in maintaining concentration,
persistence, or pace
Repeated episodes of decompensation, each of
extended duration

Incoherence, loosening of associations, illogical
thinking, or poverty of content of speech if
associated with one of the following:
a. Blunt affect
b. Flat affect
c. Inappropriate affect
Emotional withdrawal and/or isolation

Section 2
Medically documented history of a chronic schizophrenic, paranoid, or other psychotic disorder of at least
2 years' duration that has caused more than a minimal limitation of ability to do basic work activities, with
symptoms or signs currently attenuated by medication or psychosocial support, and one of the following:
Repeated episodes of decompensation, each of extended duration; or
A residual disease process that has resulted in such marginal adjustment that even a minimal increase in mental
demands or change in the environment would be predicted to cause the individual to decompensate; or
Current history of 1 or more years' inability to function outside a highly supportive living arrangement, with an
indication of continued need for such an arrangement.

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Remarks: (Please use this space if you lack sufficient room in the above sections or to provide additional
information that you believe would support a presumptive disability finding.)

Diagnostic Certification (Required)
The claimant is capable of managing benefits.

The claimant is incapable of managing benefits.

The disturbance is not due to the direct physiological effects of substance use or a general medical
condition, or due to a psychiatric condition other than schizophrenia or schizoaffective disorder. Supporting
medical evidence will be forwarded to the disability adjudicative component.
I declare under penalty of perjury that I have examined all the information on this form, and any
accompanying statements or forms, and it is true and correct to the best of my knowledge. I understand
that anyone who knowingly gives a false or misleading statement about a material fact in this information,
or causes someone else to do so, commits a crime and may be sent to prison, or may face other penalties,
or both.
Physician or Licensed Psychologist Name (Please
Print)

License Number

Address

Phone Number

Signature

Date

Please provide all evidence necessary (i.e., medical records, psychiatric evaluation reports, list of
prescribed psychotropic medication, and so forth) to support a diagnosis of schizophrenia or
schizoaffective disorder.

Field Office Use Only
Meets Presumptive Disability Criteria:

YES

NO

Field Office Unit:

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SPECIAL TERMS USED IN THE FORM
WHAT WE MEAN BY “MARKED”
Where we use "marked" as a standard for measuring the degree of limitation, it means more than
moderate but less than extreme. A marked limitation may arise when several activities or functions are
impaired, or even when only one is impaired, as long as the degree of limitation is such as to interfere
seriously with the individual’s ability to function independently, appropriately, effectively, and on a
sustained basis.
WHAT WE MEAN BY “ACTIVITIES OF DAILY LIVING”
“Activities of daily living” include adaptive activities such as cleaning, shopping, cooking, taking public
transportation, paying bills, maintaining a residence, caring appropriately for your grooming and hygiene,
using telephones and directories, and using a post office. In the context of an overall situation, we assess
the quality of these activities by their independence, appropriateness, effectiveness, and sustainability. We
will determine the extent to which the individual is capable of initiating and participating in activities
independent of supervision or direction.
WHAT WE MEAN BY “SOCIAL FUNCTIONING”
“Social functioning” refers to the capacity to interact independently, appropriately, effectively, and on a
sustained basis with other individuals. Social functioning includes the ability to get along with others,
such as family members, friends, neighbors, grocery clerks, landlords, or bus drivers. The individual may
demonstrate impaired social functioning by, for example, a history of altercations, evictions, firings, fear
of strangers, avoidance of interpersonal relationships, or social isolation. The individual may exhibit

