Exhibit_5_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 5
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Solicitation No. RRB013R001 Page 4 of 4 Exhibit 5
MENTAL RESIDUAL FUNCTIONAL CAPACITY ASSESSMENT
Based only on your examination, please provide an assessment of how the claimant’s ability to function in a work setting over a normal workday and workweek on an ongoing basis is affected by his mental impairment. (Exclude from your assessment any consideration of the individual’s age, education, sex or work experience. You conclusion should reflect only the mental condition.)
Check the box that most closely reflects the claimant’s residual functional capacity as determined by the examination.
NO EVIDENCE OF LIMITATION –when the evidence supports the conclusion that there is no limitation in a particular area and no limitation would be expected based on the nature of the illness and the examiner’s clinical experience.
NOT SIGNIFICANTLY LIMITED – when the evidence supports the conclusion that the claimant’s capacity may be slightly limited but does not prevent the consistent and useful performance of the activity.
MODERATELY LIMITED – when the evidence supports the conclusion that the conclusion that the claimant’s capacity to perform the work is seriously impaired but is not precluded.
MARKEDLY LIMITED – when the evidence supports the conclusion that the claimant cannot usefully perform or sustain the activity.
| No evidence | Not | ||
| of | Significantly | Moderately | Markedly |
| Limitation | Limited | Limited | Limited |
A. Understanding and Memory
1. The ability to remember
| locations and work-like |
| procedures. |
| 2. | The ability to understand |
| understand and remember | |
| very short and simple | |
| instructions. |
| No evidence | Not | ||
| of | Significantly | Moderately | Markedly |
| Limitation | Limited | Limited | Limited |
| 3. | The ability to understand |
| and remember detailed | |
| instructions. |
B. Sustained Concentration and Persistence
| 4. | The ability to carry out |
| very short and simple | |
| instructions. |
| 5. | The ability to carry out |
| detailed instructions. |
| 6. | The ability to maintain |
| attention and concentration | |
| for extended period. |
| 7. | The ability to perform activities |
| within a schedule, maintain | |
| regular attendance, and to be | |
| punctual within customary tolerances. |
| 8. | The ability to sustain an ordinary |
| routine without special | |
| supervision. |
| 9. | The ability to work in |
| coordination with or proximity | |
| to others without being distracted | |
| by them. |
| 10. | The ability to make simple |
| work-related decisions. |
| No evidence | Not | ||
| of | Significantly | Moderately | Markedly |
| Limitation | Limited | Limited | Limited |
| 11. | The ability to complete a normal |
| workday and workweek without | |
| interruptions from psychologically | |
| based symptoms and to perform at | |
| a consistent pace without an | |
| unreasonable number and length | |
| of rest periods. |
Social Interactions
12. The ability to interact appropriately with the general public.
| 13. | The ability to ask simple |
| questions or request assistance. |
| 14. | The ability to accept instructions |
| and respond appropriately to | |
| criticism from supervisors. |
| 15. | The ability to get along with |
| co-workers or peers without | |
| distracting them or exhibiting | |
| behavioral extremes. |
| 16. | The ability to maintain socially |
| appropriate behavior and to | |
| adhere to basic standards or | |
| neatness and cleanliness. |
D. Adaptations
| 17. | The ability to respond |
| appropriately to changes in the | |
| work setting. |
| No evidence | Not | ||
| of | Significantly | Moderately | Markedly |
| Limitation | Limited | Limited | Limited |
18. The ability to be aware of normal hazards and take appropriate precautions.
19. The ability to travel in unfamiliar places or use public transportation.
| 20. | The ability to set realistic |
| goals or make plans | |
| independently of others. |
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 psychiatric examination performed today, and my clinical assessment. The enclosed do not constitute a recommendation that specific activities be performed.
Signature Printed Name Date
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