I RFC ASSESSMENT IS FOR:
|
|
|
- Piers Shepherd
- 6 years ago
- Views:
Transcription
1 PHYSICAL RESIDUAL FUNCTIONAL CAPACITY ASSESSMENT FORM APPROVED ~ OMB NO CLAIMANT: NUMBERHOLDER (IF CDB CLAIM): PRIMARY DIAGNOSIS: I RFC ASSESSMENT IS FOR: OClAL SECURITY NUMBER: - - SECONDARY DIAGNOSIS: OTHER ALLEGED IMPAIRMENTS: Current Evaluation Date Last Insured: Other (Specify): Date 12 Months After Onset: PRIVACY ACT NOTICE: The information requested on this form is authorized by Section 223 and Section 1633 of the Social Security Act. The information provided will be used in making a decision of this claim. Failure to complete this form may result in a delay in processing the claim. Information furnished on this form may be disclosed by the Social Security Administration to another person or govenunental agency only with respect to Social Security programs and to comply with Federal laws requiring the exchange of information between Social Security and other agencies, (Date) (oatel I. LIMITATIONS: For Each Section A - F Base your conclusions on all evidence in file (clinical and laboratory findings; symptoms; observations, lay evidence; reports of daily activities; etc.). I) Check the blocks which reflect your reasoned judgement. Describe how the evidence substantiates your conclusions (Cite specific clinical and laboratory findings, observations, lay evidence, etc.). I) Ensure that you have: Requested appropriate treating and examining source statements regarding the individual's capacities (Dl ff. and Dl ff.) and that you have given appropriate weloht to treating source conclusions (See Section Ill.). Considered and responded to any alleged limitations imposed by symptoms (pain, fatigue, etc.) attributable, in your judgement, to a medically determinable impairment. Discuss your assessment of symptom-related limitations in the explanation for your conclusions in A - F below (See also Section 11.). Responded to all allegations of physical limitations or factors which can cause physical limitations. Frequently means occurring one-third to two-thirds of an 8-hour workday (cumulative, not continuous). Occasionally means occurring from very little up to one-third of an &hour workday (cumulative, not continuous). Form SSA-4734-BK ( ) ef ( ) (Formerly SSA4734-U8 Use prior editions) Page 1 [1 Continued on Page 2
2 A. EXERTIONAL LIMITATIONS None established. (Proceed to section B.) 1. Occasionally lift andlor carry (including upward pulling) (maximum) - when less than one-third of the time or less than 10 pounds, explain the amount (timelpounds) in item 6. less than 10 pounds 10 pounds 20 pounds 50 pounds 100 pounds or more 2. Frequently lift and/or carry (including upward pulling) (maximum) - when less than two-thirds of the time or less than 10 pounds, explain the amount (timelpounds) in item 6. less than 10 pounds 10 pounds 25 pounds 50 pounds or more 3. Stand andlor walk (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 about 6 hours in an &hour workday [3 medically required hand-held assistive device is necessary for ambulation 4. Sit (with normal breaks) for a total of - 0 less than about 6 hours in an &hour workday about 6 hours in an &hour workday must periodically alternate sitting and standing to relieve pain or discomfort. (If checked, explain in 6.) 5. Push andlor pull (including operation of hand andlor foot controls) - unlimited, other than as shown for lift andlor cany limited in upper extremities (describe nature and degree) limited in lower extremities (describe nature and degree) 6. Explain how and why the evidence supports your conclusions in item 1 through 5. Cite the specific facts upon which your conclusions are based. Form SSA473CBK ( ) ef ( ) Page 2 Continued on Page 3
3 6. Continue (NOTE: MAKE ADDITIONAL COMMENTS IN SECTION IV) B. POSTURAL LIMITATIONS None established. (Proceed to section C.) 1. Climbing - rampistairs b - ladder/rope/scaffolds 2. Balancing b 3. Stooping b 4. Kneeling b 5. Crouching b 6. Crawling b Frequently Occasionally Never 7. When less than two-thirds of the time for frequently or less than one-third for occasionally, fully describe and explain. Also explain how and why the evidence supports your conclusions in items 1 through 8. Cite the specific facts upon which your conclusions are based. Continued on Page 4 Form SSA473CBK ( ) ef ( ) Page 3