strength in social functioning by such things as his or her ability to initiate social contacts with
others, communicate clearly with others, or interact and actively participate in group activities.
We also need to consider cooperative behaviors, consideration for others, awareness of others'
feelings, and social maturity. Social functioning in work situations may involve interactions with
the public, responding appropriately to persons in authority (e.g., supervisors), or cooperative
behaviors involving coworkers.
WHAT WE MEAN BY “CONCENTRATION, PERSISTENCE OR PACE”
“Concentration, persistence or pace” refers to the ability to sustain focused attention and concentration
sufficiently long to permit the timely and appropriate completion of tasks commonly found in work
settings. Limitations in concentration, persistence, or pace are best observed in work settings, but may
also be reflected by limitations in other settings. In addition, major limitations in this area can often be
assessed through clinical examination or psychological testing. Wherever possible, however, a mental
status examination or psychological test data should be supplemented by other available evidence.
WHAT WE MEAN BY “REPEATED EPISODES OF DECOMPENSATION”
“Episodes of decompensation” are exacerbations or temporary increases in symptoms or signs
accompanied by a loss of adaptive functioning, as manifested by difficulties in performing activities of
daily living, maintaining social relationships, or maintaining concentration, persistence, or pace. Episodes
of decompensation may be demonstrated by an exacerbation in symptoms or signs that would ordinarily
require increased treatment or a less stressful situation (or a combination of the two). Episodes of
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decompensation may be inferred from medical records showing significant alteration in medication; or
documentation of the need for a more structured psychological support system (e.g., hospitalizations,
placement in a halfway house, or a highly structured and directing household); or other relevant
information in the record about the existence, severity, and duration of the episode.
The term “repeated episodes of decompensation, each of extended duration” means three episodes within
1 year, or an average of once every 4 months, each lasting for at least 2 weeks. If the individual
experiences more frequent episodes of shorter duration or less frequent episodes of longer duration, we
use judgment to determine if the duration and functional effects of the episodes are of equal severity.
[Comment: Although this reflects what the regulations state in section 12.00C.4 of the Listings, the
statement probably isn’t particularly helpful to a medical source. You should translate it into something
that the source can provide evidence on, such as by adding a sentence that says “You should also let us
know if the individual’s episodes do not last for 2 weeks, but occur substantially more frequently than 3
times in a year or once every 4 months, or if they occur less often than an average of 3 times a year or
once every 4 months, but last substantially longer than 2 weeks.” This language reflects what is on the
HIV PD form under the definition of “repeated.”]
WHAT WE MEAN BY “BASIC WORK ACTIVITIES”
“Basic work activities” are the abilities and aptitudes necessary to do most jobs. Examples include: (1)
physical functions such as walking, standing, sitting, lifting, pushing, pulling, reaching, carrying, or
handling; (2) capacities for seeing, hearing, and speaking; (3) understanding, carrying out, and
remembering simple instructions; (4) use of judgment; (5) responding appropriately to supervision,
coworkers, and usual work situations; and (6) dealing with changes in a routine work setting.
WHAT WE MEAN BY “MINIMAL LIMITATION OF ABILITY TO DO BASIC WORK
ACTIVITIES”
A limitation is minimal if the impairment (or combination of impairments) has such a minimal effect on
the individual that it would not be expected to interfere significantly with the individual’s ability to do
basic work activities.

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Schizophrenia Presumptive Disability Recommendation Form
Schizophrenia Presumptive Disability Recommendation Form
Privacy Act Statement
Collection and Use of Personal Information
Section 1110(b)(1) [42 U.S.C. § 1310(b)(1)] and 1631(a)(4)(B) [42 U.S.C. § 1383(a)(4)(B)] of the Social
Security Act and 20 C.F.R. 416.933 authorize us to collect this information.
We will use the information you provide to make a determination on your, disability claim.
The information you furnish on this form is voluntary. However, failure to provide the requested
information could prevent an accurate or timely decision on your disability claim or on the named
individual’s disability claim.
We rarely use the information you provide on this consent form for any purpose other than for the reasons
explained above. We also may disclose information to another person or to another agency in accordance
with approved routine uses, which include but are not limited to the following:
1.

To a congressional office in response to an inquiry from that office made at the request of the
subject of a record.

2. To enable a third party or an agency to assist Social Security in establishing rights to Social
Security benefits and/or coverage;
3.

To comply with Federal laws requiring the release of information from Social Security records to
other agencies (e.g., to the Government Accountability Office, General Services Administration,
National Archives Records Administration, and the Department of Veterans Affairs); and

4. To facilitate statistical research, audit, or investigative activities necessary to assure the
integrity and improvement of our programs (e.g., to the U.S. Census Bureau and to
private entities under contract with us).
A complete list of routine uses for this information is available in our System of Records Notice entitled,
Disability Insurance and Supplemental Security Income Demonstration Projects and Experiments System,
60-0218. This notice, additional information regarding this form, and information regarding our
programs and systems, are available on-line at www.socialsecurity.gov or at any Social Security office.

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 (OMB) control number. The OMB control number for this
information collection is 0960-XXXX. We estimate that it will take about 10 minutes to review this
form, learn the facts about this new program, and ask any questions you may have. You may send
comments on our time estimate above to: Social Security Administration, 6401 Security Blvd, Baltimore,
MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed
form.

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