Exhibit_2.docx

ESSENTIAL ELEMENTS OF

CONSULTATIVE EXAMINATION

The complete requirements for an evaluation of disability under the RR Act can be found in 20 Code of Federal Regulations (CFR), Employees’ Benefits, §220 – Appendix 1, Listing of Impairments Part A and Appendix 3, Railroad Retirement Board Occupational Disability Standards.

Disability rating decisions rendered by the RRB must follow the documentation requirements as defined in the RR Act. Therefore, it is important to note that objective findings must be provided and testing performed in accordance with the documentation requirements provided. Substitution of other testing methods or documentation standards, regardless of their accuracy, cannot be used.

All consultative examinations should provide the general information requested in Section C3 (b) including the residual functional capacity forms as found in Exhibits 4 and 5. Specific information based on type of examination (e.g., orthopedic, internal medicine, dermatology, neurology, psychiatric, etc.) is required as identified in the following protocols. In addition, a worksheet to record the physical findings should be completed for orthopedic, internal medicine with orthopedic involvement and neurological examinations.

INTERNAL MEDICINE

INSTRUCTIONS FOR INTERNAL MEDICINE EXAMINATION (EXAM 018)

The following information is required in all internal medical examinations. Refer also to the instructions that pertain to the particular impairment alleged. For example, if a claimant suffers from a respiratory and a digestive impairment, the instructions for a respiratory and a digestive examination should also be followed.

The following specific information is required:

1. The detail and format for reporting the results of the history, physical examination, laboratory findings, and discussion of conclusions should follow the standard reporting principles for a complete and competent medical examination. (Pelvic examinations should not be performed unless specifically authorized by the RRB.)

2. Both positive and negative detailed findings based on the information provided by the RRB and the claimant in the history, from the examination and ancillary tests and from the background information (if provided), must be provided as they relate to the major complaint(s). Any other abnormalities found during the examination and ancillary tests must also be included. An omission of a specific finding will not be interpreted as a negative or normal finding.

3. The claimant’s major or chief complaints and their history should be presented in detail.

4. A description of the individual’s general appearance, nutrition, and pertinent actions during the examination should be included.

5. The vital signs should include the blood pressure, pulse rate, respiratory rate, and height and weight without shoes. (If the spinal curvature distorts height, substitute arm span.)

RESPIRATORY SYSTEM

INSTRUCTIONS FOR RESPIRATORY EXAMINATION

In addition to the requirements for a general internal medical examination, the following specific information should be provided:

1. Evaluation of episodic disorders, (e.g., asthma), requires details with regard to onset, frequency, duration of attacks, mode of treatment and response to therapy. History of attacks requiring hospital admissions and their frequency should also be obtained.

2. The claimant's employment history should be taken to evaluate possible pneumoconiosis or exposure to physical irritants.

3. Dyspnea should be described with respect to dates (and mode) of onset, seasonal influence, influence of infection and precipitating activities, whether it is associated with palpitations, wheezing, chest pain, or hyperventilation symptoms. Respiratory dyspnea should be differentiated from cardiac dyspnea.

4. The occurrence of cough, labored breathing, use of accessory muscles of respiration, audible wheezing, pallor, cyanosis, hoarseness, clubbing of fingers, or the presence of chest wall deformity should be noted. The diameter of the chest on inspiration and expiration should be noted. A specific annotation should be made as to whether the expiratory phase of respiration is prolonged. The breath sounds should be described.

5. The presence or absence of adventitious sounds on auscultation of the chest should be noted and described.

6. If based on the clinical data a chronic respiratory disorder affecting ventilatory function is suspected, and ventilatory function studies were not scheduled, contact the authorized orderer for approval to administer the studies. The protocols provided in Exhibit 3 must be obtained and followed.

7. If the claimant has Fibrosis and/or Restrictive Lung Disease, but a DLCO and/or arterial blood gas study was not scheduled and you feel that it is necessary, notate this in the report.

