Form HA-1151-BK Medical Source Statement of Ability to Do Work-Related A

SOCIAL SECURITY ADMINISTRATION

Revised Title

Removed Office Name

Form Approved
OMB No.0960-0662

MEDICAL STATEMENT OF
ABILITY TO DO WORK-RELATED ACTIVITIES (PHYSICAL)

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NAME OF INDIVIDUAL

SOCIAL SECURITY NUMBER

To determine this individual’s ability to do work-related activities on a regular and continuous basis, please give us your
opinion for each activity shown below:
The following terms are defined as:
•

REGULAR AND CONTINUOUS BASIS means 8 hours a day, for 5 days a week, or an equivalent work schedule.

•

OCCASIONALLY means very little to one-third of the time.

•

FREQUENTLY means from one-third to two-thirds of the time.

•

CONTINUOUSLY means more than two-thirds of the time.

Age and body habitus of the individual should not be considered in the assessment of limitations. It is
important that you relate particular medical or clinical findings to any assessed limitations in capacity: The
usefulness of your assessment depends on the extent to which you do this.
I.

LIFTING/CARRYING
Check the boxes representing the amount the individual can lift and how often it can be lifted.
Lift

Never

A. Up to 10 lbs:

Occasionally Frequently Continuously
(up to 1/3) (1/3 to 2/3) (over 2/3)

B. 11 to 20 lbs:
C. 21 to 50 lbs:
D. 51 to 100 lbs:

Check the boxes representing the amount the individual can carry and how often it can be carried.
Carry
A. Up to 10 lbs:

Never

Occasionally Frequently Continuously
(up to 1/3) (1/3 to 2/3) (over 2/3)

B. 11 to 20 lbs:
C. 21 to 50 lbs:
D. 51 to 100 lbs:
Identify the particular medical or clinical findings (i.e., physical exam findings, x-ray findings, laboratory test results,
history, and symptoms including pain, etc.) which support your assessment or any limitations and why the findings
support the assessment.

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FORM HA-1151-BK (04-2009) ef (01-2015)
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MEDICAL STATEMENT OF ABILITY TO DO WORK-RELATED ACTIVITIES (PHYSICAL)

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II. SITTING/STANDING/WALKING

Please check how many hours the individual can (if less than one hour, how many minutes):
At One Time without Interruption
Minutes
A. Sit

________

B. Stand

________

C. Walk

________

Hours
1

2

3

4

5

6

7

8

1

2

3

4

5

6

7

8

1

2

3

4

5

6

7

8

Total in an 8 hour work day
Minutes
A. Sit

________

B. Stand

________

C. Walk

________

Hours
1

2

3

4

5

6

7

8

1

2

3

4

5

6

7

8

1

2

3

4

5

6

7

8

If the total time for sitting, standing and walking does not equal or exceed 8 hours, what activity is the individual
performing for the rest of the 8 hours?

Does the individual require the use of a cane to ambulate?

Yes

No

If the answer is “yes” please answer the following:
•

How far can the individual ambulate without the use of a cane? ____________________________________________

•

Is the use of a cane medically necessary?

•

With a cane, can the individual use his/her free hand to carry small objects?

Yes

No
Yes

No

Identify the particular medical or clinical findings (i.e., physical exam findings, x-ray findings, laboratory test results,
history, and symptoms including pain, etc.) which support your assessment or any limitations and why the findings
support the assessment.

_______________________________________________________________________________________________________

FORM HA-1151-BK (04-2009) ef (01-2015)
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MEDICAL STATEMENT OF ABILITY TO DO WORK-RELATED ACTIVITIES (PHYSICAL)

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III. USE OF HANDS

Indicate how often the individual can perform the following activities:
ACTIVITY
REACHING
(Overhead)
REACHING
(All Other)
HANDLING

Right Hand
Never Occasionally Frequently Continuously
(up to 1/3) (1/3 to 2/3) (over 2/3)

Left Hand
Never Occasionally Frequently Continuously
(up to 1/3) (1/3 to 2/3) (over 2/3)

FINGERING
FEELING
PUSH/PULL

Which is the individual’s dominant hand?

