TN 10 (12-11)

A. Description of Form SSA-1207-BK (Disability Hearing Officer’s Decision)

The DHO's decision (SSA-1207-BK or SSA-1207-BK-OP1) are documents of record for the disability hearing process. They contain the following crucial elements:

• a description of the issues addressed at the hearing;

• a description of new evidence presented (whether documentary or oral testimony by the claimant or other witnesses);

• findings of fact and the evidence used to make those findings;

• a determination of disability according to the evaluation process that applies to the type of claim involved using the findings of fact;

• a conclusion on the ultimate issue, e.g., whether the claimant continues to be disabled; and

• a conclusion on any related issues.

B. When to use Forms SSA-1207-BK or SSA-1207-BK-OP1

1. Use the following appropriate forms for writing the DHO's decision - SSA-1207-BK

Use the SSA-1207-BK for:

• all claims for disability insurance benefits (DIB),

• title II childhood disability benefits (CDB), and disabled widows(ers) benefits (DWB), including surviving divorced spouses, and

• disabled/blind individual (DI/BI) and disabled/blind spouse (DS/BS)-title XVI when the medical improvement review standard (MIRS) will be used.

The DHO will document the DHO decision in the “Analysis of Evidence and Findings of Fact” section of the SSA-1207-BK or SSA-1207-BK-OP1.

Use the SSA-1207-BK for:

If the decision is fully favorable, the DHO’s discussion of the evidence and rationale does not have to proceed past the point the claim is allowed.

2. SSA-1207-BK-OP1

Use the SSA-1207-BK-OP1 in cases where MIRS is not applicable, e.g., initial claims escalated to the reconsideration level, reconsiderations of adverse reopening, and Age 18 Redeterminations. (For cases where MIRS does not apply, see DI 28005.001D.2. For information on age 18 redetermination cases under P.L. 104-193, see DI 33025.075.)

NOTE: For Title XVI disabled or blind children, use form SSA-1209 (Disability Hearing Officer’s Decision, Title XVI Disabled Child (DC) Continuing Disability.

C. Procedure for completing the SSA-1207-BK and the SSA-1207-BK-OP1

1. General information for completing the SSA 1207-BK and SSA-1207-BK-OP1

Use the reverse side of each page of the paper forms or attach an additional sheet of paper if there is insufficient space for addressing a particular issue. Be sure to refer the reader to the location of a continuation. For example, if item 2 continues on the reverse side of the page, show “See reverse side of this page.” On the reverse side of the page, show “Continuation of item 2.”

For electronic forms where additional space is needed, continue text on the continuation page at end of forms SSA-1207-BK and SSA-1207-BK-OP1.

2. Include identifying information on the SSA-1207-BK and SSA-1207-BK-OP1

a. Complete initial entries on the SSA-1207-BK and SSA-1207-BK-OP1

Enter district office (DO), Disability Determination Service (DDS), and Disability Hearing Unit (DHU) code numbers in the upper-right-hand block of the SSA-1207-BK and SSA-1207-BK-OP1.

• Complete, as appropriate, the next entries that call for identifying information.

• Identify the reason for the cessation or reopening (e.g., claimant can do past relevant work), indicated on the cessation notice.

• For initial claims that escalate to the reconsideration level, show in the item on the reason for cessation or reopening, “Not applicable as this decision is based on the claim filed on (date)”. Identify those present at the hearing, e.g., claimant, representative, doctor, spouse, parent, etc.

b. Identify issues raised at the hearing

Fill in issues raised at the hearing necessary for a disability determination but which do not bear directly on the sequential or continuing disability review (CDR) evaluation process. Examples are:

• an allegation a later date of cessation;

• establishing a new period of disability by reason of a new intervening impairment;

• Drug Addiction/Alcoholism (DA/A) as a contributing factor.

c. Identify and describe documentary evidence submitted

Identify and describe any additional documentary evidence the claimant submitted, and provide a short, concise summary of the relevant facts the evidence shows.

d. Include Number Holder's (NH) SSN

Be sure to show the NH's SSN in the block at the top of page 2 as well as the blocks at the top of subsequent pages.

3. Document claimant's testimony

Based on the claimant’s testimony, provide a brief description of why the claimant believes he/she is disabled. Avoid writing, “Can't work.” Instead, attempt to explain the basis for the claimant's appeal. The following examples are guides for completing this section of the form:

• EXAMPLE 1

  Claimant says she has constant back pain that she describes as “agony.” She testified that she has problems with both legs including her knees and ankles. She says her legs give out and that she is unable to walk about half of the time. Sitting also causes pain. Claimant says she cannot use her left shoulder. She also has pain and burning and stomach trouble from two hernia repairs.

• EXAMPLE 2

  The claimant states that his disability is due to his heart condition and arthritis; but he also has breathing problems, allergies, and sinus problems. He wears a brace on his right knee all of the time and often wears a cervical collar. He has stiffness and a lot of pain. His ankles and knees give out and he has constant pain in his hands. His hands swell and get stiff. They get so stiff at times, that he is unable to button his shirt. Riding in a car bothers him a lot because of the vibration. In the last two months, his condition has worsened. Fluid builds up around his heart and he gets angina attacks. If he does anything much, he gets so hoarse he cannot talk.