8. For cases of cor pulmonale, inquiry should be made as to whether the claimant also has a history of heart disease, has experienced paroxysmal nocturnal dyspnea or orthopnea and whether there has been associated peripheral edema, hypertension, past myocardial infarction, angina, rheumatic heart disease, cardiac murmur, etc. Distention of neck veins and ankle edema should also be described, if present.

CARDIOVASCULAR SYSTEM

INSTRUCTIONS FOR CARDIOVASCULAR EXAMINATION

In addition to the requirements for a general internal medical examination, the following specific information should be provided:

1. Chest pain, if present, should be fully described in the claimant's own words with respect to character, location, radiation, frequency, duration, precipitating factors, relieving factors and associated symptoms.

2. If the claimant has undergone an exercise stress test, inquire as to the location, date and result, and include in report.

3. Provide a detailed description of the examination of the heart, including comment on the heart sounds and rhythm, any jugular vein distention (including angle of reclining at which distention occurs), abnormal adventitious lung sounds, hepatomegaly, or peripheral edema. Findings on funduscopic examination must be reported. Describe any evidence of cerebral involvement or other end-organ complications.

4. Where the primary issue is congestive heart failure, the history of heart disease must include discussion of the known factors in the development of the cardiac condition (e.g., myocardial infarction, rheumatic heart disease, and hypertension). Include pertinent symptoms such as dyspnea, including level of exertion at which dyspnea occurs, orthopnea, and paroxysmal nocturnal dyspnea.

5. Participation in a cardiac rehabilitation program should be noted. The impact of the chest pain, dyspnea or other cardiac symptoms on daily activities should be specifically described.

6. Describe any intermittent claudication and the level of exertion at which it occurs. Provide quantified leg pulses. If intermittent claudication is present and pulses are abnormal and peripheral doppler studies were not scheduled, contact the authorized orderer for approval to administer the studies. The protocol provided in Exhibit 3 must be obtained and followed.

7. Describe any signs of venous insufficiency such as brawny edema, stasis dermatitis, ulceration and/or results of tests such as the Trendelenburg.

DIGESTIVE SYSTEM

INSTRUCTIONS FOR DIGESTIVE SYSTEM EXAMINATION

In addition to the requirements for a general internal medical examination, the following specific information should be provided:

1. A detailed description of the symptoms alleged, including a description of past and present symptoms with dates and severity (i.e., weight loss, pain, hemorrhage, jaundice, anorexia, nausea, vomiting, diarrhea, weakness, arthritis, iritis, fever).

2. Provide date(s) and reason(s) for any hospitalization as well as present treatment.

3. Presence of fistulae or external diversionary procedures and present condition (i.e., discharge, odor, prolapse, etc.) with duration and severity.

GENITO-URINARY SYSTEM

INSTRUCTIONS FOR GENITO-URINARY EXAMINATION

In addition to the requirements for a general internal medical examination, the following specific information should be provided:

1. Description of past and present symptoms of impairment of renal function such as bone pain, intractable pruritus, anorexia and weight loss. Obtain detailed history as to cause of renal failure and past and present modes of therapy received.

2. Positive and relevant negative findings (i.e., edema, evidence of pruritus, congestive heart failure, malnutrition, neuropathy, or others).

HEMIC AND LYMPHATIC SYSTEM

INSTRUCTIONS FOR HEMIC AND LYMPHATIC EXAMINATION

In addition to the requirements for a general internal medical examination, the following specific information should be provided:

1. A detailed description of the individual's statement of the current complaints (i.e., anemia, bleeding tendencies, recurrent infections, bone pain, chemotherapy).

2. Present significant occurrences, including changes in the status of those complaints over time, hospitalizations and treatment. Provide a detailed description of those factors which increase the problem and those which may provide relief. Pertinent descriptive statements of the claimant, such as a description of weakness, lassitude, excessive bleeding, etc., should be recorded.

