Exhibit_4_RRB13R001.docx
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- Attached to
- Disability Medical Exam Services
- Solicitation number
- RRB13R001
- Issued by
-
Railroad Retirement Board
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Exhibit 4
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PHYSICAL RESIDUAL FUNCTIONAL CAPACITY ASSESSMENT
Describe any restrictions in the claimant’s ability to perform the work-related functions within a regular work setting on a day-to-day basis. Relate any assessed reduction in capacity to particular medical findings. Do not consider non-medical factors such as age, education, or work experience.
For the purposes of this form, occasionally means occurring from very little to up to one-third of an 8hour 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 8hour workday.
| A. | EXERTIONAL LIMITATIONS | |
| |_| | None Established (go to Item B) | |
| |_| | 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 workday | |
| |_| At least 2 hours in an 8-hour workday | |
| |_| At least 6 hours in an 8-hour workday |
| 3. | Sitting |
| With normal breaks for a total of: | |
| |_| Less than 6 hours in an 8-hour workday | |
| |_| At least 6 hours in an 8-hour workday |
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
Solicitation No. RRB13R001 Page 3 of 3 Exhibit 4
NAME - 3 -NAME
CLAIM NUMBER
Form G-137 (10-00) Form G-137 SUP (11-00)
PLEASE INITIAL ANY ERASURES OR WHITE-OUTS MADE ON THIS FORM
PLEASE INITIAL ANY ERASURES OR WHITE-OUTS MADE ON THIS FORM
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)
|_| Limited in lower extremities (describe in detail the type of limitations)
| B. | POSTURAL LIMITATIONS | |
| |_| | None established (go to Item C) | |
| |_| | Postural limitations are noted below |
| Never |
| Occasionally |
| Frequently |
| Constantly |
| Climbing (Ladder) | |_| | |_| | |_| | |_| | |
| Climbing (Stairs) | |_| | |_| | |_| | |_| | |
| Balancing | |_| | |_| | |_| | |_| | |
| Stooping | |_| | |_| | |_| | |_| | |
| Kneeling | |_| | |_| | |_| | |_| | |
| Crouching | |_| | |_| | |_| | |_| | |
| Crawling | |_| | |_| | |_| | |_| |
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)
| C. | MANIPULATIVE LIMITATIONS | |
| |_| | None Established (go to Item D) | |
| |_| | Manipulative limitations are noted below |
| Reaching all directions | |
| (including overhead) |
| Never |
| Occasionally |
| Frequently |
| Constantly |
Right Left
| Handling (gross manipulation) | |
| Right |
Left
| Fingering (fine manipulation) | |
| Right |
Left
| Feeling (skin receptors) | |
| Right |
Left
| D. | VISUAL LIMITATIONS |
| |_| | None Established (go to Item E) |
| |_| | Visual limitations are noted below |
Limited
Unlimited
| Right |
| Left |
| Near acuity | |
| |_| | |
| |_| |
| Far acuity | |
| |_| | |
| |_| |
| Depth perception | |
| |_| | |
| |_| |
| Accommodation | |
| |_| | |
| |_| |
| Field of vision | |
| |_| | |
| |_| |
| Color vision | |
| |_| |
| E. | COMMUNICATIVE LIMITATIONS |
| |_| | None Established (go to Item F) |
| |_| | Communicative limitations are noted below |
Limited
Unlimited
| Right |
| Left |
| Hearing | |
| |_| | |
| |_| |
| Speaking | |
| |_| |
| F. | 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.) |
| |_| |
| |_| |
| |_| |
COMMENTS: Explain ALL limitations noted above and summarize the medical basis for your RFC Assessment in your narrative report (capability statement).
These findings are based solely on the history obtained, the physical performed today, and my clinical assessment. The opinions enclosed do not constitute a recommendation that specific activities be performed.
Physician’ Printed Name Physician’s Signature Date
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