Right Hand

Left Hand

Identify the particular medical or clinical findings (i.e., physical exam findings, x-ray findings, laboratory test results,
history, and symptoms including pain, etc.) which support your assessment or any limitations and why the findings
support the assessment.

IV. USE OF FEET
Indicate how often the individual can perform the following activities:
ACTIVITY
Operation of Foot
Controls

Right Foot
Never Occasionally Frequently Continuously
(up to 1/3) (1/3 to 2/3) (over 2/3)

Left Foot
Never Occasionally Frequently Continuously
(up to 1/3) (1/3 to 2/3) (over 2/3)

Identify the particular medical or clinical findings (i.e., physical exam findings, x-ray findings, laboratory test results,
history, and symptoms including pain, etc.) which support your assessment or any limitations and why the findings
support the assessment.

________________________________________________________________________________________________________

FORM HA-1151-BK (04-2009) ef (01-2015)
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MEDICAL STATEMENT OF ABILITY TO DO WORK-RELATED ACTIVITIES (PHYSICAL)

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V.

POSTURAL ACTIVITIES

How often can the individual perform the following activities?
ACTIVITY

Never

Climb stairs and ramps

Occasionally Frequently Continuously
(up to 1/3) (1/3 to 2/3) (over 2/3)

Climb ladders or scaffolds
Balance
Stoop
Kneel
Crouch
Crawl
Identify the particular medical or clinical findings (i.e., physical exam findings, x-ray findings, laboratory test results,
history, and symptoms including pain, etc.) which support your assessment or any limitations and why the findings
support the assessment.

VI. DO ANY OF THE IMPAIRMENTS AFFECT THE CLAIMANT’S HEARING OR VISION?
No

Yes

Not Evaluated

If “yes” please complete the following questions (where appropriate)
1.

If a hearing impairment is present,
a.
b.

2.

Does the individual retain the ability to hear and understand simple oral instructions and to communicate simple
information?
Yes
No
Can the individual use a telephone to communicate?
Yes
No

If a visual impairment is present,
a.

Is the individual able to avoid ordinary hazards in the workplace, such as boxes on the floor, doors ajar, or
approaching people or vehicles?
Yes
No

b.

Is the individual able to read very small print?

c.

Is the individual able to read ordinary newspaper or book print?

Yes

d.

Is the individual able to view a computer screen?

No

e.

Is the individual able to determine differences in shape and color of small objects such as
screws, nuts or bolts?
Yes
No

Yes

Yes

No
No

Identify the particular medical or clinical findings (i.e., physical exam findings, x-ray findings, laboratory test
results, history, and symptoms including pain, etc.) which support your assessment or any limitations and why the
findings support the assessment.

________________________________________________________________________________________________________

FORM HA-1151-BK (04-2009) ef (01-2015)
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MEDICAL STATEMENT OF ABILITY TO DO WORK-RELATED ACTIVITIES (PHYSICAL)

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VII. ENVIRONMENTAL LIMITATIONS

How often can the individual tolerate exposure to the following conditions?
Condition

Never

Unprotected
Heights
Moving
Mechanical
Parts
Operating a
motor vehicle
Humidity
and wetness
Dust, odors,
fumes and
pulmonary
irritants
Extreme cold
Extreme heat
Vibrations
Others:
(Identify)
Condition

Quiet
(Library)

Noise

Occasionally
(up to 1/3)

Moderate
(Office)

Frequently
(1/3 to 2/3)

Loud
(Heavy
Traffic)

Continuously
(over 2/3)

Very Loud
(Jackhammer)

Identify the particular medical or clinical findings (i.e., physical exam findings, x-ray findings, laboratory test results,
history, and symptoms including pain, etc.) which support your assessment or any limitations and why the findings
support the assessment.