3. Describe any pallor, noted not only on the skin but also in the mucous membranes (e.g. conjunctiva, buccal mucosa). Abdominal findings should include the presence or absence of splenomegaly. If sickle cell disease is present, include findings of joint swelling and/or deformity as well as splenomegaly. If the claimant has leukemia, describe symptoms such as bone pain and obtain a detailed history pertaining to blood transfusions, spontaneous hemorrhages, recurrent systemic bacterial infections and modes of therapy received such as bone marrow transplant and /or chemotherapy.

4. Physical examination should include status of lymph nodes and spleen.

ENDOCRINE SYSTEM

INSTRUCTIONS FOR ENDOCRINE SYSTEM EXAMINATION

In addition to the requirements for a general internal medical examination, the following specific information should be provided:

1. A description of symptoms of thyroid and parathyroid dysfunction. (i.e., weakness, weight loss, neuropathy, tetany, syncope, progressive exophthalmos, etc.). Describe the duration, frequency and severity of the symptoms. Also, provide detailed information regarding the treatment given including the type and dosage of medication, the response to the treatment, and any adverse side effects from the treatment.

2. A description of symptoms related to diabetes (i.e., weakness, excessive hunger or thirst, polyuria, etc.). Describe any end organ involvement to the eyes, heart, kidney and brain. Include details regarding, but not limited to:

a. Occular disorders

b. Neuropathy, disturbances of gait and station, fine and gross movements, atrophy,

c. Peripheral vascular findings and intermittent claudication

d. Renal failure

A history and frequency of hospitalizations for ketoacidosis, should be included.

IMMUNE SYSTEM

INSTRUCTIONS FOR IMMUNE SYSTEM EXAMINATION

In addition to the requirements for a general internal medical examination, specific information should be provided as listed in Exhibit 2 based on the body system(s) that has been affected by the immune system deficiency. For example, if the deficiency has affected the respiratory and digestive systems, the specific information requested in Exhibit 2 for a respiratory examination and a digestive examination should be provided.

NEOPLASTIC DISEASES, MALIGNANT

INSTRUCTIONS FOR NEOPLASTIC DISEASES EXAMINATION

In addition to the requirements for a general internal medical examination, the following specific information should be provided:

1. Description of the claimant's present symptoms, i.e., general weakness, weight loss, nausea, vomiting, diarrhea, dermatologic disorders and any symptom of a mental disorder.

2. Date(s) and reason(s) for past hospitalization(s), especially related to the neoplastic disease condition.

3. Treatment given, i.e., surgery, radiotherapy, chemotherapy, hormonal therapy, etc., with dates, and any residual local or distant metastasis.

4. Response to therapy.

5. Side effects of therapy.

6. Other relevant history.

7. In addition, describe any significant post-therapeutic residuals.

8. Describe status of any external diversionary stomas present.

MUSCULOSKELETAL SYSTEM

INSTRUCTIONS FOR ORTHOPEDIC EXAMINATION (EXAM 016 AND 116)

Note: When examination number 016 is ordered by the RRB, it is preferred that the examination be done by an orthopedic specialist. For examination number 116 orders, the examination must be done by an orthopedic specialist.

The following specific information is required:

1. The detail and format for reporting the results of the history, physical examination, laboratory findings, and discussion of conclusions should follow the standard reporting principles for a complete and competent medical examination.

2. Both positive and negative detailed findings based on the information provided by the RRB and the claimant in the history, from the examination and ancillary tests and from the background information (if provided), must be provided as they relate to the major complaint(s). Any other abnormalities found during the examination and ancillary tests must also be included. An omission of a specific finding will not be interpreted as a negative or normal finding.

3. The claimant’s major or chief complaints and their history should be presented in detail.

4. A statement concerning the claimant’s general appearance and nutrition, and any apparent musculoskeletal abnormalities or loss of function should be provided.

5. The vital signs should include the blood pressure, pulse rate, respiratory rate, and height and weight without shoes. (If the spinal curvature distorts height, substitute arm span.)

6. The gait and station must be described in detail. Provide a description of the claimant’s ability to tandem walk, walk on heels and toes, hop, bend, squat, arise from squatting position, dress and undress, get up from a chair, get on and off the examining table, and generally cooperate during the examination.