4. Include witness testimony

Briefly identify and summarize the testimony of all witnesses. Use the “Disability Hearing Officer's Report of Disability Hearing” for guidance since the form contains a section for recording the testimony of witnesses. Use the following examples as a guide for completing this section of the form:

• EXAMPLE 1

  Mrs. X, the claimant's niece, testified that she is with the claimant every day. She cooks and cleans for the claimant. She says that the claimant is constantly in bed and taking medicine. Mrs. X believes it is impossible for the claimant to work. She has seen the claimant's legs give out.

• EXAMPLE 2

  Mrs. Y, the claimant's wife, states that her husband has trouble walking and getting up and down. He cannot sleep at night and cannot ride in a car. He gets nauseated and cannot eat. When he does eat, he has a problem opening his jaws. She does all the errands and all the work around the house because his pain is so bad. He used to be able to out walk anybody, but he cannot now. He cannot do anything anymore. He cannot even visit relatives. She knows he is sick because he would prefer working 2-3 jobs instead of not working any.

5. Analysis of evidence and findings of fact

NOTE: The first paragraph is pre-printed and states that we reviewed and considered all relevant evidence (in the claims folder and addressed at the hearing). This prompts the DHO to analyze the relevant evidence and make findings of fact based on his or her analysis of the evidence.

• Be sure this section contains all findings required for making your determinations in the SSA-1207-BK and SSA-1207-BK-OP1.

• State your findings of fact and cite the doctor's report(s) used in making the finding when there is no conflict or inconsistency in the medical evidence.

• If there is no conflict in the evidence, assess the vocational factors and state the finding. For example, “Claimant is 43 years old.”

• Explain how you resolved conflicts or inconsistencies in the evidence and how you reached your finding. For example, if two medical reports conflict as to the nature of the impairment, you must assess the reports for their probative value and make a finding on the nature of the impairment. You may also consider lay evidence such as a claimant's appearance and testimony and witness testimony when making the finding. Make sure you properly consider medical opinions according to DI 24503.025 and DI 24503.035.

• Explain how you considered evidence from medical sources, nonmedical sources, and DDS medical and psychological consultants about the nature and severity of an individual’s impairments. The DHO is not bound to agree with this evidence.

• Analyze and make a finding on any related issues indicated in the “Other Issues” portion of the decision.

Be sure to attach to the decision Form SSA-887, (Summary of Evidence). This is important because the Summary of Evidence and the documentary description of evidence the claimant submits at the hearing constitute relevant evidence used to make a decision.

6. Determination of Disability- Sequential Evaluation and Forms SSA-1207-BK and SSA-1207-BK-OP1

• Check the appropriate block in item 1.

  NOTE: This first review step of the sequential evaluation is pre-printed on both forms. The FO determines if the claimant is engaging in substantial gainful activity (SGA). The decision is not within the DHO's authority. However, if the FO determines that the claimant is engaging in SGA and needs a medical decision for possible establishment of an extended period of eligibility (EPE), the DHO is responsible for making the medical determination.

• Use the findings of fact made in the previous section of the decision form to complete the remaining items on the forms. Refer to a particular finding without restating it when appropriate.

• Complete only those items that are relevant to the claim(s). Mark N/A for items which do not apply.

• Remember, the regulations give the DHO authority to make binding decisions on whether the impairment(s) equals a listed impairment. However, since the assessment of a physician designated by the Commissioner on this issue must be part of the evidence in the claims folder, be sure it is included and evaluated.

• Share the physician’s assessment with the claimant per DI 33015.035 if, after considering the assessment, you decide that an unfavorable determination must be made.

• Make sure the evidence of record consists of a psychiatric review technique form (PRTF) that has been completed and signed by a medical consultant in all mental impairment cases.

7. Title XVI blindness cases

For Title XVI blindness cases, follow the CDR evaluation process in DI 28005.090.

Write the determination in the blank space under “Are there other issues relating to this determination” on page 8 of the SSA-1207-BK.

NOTE: If the determination is that the individual is not statutorily blind, make a determination using the pre-printed evaluation process on the form, because a visual impairment may not meet the statutory blindness definition, but may be disabling.

8. Other issues

To make a determination regarding any related issues that were raised, use the blank space under “Are there other issues relating to this determination” on page 8 of the SSA-1207-BK.

9. Conclusion

• Check the appropriate block. Make sure the individual meets insured status at the time any new period of disability is established. Before establishing a new period of disability in title II cases, make sure a new application is filed. Contact the FO and request the FO to secure a title II application on a priority basis if the claimant is establishing a new period of disability and a new application is not in the claims folder.

  NOTE: In title XVI cases, we do not need a new application to establish a new period of disability.

• If a new period of disability or a later cessation date is established, provide the basis for the conclusion in the “Analysis of Evidence and Findings of Fact” and the “Determination of Disability” sections. In the blank space provided, write your conclusions on any related issues addressed at the hearing.

• Sign the form.

• Prepare an

  • SSA-831-U3 (Disability Determination and Transmittal),

  • SSA-832-U3 (Cessation or Continuance of Title XVI) or

  • SSA-833-U3 (Cessation or Continuance of Disability or Blindness Determination and Transmittal)

D. Exhibits of the SSA 1207-BK and SSA 1207-BK-OP1

1. SSA-1207-BK

   To view this form, SSA-1207-BK, select View PDF.

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2. SSA-1207-BK-OP1

   To view this form, SSA-1207-BK-OP1, select View PDF.

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