4 C. MANIPULATIVE LIMITATIONS None established. (Proceed to section D.) LIMITED UNLIMITED 1. Reaching all directions (including overhead) ' 2. Handling (gross manipulation) 3. Fingering (fine manipulation) 4. Feeling (skin receptors) b 5. Describe how the activities checked "limited" are impaired. Also, explain how and why the evidence supports your conclusions in item 1 through 4. Cite the specific facts upon which your conclusions are based. b b D. VISUAL LIMITATIONS None established. (Proceed to section E.) LIMITED UNLIMITED 1. Near acuity 2. Far acuity b * 3. Depth perception b 4. Accommodation b 5. Color vision 6. Field of vision b 7. Describe how the faculties checked "limited" are impaired. Also explain how and why the evidence supports your conclusions in items 1 through 6. Cite the specific facts upon which your conclusions are based. Form SSA4734-BK ( ) ef ( ) Page 4 Continued on Page 5
5 E. COMMUNICATIVE LIMITATIONS None established. (Proceed to section F.) 1. Hearing 0 2. Speaking 0 LIMITED UNLIMITED 3. Describe how the faculties checked "limited" are impaired. Also, explain how and why the evidence supports your conclusions in items 1 and 2. Cite the specific facts upon which your wndusions are based. F. ENVIRONMENTAL LIMITATIONS None established. (Proceed to section 11.) 1. Extreme cold -b 2. Extreme heat b 3. Wetness bn 4. Humidity 5. Noise -' 6. Vibration 7. Fumes, odors, -b dusts, gases, poor ventilation, etc. 8. Hazards (machinery, heights, etc.) AVOID AVOID EVEN CONCENTRATED MODERATE AVOID ALL UNLIMITED EXPOSURE EXPOSURE EXPOSURE 0 9. Describe how these environmental factors impair activities and identify hazards to be avoided. Also, explain how and why the evidence supports your conclusions in items I through 8. Cite the specific facts upon which your conclusions are based. Form SSA-4734-BK ( ) ef ( ) Page 5 Continued on Page 6
6 9. Continue (NOTE: MAKE ADDITIONAL COMMENTS IN SECTION IV) II. SYMPTOMS For symptoms alleged by the claimant to produce physical limitations, and for which the following have not previously been addressed in section I, discuss whether: A. The symptom(s) is attributable, in your judgment, to a medically determinable impairment. B. The severity or duration of the symptom(s), in your judgment, is disproportionate to the expected severity or expected duration on the basis of the claimant's medically determinable impairment(s). C. The severity of the symptom(s) and its alleged effect on function is consistent, in your judgment, with the total medical and nonmedical evidence, including statements by the claimant and others, observations regarding activities of daily living, and alterations of usual behavior or habits. Fom SSA-4734-BK ( ) ef ( ) Page 6 Continued on Page 7
7 Ill. TREATING OR EXAMINING SOURCE STATEMENT(S) A. Is a treating or examining source statement@) regarding the claimant's physical capacities in file? Yes No (Includes situations in which there was no source or when the source(s) did not provide a statement regarding the claimant's physical capacities.) B. If yes, are there treatinglexamining source conclusions about the claimanfs limitations or restrictions which are significantly different from your findings? Yes C. If yes, explain why those conclusions are not supported by the evidence in file. Cite the source's name and the statement date. Continued on Page 8
8 IV. ADDITIONAL COMMENTS: 5 THESE FINDINGS COMPLETE THE MEDICAL PORTION OF THE DISABILITY DETERMINATION. MEDICAL CONSULTANT'S SIGNATURE: MEDICAL CONSULTANTS CODE: DATE: Form SSA473CBK ( ) ef ( ) Page 8
9 The following revised PRA Statement will be inserted into the form at its next scheduled reprinting: Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C , as amended by section 2 of the Paperwork Reduction Act of You do not need to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take about 20 minutes to read the instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is listed under U. S. Government agencies in your telephone directory or you may call Social Security at (TTY ). You may send comments on our time estimate above to: SSA, 6401 Security Blvd, Baltimore, MD Send & o comments relating to our time estimate to this address, not the completed form.
4. Pertinent physical findings including: a. Results of tests performed on patient, including dates and specific findings:
Medical Assessment Form Patient: SSN: Please answer each of the following questions about the patient. They concern the patient s claim of entitlement to disability benefits under the Social Security Act.