7. If an ambulatory aide is used, indicate if it is a medical necessity, and provide the medical reason for its necessity (e.g., 2/5 muscle strength of both lower extremities). Also describe the claimant’s ability (or inability) to ambulate effectively with and without the ambulatory aide.

8. In amputation cases, comment on the stump, any stump complications and the ability to use a prosthesis effectively. If an orthotic device is used, describe the claimant’s ability to walk with the device in place. If the claimant has difficulties with the device, provide the medical basis for the difficulty and describe the ability to ambulate without the device.

9. Range of motion in all joints and the spine must be reported in degrees. Joints with no limitation should be identified. Measurement of joint motion should be based on the techniques described in the chapter on extremities, spine and pelvis in the current edition of the “Guides to the Evaluation of Permanent Impairment” published by the American Medical Association.

10. Include a straight leg-raising test from both the sitting and supine positions.

11. Describe the presence or absence of paravertebral muscle spasms and/or tenderness.

12. Include detailed comments on any joint abnormalities such as heat, redness, swelling, ankylosis, contractures and subluxation. If not present, so state.

13. Give detailed motor, sensory and reflex findings. Motor function should be provided on a grading system of 0 to 5, with 0 being complete loss of strength and 5 being maximum strength. The report should also describe to what degree motor function is inhibited by spasticity, rigidity, or pain. When sensory deficit is reported, the specific distribution of these findings must be described. Deep tendon reflexes should be described as to intensity and symmetry.

14. Muscle bulk should be described, and when there is asymmetry, specific measurements must be reported. Atrophy must be reported in terms of circumferential measurements of both thighs and lower legs (or upper and lower arms) at stated points above and below the knee (or elbow) given in inches or centimeters. A specific description of atrophy of hand muscles may be given without measurement of atrophy.

15. Measurement of grip strength is required in all cases. It is preferred that a dynamometer is used to record the grip strength but a 0-5 graded scale is acceptable.

16. A description of the claimant’s ability to perform fine and gross manipulation should be provided. This description should include the observation of the claimant’s ability to pick up coins, button clothing, make a fist, handle paper, etc.

INTERNAL MEDICINE WITH ORTHOPEDIC INVOLVEMENT

INSTRUCTIONS FOR THE COMBINED INTERNAL MEDICINE AND ORTHOPEDIC EXAMINATION (EXAM 017)

The following specific information is required in all instances. Refer also to the instructions that pertain to the particular non-musculoskeletal impairment alleged. For example, if a claimant suffers from a respiratory or cardiovascular impairment, the instructions for a respiratory or cardiovascular examination should also be followed.

The following specific information is required:

1. The detail and format for reporting the results of the history, physical examination, laboratory findings, and discussion of conclusions should follow the standard reporting principles for a complete and competent medical examination. (Pelvic examinations should not be performed unless specifically authorized by the RRB.)

2. Both positive and negative detailed findings based on the information provided by the RRB and the claimant in the history, from the examination and ancillary tests and from the background information (if provided), must be provided as they relate to the major complaint(s). Any other abnormalities found during the examination and ancillary tests must also be included. An omission of a specific finding will not be interpreted as a negative or normal finding.

3. The claimant’s major or chief complaints and their history should be presented in detail.

4. A statement concerning the claimant’s general appearance and nutrition, and any apparent musculoskeletal abnormalities or loss of function should be provided.

5. The vital signs should include the blood pressure, pulse rate, respiratory rate, and height and weight without shoes. (If the spinal curvature distorts height, substitute arm span.)

6. The gait and station must be described in detail. Provide a description of the claimant’s ability to tandem walk, walk on heels and toes, hop, bend, squat, arise from squatting position, dress and undress, get up from a chair, get on and off the examining table, and generally cooperate during the examination.

7. If an ambulatory aide is used, indicate if it is a medical necessity, and provide the medical reason for its necessity (e.g., 2/5 muscle strength of both lower extremities). Also describe the claimant’s ability (or inability) to ambulate effectively with and without the ambulatory aide.