________________________________________________________________________________________________________

FORM HA-1151-BK (04-2009) ef (01-2015)
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MEDICAL STATEMENT OF ABILITY TO DO WORK-RELATED ACTIVITIES (PHYSICAL)

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VIII. PLEASE PLACE A CHECK IN APPROPRIATE BOXES BASED SOLELY ON THE CLAIMANT’S PHYSICAL
IMPAIRMENTS
ACTIVITY
Can the individual perform activities like shopping?
Can the individual travel without a companion for
assistance?
Can the individual ambulate without using a wheelchair,
walker, or 2 canes or 2 crutches?
Can the individual walk a block at a reasonable pace on
rough or uneven surfaces?
Can the individual use standard public transportation?
Can the individual climb a few steps at a reasonable pace
with the use of a single hand rail?
Can the individual prepare a simple meal & feed
himself/herself?
Can the individual care for their personal hygiene?

YES

No

Can the individual sort, handle, or use paper/files?
Please identify the medical findings that support this assessment and why the finding support the assessment
(unless a narrative report is attached).

IX.

STATE ANY OTHER WORK-RELATED ACTIVITIES, WHICH ARE AFFECTED BY ANY IMPAIRMENTS,
AND INDICATE HOW THE ACTIVITIES ARE AFFECTED. WHAT ARE THE MEDICAL FINDINGS THAT
SUPPORT THIS ASSESSMENT?

X.

THE LIMITATIONS ABOVE ARE ASSUMED TO BE YOUR OPINION REGARDING CURRENT
LIMITATIONS ONLY.
HOWEVER, IF YOU HAVE SUFFICIENT INFORMATION TO FORM AN OPINION WITHIN A
REASONABLE DEGREE OF MEDICAL PROBABILITY AS TO PAST LIMITATIONS, ON WHAT DATE
WERE THE LIMITATIONS YOU FOUND ABOVE FIRST PRESENT? __________________

XI.

HAVE THE LIMITATIONS YOU FOUND ABOVE LASTED OR WILL THEY LAST FOR
12 CONSECUTIVE MONTHS?
Yes
No

SIGNATURE

DATE

Print Name, Title and Medical Specialty (Legibly Please)

________________________________________________________________________________________________________

FORM HA-1151-BK (04-2009) ef (01-2015)
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Revised PA and PRA Statements

Privacy Act Statement
Collection and Use of Personal Information
Sections 205(a), 702(a)(5), 223(d), 1614(a) and 1631(d) of the Social Security Act, as amended,
allow us to collect this information. Furnishing us this information is voluntary. However,
failing to provide all or part of the information may prevent us from making an accurate or
timely determination on the named patient’s claim for benefits.
We will use the information to make a determination on the named patient’s eligibility for
benefits. We may also share your information for the following purposes, called routine uses:
• To Federal, State, or local agencies (or agents on their behalf), for administering
income or health maintenance programs including programs under the Social
Security Act; and
• To student volunteers, individuals working under a personal services contract, and
other workers who technically do not have the status of Federal employees, when
they are performing work for us, as authorized by law, and they need access to
personally identifiable information in our records in order to perform their
assigned agency functions.
In addition, we may share this information in accordance with the Privacy Act and other Federal
laws. For example, where authorized, we may use and disclose this information in computer
matching programs, in which our records are compared with other records to establish or verify a
person’s eligibility for Federal benefit programs and for repayment of incorrect or delinquent
debts under these programs.
A list of additional routine uses is available in our Privacy Act System of Records Notice
(SORN) 60-0089, entitled Claims Folders System, as published in the Federal Register (FR) on
October 31, 2019, at 84 FR 58422. Additional information, and a full listing of all of our
SORNs, is available on our website at www.ssa.gov/privacy/.
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 15 minutes to read the instructions, gather the
facts, and answer the questions. SEND THE COMPLETED FORM TO YOUR LOCAL
SOCIAL SECURITY OFFICE or HEARING OFFICE. You can find your local Social
Security office through SSA’s website at www.socialsecurity.gov. Offices are also 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). You may send comments regarding this
burden estimate or any other aspect of this collection, including suggestions for reducing this
burden to: SSA, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating
to our time estimate or other aspects of this collection to this address, not the completed form.

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_ FORM HA-1151-BK (04-2009) ef (01-2015)

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