Residual Functional Capacity Questionnaire MULTIPLE SCLEROSIS
Residual Functional Capacity Questionnaire MULTIPLE SCLEROSIS Patient: DOB: Physician completing this form: Please complete the following questions regarding this patient's impairments and attach all supporting
POST CANCER TREATMENT MEDICAL SOURCE STATEMENT
POST CANCER TREATMENT MEDICAL SOURCE STATEMENT From: Re: (Name of Patient) (Social Security No.) Please answer the following questions concerning your patient's impairments. Attach relevant treatment notes,
Residual Functional Capacity Questionnaire CARDIAC Patient:
Residual Functional Capacity Questionnaire CARDIAC Patient: DOB: Physician completing this form: Please complete the following questions regarding this patient's impairments and attach all supporting treatment
RESIDUAL FUNCTIONAL CAPACITY CERVICAL SPINE
RESIDUAL FUNCTIONAL CAPACITY CERVICAL SPINE Name: Claim #: Date of Injury: Please Print Name of Medical Evaluator: Medical Specialty: Has any medication necessary to relieve and/or control pain and/or
PHYSICAL RESIDUAL FUNCTIONAL CAPACITY QUESTIONNAIRE
PHYSICAL RESIDUAL FUNCTIONAL CAPACITY QUESTIONNAIRE To: Re: SS: The Social Security Administration needs your expert opinion of your patient s functional limitations caused by his/her impairments. You
Residual Functional Capacity Questionnaire PARKINSON S DISEASE
Residual Functional Capacity Questionnaire PARKINSON S DISEASE Patient: DOB: Physician completing this form: Please complete the following questions regarding this patient's impairments and attach all
PHYSICAL RESIDUAL FUNCTIONAL CAPACITY QUESTIONNAIRE
PHYSICAL RESIDUAL FUNCTIONAL CAPACITY QUESTIONNAIRE To: Re: (Name of Patient): (Social Security.): (Date of Birth): Please answer the following questions concerning your patient's impairments. Attach all
Residual Functional Capacity Questionnaire VESTIBULAR DISORDER
Residual Functional Capacity Questionnaire VESTIBULAR DISORDER Patient: DOB: Physician completing this form: Please complete the following questions regarding this patient's impairments and attach all
Residual Functional Capacity Questionnaire CERVICAL SPINE
Residual Functional Capacity Questionnaire CERVICAL SPINE Patient: DOB: Physician completing this form: Please complete the following questions regarding this patient's impairments and attach all supporting
Residual Functional Capacity
Fatigue RFC Name: Claim #: Date of Injury: What is the first date at which your patient s impairment(s) became severe meaning that his Date: or her impairment(s) caused interference their ADL s or ability
Residual Functional Capacity Questionnaire THYROID
Residual Functional Capacity Questionnaire THYROID Patient: DOB: Physician completing this form: Please complete the following questions regarding this patient's impairments and attach all supporting treatment
Duke University/Health System
Duke University/Health System ESSENTIAL AND MARGINAL JOB FUNCTION ANALYSIS FORM Under the guidelines of the American with Disabilities Act (ADA), departments are required to complete an essential function
DISORDERS OF THE SPINE TREATING PHYSICIAN DATA SHEET
DISORDERS OF THE SPINE TREATING PHYSICIAN DATA SHEET Short form FOR REPRESENTATIVE USE ONLY REPRESENTATIVE S NAME AND ADDRESS REPRESENTATIVE S TELEPHONE REPRESENTATIVE S EMAIL PHYSICIAN S NAME AND ADDRESS
Program Specifications RESPIRATORY THERAPIST PROGRAM. Function Number Essential Functions RESPIRATORY THERAPY
WESTERN TECHNICAL COLLEGE Health and Public Safety Division Function Essential Functions RESPIRATORY THERAPY 1 Review, collect and interpret data in the patient s medical record 2 Assess patient s overall
Chief Executive Office Risk Management Division P.O. Box 1723, Modesto, CA Phone (209) Fax (209)
Employer: Occupation: Classification: Company Contact: Analysis Provided By: Stanislaus County Librarian I, II, III Risk Management 1010 10 th Street Modesto, California 95354 (209) 525-5770 Date: February
LUPUS (SLE) MEDICAL SOURCE STATEMENT
LUPUS (SLE) MEDICAL SOURCE STATEMENT From: Re: (Name of Patient) (Social Security No.) Please answer the following questions concerning your patient s impairments. Attach relevant treatment notes, radiologist