8. In amputation cases, comment on the stump, any stump complications and the ability to use a prosthesis effectively. If an orthotic device is used, describe the claimant’s ability to walk with the device in place. If the 9.

claimant has difficulties with the device, provide the medical basis for the difficulty and describe the ability to ambulate without the device.

10. Range of motion in all joints and the spine must be reported in degrees. Joints with no limitation should be identified. Measurement of joint motion should be based on the techniques described in the chapter on extremities, spine and pelvis in the current edition of the “Guides to the Evaluation of Permanent Impairment” published by the American Medical Association.

11. Include a straight leg-raising test from both the sitting and supine positions.

12. Describe the presence or absence of paravertebral muscle spasms and/or tenderness.

13. Include detailed comments on any joint abnormalities such as heat, redness, swelling, ankylosis, contractures and subluxation. If not present, so state.

14. Give detailed motor, sensory and reflex findings. Motor function should be provided on a grading system of 0 to 5, with 0 being complete loss of strength and 5 being maximum strength. The report should also describe to what degree motor function is inhibited by spasticity, rigidity, or pain. When sensory deficit is reported, the specific distribution of these findings must be described. Deep tendon reflexes should be described as to intensity and symmetry.

16. Measurement of grip strength is required in all cases. It is preferred that a dynamometer is used to record the grip strength but a 0-5 graded scale is acceptable.

17. A description of the claimant’s ability to perform fine and gross manipulation should be provided. This description should include the observation of the claimant’s ability to pick up coins, button clothing, make a fist, handle paper, etc.

NEUROLOGICAL

INSTRUCTIONS FOR NEUROLOGICAL EXAMINATION (EXAM 012)

The examination of a claimant who suffers from a neurological impairment is to be done by a neurologist.

The following specific information is required:

1. The detail and format for reporting the results of the history, physical examination, laboratory findings, and discussion of conclusions should follow the standard reporting principles for a complete and competent medical examination.

2. Both positive and negative detailed findings based on the information provided by the RRB and the claimant in the history, from the exami-nation and ancillary tests and from the background information (if provided), must be provided as they relate to the major complaint(s). Any other abnormalities found during the examination and ancillary tests must also be included. An omission of a specific finding will not be interpreted as a negative or normal finding.

3. The claimant’s major or chief complaints and their history should be presented in detail.

4. A description of the claimant’s general appearance, nutrition, and pertinent actions during the examination should be included.

5. The vital signs should include the blood pressure, pulse rate, respiratory rate, and height and weight without shoes. (If the spinal curvature distorts height, substitute arm span.)

6. Mental status examination documenting level of consciousness, orientation to time, person, place, extent of intellectual deterioration should be provided. Describe any abnormal behavior pattern.

7. Speech description (e.g. aphasia, dysarthria, stuttering and involuntary vocalizations) must be noted and comments made as to whether the speech is intelligible and fluent.

8. Cranial nerve exam including any visual and/or hearing defects must be provided.

9. Cerebellar function test must be described in detail, including gait and station, presence or absence of ataxia, hemiparesis, limping or abnormal ambulation. Include testing such as Romberg, finger to nose, and rapid alternating movements.

10. If an ambulatory aide is used, indicate if it is a medical necessity, and provide the medical reason for its necessity (e.g. 2/5 muscle strength of both lower extremities). Also, describe the claimant’s ability (or in- ability) to ambulate effectively with and without the ambulatory aide.

11. Motor function examination including presence or absence of rigidity, tremors, weakness, etc., must be included.

Quantify muscle weakness in detail on a graded scale (e.g. 4/5). In cases of multiple sclerosis or myasthenia gravis, provide quantified results of motor function testing on repetitive activity. Grip strength should be measured by a dynamometer, if available. Otherwise, a graded 0-5 scale is acceptable.

12. Sensory system examination, including touch, pain, temperature, vibration and position must be provided. Describe distribution of abnormal findings.

13. Reflex examination including quantified findings of upper and lower extremities. Any pathological finding of superficial reflex abnormalities should be noted.

