Exhibit 4 Physical Resdual Funtional Capacity Assessment.pdf

NAME CLAIM NUMBER

Form G-137 SUP (08-11)

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

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.

None Established (go to Item D)

EXERTIONAL LIMITATIONS

Exertional limitations are noted below

1.

a.

Lifting/Carrying

Objects weighing:

Occasionally up to 10 pounds up to 20 pounds up to 50 pounds up to 100 pounds more than 100 pounds b.

Objects weighing:

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

2.

With normal breaks for a total of:

Standing/Walking

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

3.

With normal breaks for a total of:

Sitting

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

4.

Unable to walk on uneven terrain

Special Limitations Apply to Standing, Walking, or Sitting

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

5. Pushing/Pulling

Unlimited, other than as shown in 1., above

(including operation of hand and/or foot controls)

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

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

D.

None established (go to Item E)

POSTURAL LIMITATIONS

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)

E. MANIPULATIVE LIMITATIONS

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

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:

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.)

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

D. Signature (use Ink)

Consultant's Signature

For RRB Use Only

M/O Accepted M/O Rejected

Name

Date

Consultant's Name (Print)

Date