1. Does your patient experience dizziness? Yes No 2. Does your patient experience seizures? Yes No
VERTIGO/SEIZURES RESIDUAL FUNCTIONAL CAPACITY Name: Claim #: Date of Injury: Please Print Name of Medical Evaluator: Medical Specialty: What is the first date claimant s impairment(s) became severe meaning
Residual Functional Capacity Questionnaire SYSTEMIC LUPUS ERYTHEMATOSUS
Residual Functional Capacity Questionnaire SYSTEMIC LUPUS ERYTHEMATOSUS Patient: DOB: Physician completing this form: Please complete the following questions regarding this patient's impairments and attach
Residual Functional Capacity Questionnaire AUTO IMMUNE DISORDER
Residual Functional Capacity Questionnaire AUTO IMMUNE DISORDER Patient: DOB: Physician completing this form: Please complete the following questions regarding this patient's impairments and attach all
PHYSICAL AND MENTAL ACTIVITY FORM 10/30/07 MAINTENANCE AND CONSTRUCTION HELPER
PHYSICAL AND MENTAL ACTIVITY FORM 10/30/07 Job Class Class Code MAINTENANCE AND CONSTRUCTION HELPER 3115 Instructions: Below is a list of activities and other characteristics of the job class. First indicate
PHYSICAL AND MENTAL ACTIVITY FORM 10/30/07
PHYSICAL AND MENTAL ACTIVITY FORM 10/30/07 Job Class: Refuse Collection Truck Operator Class Code: 3580 Instructions: Below is a list of activities and other characteristics of the job class. First indicate
PARKINSON S DISEASE MEDICAL ASSESSMENT FORM FOR SOCIAL SECURITY DISABILITY APPLICATION
PARKINSON S DISEASE MEDICAL ASSESSMENT FORM FOR SOCIAL SECURITY DISABILITY APPLICATION TO: RE: SSN: Dr: Please answer the following questions concerning your patient s Parkinson s disease and other impairments.
Office of Human Resources. Crime Scene Investigator I
Office of Human Resources Crime Scene Investigator I General Statement of Duties Performs entry-level professional work while receiving training in the principles, practices, methods, and techniques of
SEIZURES MEDICAL SOURCE STATEMENT
SEIZURES MEDICAL SOURCE STATEMENT From: Re: (Name of Patient) (Social Security No.) Please answer the following questions concerning your patient's seizures. treatment notes, laboratory and test results
SIGN LANGUAGE INTERPRETER Job Description
CATEGORY: INSTRUCTIONAL SUPPORT POSITION STATUS: FULL-TIME FLSA STATUS: NON-EXEMPT SALARY CODE: 52 The incumbent in this job is expected to assist the College in achieving its vision and mission of student
Completing the Physical Job Description Form
Completing the Physical Instructions Page The Physical (PJD) is a form used to gather and document key information about the physical demands of the job. This form will assist with rehabilitation planning,
GENERAL STATEMENT OF JOB. Specific Duties and Responsibilities
GENERAL STATEMENT OF JOB Provide support services involving all aspects of crime scene investigations, including but not limited to, identification and processing of latent fingerprints, technical photography,
Product Brochure (734)
Product Brochure www.fcesoftware.com (734) 904-1895 Our primary focus is to assist physicians and therapists in the objective evaluation of functional abilities by developing, providing and supporting
iappeals Screens for the final PSA (May 24) 5
iappeals Screens for the final PSA (May 24) 5 Welcome! This is the starting point to request a review of our medical decision about your eligibility for disability benefits. There are two parts to this
Prepared by the Canadian Centre for Occupational Health and Safety. 5th Edition
Prepared by the Canadian Centre for Occupational Health and Safety 5th Edition Summary Ergonomics deals with the compatibility between workers and their work. Work is made up of the work environment, workstations,
DEPARTMENT OF TRANSPORTATION. National Highway Traffic Safety Administration. [Docket Number: NHTSA ]
![DEPARTMENT OF TRANSPORTATION. National Highway Traffic Safety Administration. [Docket Number: NHTSA ]](/thumbs/96/128041132.jpg "DEPARTMENT OF TRANSPORTATION. National Highway Traffic Safety Administration. [Docket Number: NHTSA ]")
This document is scheduled to be published in the Federal Register on 10/04/2018 and available online at https://federalregister.gov/d/2018-21623, and on govinfo.gov DEPARTMENT OF TRANSPORTATION National
