TN 5 (10-91)

Citations:

20 CFR 404.1545-1546 and 416.945-946;

SSR 82-52; SSR 82-53; SSR 85-16;

SSR 85-28; SSR 86-8; and SSR 88-13.

A. Policy principle

1. Definition

The RFC assessment:

• is based primarily on medical evidence but may also include observation or description of limitations (e.g., lay evidence, including the claimant's statement);

• describes what an individual is able to do, despite functional limitations resulting from a medically determinable impairment(s) and impairment-related symptoms; and

• is an administrative determination of an individual's capacity to perform work-related physical and mental activities.

2. When required

An RFC assessment is required:

1. in all disability determinations where:

   • a medical decision is necessary; and

   • the individual has a severe impairment or multiple not severe impairments which in combination are severe; and

   • the impairment does not meet or equal the Listing of Impairments; and

   • a determination of ability to perform substantial gainful activity (SGA) is required (i.e., title II disability insurance benefits (DIB) and childhood disability benefits (CDB) claims; title II disabled widows, widowers and surviving divorced spouses (DWB); title XVI disabled individual/disabled spouse (DI/DS) claims); or claims for months of entitlement;) title XVI disabled individual/disabled spouse (DI/DS) claims); or

   • an otherwise not severe impairment(s) precludes past relevant work (because of the unique features of the work).

2. at each adjudicative level (when criteria in A.2.a. above are met). Since a claimant is entitled to a new determination at each decisionmaking level, a new RFC assessment must be made, independent of prior RFC assessments.

   NOTE: When assessing RFC, the disability hearing officer (DHO), administrative law judge (ALJ), and Appeals Council (AC) will consider the State agency medical consultant's RFC assessment (or the RFC assessment of any other physician designated by the Secretary). While not binding, the RFC assessment(s) constitutes opinion evidence.

3. Content

1. Describes work-related functions a person can do on a sustained basis.

2. Addresses all functional capabilities and provides a written analysis of how the evidence in file supports or refutes the following:

   • claimant allegations (including allegations of symptoms, such as pain, and their effects on functioning).

   • descriptions, observations, and all conclusions of all treating and examining sources.

   • other pertinent medical and nonmedical evidence.

3. Resolves all issues of functional capacity pertinent to a determination of ability to do past relevant work or other work.

4. Provides conclusions as to functional capabilities (with a citation of pertinent evidence) and the reasoning to support these findings.

B. Operating policy

1. Forms

1. Physical Impairment - SSA-4734-U8. See DI 24510.055.

2. Mental Impairment - SSA-4734-F4-SUP. See DI 24510.090.

3. Physical and Mental Impairment - SSA-4734-U8 and SSA-4734-F4-SUP.

2. Location in folder

RFC assessment forms are a permanent part of the disability record and are filed on the left side of the folder, under the SSA-831-U5, SSA-832-U5, or SSA-833-U5.

3. Court actions

Local modifications of these instructions may be required by court orders.

C. References

1. Evidence

See DI 24503.005 for categories of evidence

2. RFC assessment in CDRs

See DI 28015.005 for sequential analysis issues relating to RFC assessment in CDRs.

3. Vocational glossary

See DI 25001.001 for definition of terms used in medical-vocational evaluation.