14. If an individual suffers from a seizure disorder, the history should include:

a. Frequency of major and/or minor seizures.

b. Date of onset.

c. Description of typical seizure must include:

1) Whether diurnal or nocturnal;

2) Presence of aura;

3) Actual seizure manifestations (e.g. tongue bites, loss of sphincter control; injuries incurred during attacks, etc.)

4) Length of seizure;

5) Postictal manifestation and it’s duration; and

6) Identify informant since seizure description must be given by someone other than the claimant.

Solicitation No. 60RRBH18R0015 Page 1 of 43 Exhibit 2

MENTAL DISORDERS

INSTRUCTIONS FOR A PSYCHIATRIC EXAMINATION ( EXAM 013)

The examination may be done by a psychiatrist or a psychologist, but a psychiatrist is preferred.

The examining psychiatrist's/psychologist’s report should consist of clinical data which includes objective and detailed description of findings (including pertinent negatives) of a current and complete mental status examination. Your opinions and conclusions must be supported by the description of objective findings upon which they are based.

Your report must enable an independent reviewing psychiatrist to assess the nature and severity of the claimant's mental impairment. Do not include statements about the presence or absence of disability, as a disability determination is an administrative decision in which both medical and non-medical factors are considered.

The following specific areas should be included in your narrative report:

1. History of present illness

a. Indicate source and reliability of source.

b. Include chief complaints and symptoms, their onset and progression, treatment dates, type of treatment, medications, hospitalizations, duration of hospitalizations, response to therapy, side effect of therapy.

2. Personal/ Social History and Family History

a. Include pertinent family history.

b. Provide a longitudinal biographical profile of the claimant's relevant educational, social, military, marital, and occupational adjustments in terms of ability to conform to social standards, to hold employment and advance in career, and to adjust to superiors and fellow workers. Comment on consistency of finding to allegations.

c. With respect to the vocational history, provide complete details concerning the claimant's adaptation on all jobs in the recent past (one or two years). Comment on consistency of finding to allegations. Also, does the claimant believe himself/herself unable to work and if so, explain why.

3. General Observations

a. Include information about the claimant's ability to travel alone, such as how the claimant came to the examination and whether the claimant came alone. If the claimant was accompanied, why was company needed? What was the distance traveled and the mode of transportation? Is the claimant able to use public transportation? Was the claimant punctual and if not, why not?

b. Estimate the claimant's age, height, and weight for identification purposes.

c. Describe the claimant's posture and gait, clothing, grooming and hygiene, manners, attitude and degree of cooperation and responsiveness.

4. Full and Complete Description of Mental Status

Include a detailed description of objective findings, including pertinent negatives, upon which your assessment is based. Provide detailed examples of the claimant’s statements and actions, including verbatim quotes from the claimant.

Include detailed description of:

a. Characteristics of Speech e.g., relevance, coherence, associations, etc.

b. Characteristics of Thought e.g., delusions, hallucinations, obsessions, compulsions, phobias, preoccupations, paranoid tendencies, confusion, hyperactivity, suicidal/homicidal ideation.

c. Mood and Affect (e.g., depth, broadness, appropriateness, etc.) Use of one word descriptions regarding mood or affect such as “distressed,” "anxious," “tense," are not sufficient and should be amplified. Describe any bizarre behavior.

d. Sensorium and Intellectual Functions e.g., orientation, memory, attention and concentration, information, serial sevens, calculations, etc.

e. Insight and Judgement e.g., self assessment, plans for the future, etc.

