60RRBH25R0009 CMOS Form G-137 SUP Attachment 2.pdf

NAME R . R . W o r k e r CLAIM NUMBER 123-45-6789

PART I - TREATING OR EXAMINING SOURCE STATEMENT(S)

For the purposes of this form, occasionally means occurring from very little to up to one-third of an 8-hour workday; cumulative not continuous; frequently means occurring from one-third to two-thirds of an 8-hour workday; cumulative not continuous; and constantly means occurring more than two-thirds of an 8-hour workday.

A. Does the claimant meet/equal the listing?

YES (go to Part II, complete Items A-D. In Item A cite how the claimant met or equaled the listing) NO (go to Item B)

B. Regarding the claimant's physical capacities, are the treating or examining source statements that are in the file complete and consistent with the medical evidence?

YES (go to Part II, complete Items A-D. In Item A cite which doctor's RFC applies and explain why you disagree with the remaining treating or examining source severity assessment(s) in file)

NO (complete the rest of the form. In Part II justify your assessment and explain why you disagree with all treating or examining source severity assessment(s) in file)

C. EXERTIONAL LIMITATIONS * See Desk Guide for Clarifying Physical RFC*

None Established (go to Item D) Exertional limitations are noted below

1. Lifting/Carrying

a. Occasionally

Objects weighing:

up to 10 pounds up to 20 pounds up to 50 pounds up to 100 pounds more than 100 pounds

b. Frequently

Objects weighing:

up to 10 pounds up to 25 pounds up to 50 pounds more than 50 pounds

2. Standing/Walking With normal breaks for a total of:

Less than 2 hours in an 8-hour workda At least 2 hours in an 8-hour workday At least 6 hours in an 8-hour workday ay

3. Sitting With normal breaks for a total of:

Less than 6 hours in an 8-hour workda At least 6 hours in an 8-hour workday ay

4. Special Limitations Apply to Standing, Walking, or Sitting

Unable to walk on uneven terrain Must periodically alternate sitting and standing to relieve pain or discomfort Medically required handheld assistive device is necessary for ambulation

PLEASE INITIAL ANY ERASURES OR WHITE-OUTS MADE ON THIS FORM

Form G-137 SUP (08-11)

5. Pushing/Pulling (including operation of hand and/or foot controls)

Unlimited, other than as shown in 1., above Limited in upper extremities (describe in detail the type of limitations)

Example: May not lift more than 20 pounds higher than waist (shoulder) level Must be allowed to wear arm sling while working

Limited in lower extremities (describe in detail the type of limitations)

Example: May not work vehicles requiring clutch or 2 foot to operate

D. POSTURAL LIMITATIONS * See Desk Guide for Clarifying Physical RFC *

None established (go to Item E) Postural limitations are noted below

Never Occasionally Frequently Constantly Climbing (Ladder/Rope/Scaffold) Climbing (Stairs/Ramp)

Stooping

Kneeling

Crouching

Crawling

Balancing

Describe specific type of physical activity where balancing is limited in the space provided below.

(e.g. on a ladder, ascending/descending stairs, standing/walking) If balancing is limited, there must be an explanation in this box with restrictions supported by medical rationale Examples: Due to risk of seizure, May not work unrestrained from heights more than 2 ft above ground level Due to hip injury, May work from heights such as in cherry picker, but may not climb to heights

E. MANIPULATIVE LIMITATIONS* See Desk Guide for Clarifying Physical RFC *

None Established (go to Item F) Manipulative limitations are noted below

Never Occasionally Frequently Constantly

Reaching all directions (including overhead)

Right Left

Handling (gross manipulation)

Fingering (fine manipulation)

Feeling (skin receptors)

F. VISUAL LIMITATIONS

None Established (go to Item G) Visual limitations are noted below

Limited Unlimited Right Left

Near acuity

Far acuity

Depth perception

Accommodation

Field of vision

Color vision

G. COMMUNICATIVE LIMITATIONS

None Established (go to Item H) Communicative limitations are noted below

Limited Unlimited Right Left

Hearing

Speaking

H. ENVIRONMENTAL LIMITATIONS ** See Desk Guide for Clarifying Physical RFC *

None Established Environmental limitations are noted below

Must Avoid

All Exposure

Must Avoid Concentrated

Exposure

Must Avoid Moderate Exposure

Unlimited

Extreme cold

Extreme heat

Wetness

Humidity

Noise

Vibration

Fumes, Odors, Dust, Gases, Poor Ventilation, Etc.

Hazards (machinery, heights, etc.)

Description:

1. If Hazard exposure is limited, please describe the type of hazard(s) to be avoided.

2. If other environmental hazards are to be avoided, please connect restriction to a medical condition Example:

Fumes/Cold exposure restricted due to COPD

Vibration restriction due to multiple spine surgeries

PART II - MEDICAL CONSULTANT COMMENTS

A. Comments - (Explain all limitations described in Part I and summarize the medical basis for your decision and RFC. Include the reasons you disagree with any treating and/or examining source severity assessment(s) in file.)

Notes Regarding medical evidence and rationale:

Please do not just copy a list of diagnoses without medical evidence to support that the condition is still active.

Do not just list imaging results as evidence of severity. Subjective and objective/physical exams must also support your opinion. (See CFR 220.113 which notes Medical findings consist of Signs, Symptoms, and Laboratory Findings.) Therefore, you must also record Subjective history(ies) given to providers by the claimant.

Record if the current medical supports claims that may have been made at time of the AA1-D signature. For example, as noted on the AA1-D, is the claimant still not able to stand/walk more than 15 min and unable to bend/twist? Or, does recent history show he’s now running 3 miles a day and playing pickleball?

For Onset date, please give rationale to support and not just “ME supports AOD” as this does not help medical examiner follow your rationale. A response such as “AOD supported as date of PET Scan showing metastatic disease”. Or, “Onset date consistent with date of ER visit due to MVA which caused injury which is now chronic with residuals lasting more than 12 months.”

Or even “AOD not supported as it appears to be date of diagnosis of Diabetes which, after 6 months, was controlled for several years with no working restrictions or residuals until date of xx-xx-xxxx, which is correct onset date of disability.

Check if additional pages are included

B. Onset Date C. Diary (Complete for all cases that meet/equal the listing or have an RFC)

Medical improvement not expected Medical improvement possible Medical improvement expected, set call-up for months Make sure call up is consistent with any Listing Guidelines eg: One year post kidney transplant or transfusion for GI bleeding due to CLD, Three years post Lung transplant, etc.

C. Signature (use Ink)

Consultant's Signature

For RRB Use Only

M/O Accepted M/O Rejected

Name

Date

Consultant's Name (Print)

Date