Form HA-1152 Medical Source Statement of Ability to Do Work-Related A

SOCIAL SECURITY ADMINISTRATION
Removed Office Name

Form Approved
OMB No. 0960-0662

Revised Title

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

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NAME OF INDIVIDUAL

SOCIAL SECURITY NUMBER

INSTRUCTIONS:
Please assist us in determining this individual’s ability to do work-related activities on a sustained basis.
“Sustained basis” means the ability to perform work-related activities eight hours a day for five days a week,
or an equivalent work schedule. (SSR 96-8p). Please give us your professional opinion of what the individual
can still do despite his/her impairment(s). The opinion should be based on your findings with respect to medical
history, clinical and laboratory findings, diagnosis, prescribed treatment and response, and prognosis.
For each activity shown below, respond to the questions about the individual’s ability to perform the activity.
When doing so, use the following definitions for the rating terms:
•
•
•
•
•

None Mild limited.
Moderate Marked limited.
Extreme -

Able to function in this area independently, appropriately, effectively, and on a sustained basis.
Functioning in this area independently, appropriately, effectively, and on a sustained basis is slightly
Functioning in this area independently, appropriately, effectively, and on a sustained basis is fair.
Functioning in this area independently, appropriately, effectively, and on a sustained basis is seriously
Unable to function in this area independently, appropriately, effectively, and on a sustained basis.

IT IS VERY IMPORTANT TO DESCRIBE THE FACTORS THAT SUPPORT YOUR ASSESSMENT.
WE ARE REQUIRED TO CONSIDER THE EXTENT TO WHICH YOUR ASSESSMENT IS SUPPORTED.
(1) Is ability to understand, remember, and carry out instructions affected by the impairment?
No
If “no,” go to question #2. If “yes,” please check the appropriate block to describe the individual’s
restriction for the following work-related mental activities.
Understand and remember simple instructions.

None

Mild

Moderate

Marked

Yes

Extreme

Carry out simple instructions.
The ability to make judgments on
simple work-related decisions.
Understand and remember complex instructions.
Carry out complex instructions.
The ability to make judgments on
complex work-related decisions.
Identify the factors (e.g., the particular medical signs, laboratory findings, or other factors described above) that support
your assessment.

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FORM HA-1152-U3 (01-2017) ef (01-2017)
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(2) Is ability to interact appropriately with supervision, co-workers, and the public, as well
as respond to changes in the routine work setting, affected by impairments?
No
If “no,” go to question #3. If “yes,” please check the appropriate block to describe the individual’s
restriction for the following work-related mental activities.
None
Mild
Moderate
Marked
Interact appropriately with the public.

Yes
Extreme

Interact appropriately with supervisor(s).
Interact appropriately with co-workers.
Respond appropriately to usual work
situations and to changes in a routine
work setting.
Identify the factors (e.g., the particular medical signs, laboratory findings, or other factors described above) that support
your assessment.

(3) Are any other capabilities (such as the ability to concentrate, persist, or maintain pace and the ability to adapt or manage
oneself) affected by the impairment?
No
Yes
If “yes,” please identify the capability and describe how it is affected.

Identify the factors (e.g., the particular medical signs, laboratory findings, or other factors described above) that support
your assessment.

(4) 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 or psychological
probability as to past limitations, on what date were the limitations you found above first present?_______________
(5) If the claimant’s impairment(s) include alcohol and/or substance abuse, do these impairments contribute to any of the
claimant’s limitations as set forth above? If so, please identify and explain what changes you would make to your
answers if the claimant was totally abstinent from alcohol and/or substance use/abuse.

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FORM HA-1152-U3 (01-2017) ef (01-2017)
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(6) Can the individual manage benefits in his/her own best interest?

Signature

No

Yes

Date

Print Name, Title and Medical Specialty (Legibly Please)

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FORM HA-1152-U3 (01-2017) ef (01-2017)
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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-1152-U3 (01-2017) ef (01-2017)
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