5. Daily Activities

Your detailed description for each of the following five areas should include an adequate objective description for us to determine the extent to which the claimant is capable of initiating and independently participating in the described activities, and the appropriateness and quality of the activities. Comparison of pre-morbid behavior to current behavior would be useful.

a. Describe the claimant's interests, such as hobbies, reading materials, ability to care for pets, etc. Describe frequency, quality, and independence of participation by claimant.

b. Describe the claimant's activities on a typical day, e.g., time patient gets out of bed, sleeping habits, household chores, shopping, meal preparation, time spent reading or watching television, sports activities, church activities, social activities, visits with friends and relatives. Again, describe frequency, quality, and independence of participation by claimant.

c. Describe the claimant's ability to relate, e.g., how the claimant gets along with family, neighbors, friends, co- workers, and employers and how the claimant related to the examining psychiatrist/psychologist and office personnel.

d. Describe and provide examples of deficiencies of concentration, persistence, or pace resulting in failure to complete tasks in a timely manner. Address whether the claimant is unable to complete tasks in a timely manner because of a physical or mental complaint.

e. Describe and provide examples of episodes of decompensation in work-like settings which cause the claimant to withdraw from that situation or to experience exacerbation of signs and symptoms (include any deterioration of adaptive behaviors).

6) Diagnosis and Prognosis

Use the latest Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, including Axes.

Comment on expected duration of the condition and frequency and quality of any intervening period of remission.

If in your clinical judgment, the claimant’s mental impairment restricts his/her daily activities, please comment on the degree of restriction.

7). Capability Statement

Based on objective findings, state whether or not the claimant is mentally competent to handle his/her own finances.

Note: Claimants should not be tested who are under the influence of any substance that would affect the validity of the test.

IQ TEST

INSTRUCTIONS FOR I.Q. TESTING (EXAM 011)

The examination of a claimant who suffers from mental retardation, organic brain syndrome or residuals of substance abuse is to be done by a psychologist.

The following specific information is required:

1. Provide a Wechsler Adult Intelligence Scale including total I.Q., performance I.Q., and verbal I.Q., or a Stanford Binet. Provide all sub-test scores with interpretation of findings on the various sub-tests and assess their validity.

NOTE: The test must be administered in the claimant’s native language. Use of an interpreter is not acceptable unless authorized in advance by the authorized orderer.

2. Self- sufficiency of the claimant in coming to the examination, personal appearance, mannerisms, and behavior during examination.

3. Daily activities and level of social functioning (normal routines, habits, pets, self-care, relationships with friends and relatives, etc.)

4. History of present illness.

5. Pertinent personal, social, family and employment history.

6. Based on your observation during the administration of the I.Q. test, give a detailed mental status examination which includes a description of the following:

a. General assessment of the claimant’s abilities in maintaining attention and concentration, following simple directions, reading writing, conversation, and performing simple calculations.

b. Claimant’s attitude and behavior.

c. Description of the claimant’s self-sufficiency with respect to personal and social competence.

d. Stream of conversation and psychomotor activity.

7. State whether or not the claimant is mentally competent to handle his/her own finances.

Based on findings and on other objective material which may have been furnished to you, provide a diagnosis and prognosis for the claimant’s condition.

OPHTHALMOLOGY

INSTRUCTIONS FOR OPHTHALMOLOGIC EXAMINATION (EXAM 007)

The examination must be done by an ophthalmologist.

The following specific information is required:

1. The history obtained should present a detailed longitudinal description of the loss of vision (congenital or acquired). Current and pertinent past therapy for this disorder, and response to therapy should be reported. Hospitalizations, surgical procedures and laser treatments should be reported giving the dates of the hospitalization and results of the procedure in as much detail as the claimant can provide.

2. A detailed description of the symptoms alleged, types of medication used and any relevant information is required.

3. Exact degree of central visual acuity of each eye including:

4. Tension in each eye.

5. Complete fundoscopic and/or slit-lamp findings.

6. Muscle function.

7. A separate diagnosis for each eye, including etiology must be furnished.

8. Describe any other significant condition present.

If central visual acuity in the better eye is less than 20/200 with best correction, a peripheral visual field test is not necessary. Otherwise, there must be peripheral visual fields, as tested in the presence of visual field contraction without corrective spectacle lenses. Tangent screen tests are not acceptable for our disability determination purposes. Therefore, regardless of availability of other testing methods, it is required that the following be used:

Aphakic Eye – Goldmann Perimeter (use a setting of IV).

NOTE: A claimant who has undergone cataract extraction and had a plastic lens implant is not considered Aphakic for purposes of visual field testing.

If visual fields are normal, so state.

Octopus VTAP results, if abnormal, cannot be used for disability determination purposes.

OTOLARYNGOLOGY

INSTRUCTIONS FOR OTOLARYNGOLOGIC EXAMINATION

(EXAM 003) AND OTOLARYNGOLIC EXAMINATION WITH CALORIC TESTING (EXAM 005) AND OTOLARYNGOLOGIC EXAMINATION WHICH INCLUDES A SPEECH DISCRIMINATION TEST WITH HEARING IN NOISE TEST (HINT) (EXAM 006)

These examinations must be done by an otolaryngologist.

The following specific information is required for both exam 003 and 005:

1. The history should include the onset as well as the cause of the deafness, if it is known, along with the diagnosis and the development of symptoms. If the condition is amenable to therapy, indicate it. List the date(s) and reason(s) for any hospitalizations and the nature of treatment given and response.

2. A complete physical ear examination must be done.

3. A complete audiometric examination is to be done and the results of that examination must accompany the report. The audiometric examination should include the charts from the Air and Bone Conduction Studies (without hearing aides) as well as Speech Reception Threshold and Speech Discrimination Test results with best amplification.

4. Where the history suggests the probability that hearing can be restored by a hearing aid, or when the claimant uses a hearing aid, pure tone audiometry and speech discrimination testing must be done with a fully functional hearing aid or an amplification device provided by the examining personnel in place that gives best correction. A statement regarding whether a hearing aid or amplification device was used in the testing must be included.

5. Describe any significant condition present.

6. The findings from the physical examination should include comments on the presence of nystagmus if positive or negative Romberg sign, or if there is any impairment in ambulation, i.e., describe gait (ordinary and tandem) with open and closed eyes.

7. When an exam 005 is ordered, also perform an electronystagmography (ENG) or a caloric test.

8. If Meniere’s disease is the working diagnosis, a detailed history of the cause, if known, onset, development of symptoms including vertigo, tinnitus and fluctuation of hearing loss should be provided. Also, include the activities which precipitate vertigo attacks, frequency, severity and duration of attacks. Presence of any other symptoms (i.e., increasing deafness, immobility, headache, syncope, nausea, vomiting) should also be included.

9. If the findings show that there is a cochlear implant, the impairment will be considered disabling until 1 year after the initial implantation. After that period, when an exam 006 is ordered, a word recognition test should be performed with any version of the Hearing in Noise Test (HINT). The testing should be conducted in quiet in a sound field. The implant must be functioning properly and adjusted to normal settings. The sentences should be presented at 60 dB HL (hearing level) and without any visual cues.

If the claimant exhibits signs of labyrinthine-vestibular disturbance but an ear vestibular examination was not scheduled and an electronystagmography is needed, contact the authorized orderer for approval to administer the test.

SKIN

Instructions for Dermatological Examination (Exam 001)

The examination of a claimant who suffers from a skin impairment is to be done by a dermatologist.

The following specific information is required:

1. The history should include the onset as well as the cause of the skin impairment if it is known. Also it should include description of the symptoms (i.e. pruritus, ulceration, eczema, edema, weight loss, motion loss, pain, etc.) with the location, severity and duration. Provide the treatment given (i.e. drugs, radiation, etc.) and response. Describe any adverse side effects from the treatment.

2. Define the characteristic skin lesions (papules, nodules and vesicles, scales, crusts and ulcers) by the areas involved in the disease process.

3. If the findings show that the skin disease is a manifestation of a systemic disorder, but no appropriate laboratory test was scheduled, contact the authorized orderer for approval to administer the tests.

4. If the claimant has contractures that occurred secondary to burns, provide the range of motion of the affected area, expressed in degrees.

5. When disfigurement is found to be a significant factor in the skin impairment examination, provide a description of the claimant’s daily activities, potential constriction of interest, reclusiveness and relationship with others. Also describe the physical defect and therapy received along with the side effects of therapy and the therapeutic response.