TULSA COMMUNITY COLLEGE DIAGNOSTIC MEDICAL SONOGRAPHY CLINICAL/ACADEMIC STANDARDS
TULSA COMMUNITY COLLEGE DIAGNOSTIC MEDICAL SONOGRAPHY CLINICAL/ACADEMIC STANDARDS The Diagnostic Medical Sonography Program at Tulsa Community College complies with the 2008 Americans with Disabilities
TASK ANALYSIS REPORT. Job role
TASK ANALYSIS REPORT Job role Hours of work Workplace/ location Equipment/tools Description of normal task Office Based Role 8:30am 5:00pm, 45 minute lunchbreak, ability for flexi time hours 8:15am 5:00pm
Puritz Chiropractic Center Patient Health Questionnaire
PERSONAL INFORMATION Puritz Chiropractic Center Today's Date: File #: First Name: Middle Initial: Last Name: Preferred First Name / Nickname: Social Security #: - - Are you: right handed left handed ambidextrous
ANXIETY-RELATED DISORDERS PROFESSIONAL SOURCE DATA SHEET
ANXIETY-RELATED DISORDERS PROFESSIONAL SOURCE DATA SHEET Short form FOR REPRESENTATIVE USE ONLY REPRESENTATIVE S NAME AND ADDRESS REPRESENTATIVE S TELEPHONE REPRESENTATIVE S EMAIL PROFESSIONAL SOURCE NAME
Office of Human Resources. Crime Scene Investigator II CE2826
Office of Human Resources Crime Scene Investigator II CE2826 General Statement of Duties Performs full performance professional level forensic crime scene investigation and analysis work conducting field
Changes to Chronic Pain Policy Introduction
Changes to Chronic Pain Policy 3.3.5 Introduction As a result of Court of Appeal and WCAT decisions, the WCB is required to make changes to Policy 3.3.5 Eligibility Criteria and Compensation Related to
Name Date Date of Birth Last Name First Name Middle Initial. Employment Information
Zindt Chiropractic Center 3819 S M St Workmen s Compensation Tacoma, WA 98418 Information Name Date Date of Birth Last Name First Name Middle Initial Employment Information Employer s business name (at
Manual Handling/Manual Tasks Checklist
Manual Handling/Manual Instruction: Complete for all manual tasks in consultation with workers undertaking the task. Date checklist completed Date for review Name of person completing checklist Position
RIDGEVIEW MEDICAL CENTER PHYSICAL DEMANDS / POTENTIAL EXPOSURES
RIDGEVIEW MEDICAL CENTER PHYSICAL DEMANDS / POTENTIAL EPOSURES A. DEPARTMENT: Ambulance JOB TITLE: Paramedic/EMT/Paramedic Manager/Supervisor/Adm JOB PURPOSE: Providing emergency medical care SHIFTS: Day
Work Conditioning Evaluation
Client: Gender: OccuPro 3921 30th Ave Suite A Kenosha, WI 53144 (p) 866-470-4440 Work Conditioning Evaluation Jane Q Tees Female Date of Birth: 10/22/1970 Evaluation Date: 1/19/2015 Diagnosis: Referring
NOT RECOMMENDED FOR FULL-TEXT PUBLICATION File Name: 15a0498n.06. No UNITED STATES COURT OF APPEALS FOR THE SIXTH CIRCUIT
NOT RECOMMENDED FOR FULL-TEXT PUBLICATION File Name: 15a0498n.06 UNITED STATES COURT OF APPEALS FOR THE SIXTH CIRCUIT ANTHONY REEVES, Plaintiff-Appellant, v. COMMISSIONER OF SOCIAL SECURITY, Defendant-Appellee.
Nashoba Valley Chiropractic (978)
(978) 448-2800 Last Name: First Name: MI: Mailing Address: City: State: Zip: O.K. to call home? Yes No Home Phone: O.K. to call cell? Yes No: Cell Phone: Sex M F Birthdate: Age: Marital Status: Single
Commonwealth Health Corporation NEXT
Commonwealth Health Corporation This computer-based learning (CBL) module details important aspects of musculoskeletal disorders, body mechanics and ergonomics in the workplace. It examines: what causes
Instructions for Attorneys on completing the Patient Questionnaire
Instructions for Attorneys on completing the Patient Questionnaire (please remove this cover page before providing to the questionnaire to the patient) In order to minimize the amount of time that is spent
Announcing a Position Opening: Head of School Northwest School for Deaf and Hard-of-Hearing Children
Announcing a Position Opening: Head of School Northwest School for Deaf and Hard-of-Hearing Children Overview Northwest School for Deaf and Hard-of-Hearing Children is a national leader in the education
Relevant Listings for Evaluating Traumatic Brain Injury at Step 3 of the Sequential Evaluation
Relevant Listings for Evaluating Traumatic Brain Injury at Step 3 of the Sequential Evaluation I. Neurological Disorders Revised Medical Criteria for Evaluating Neurological Disorders went into effect
Hospice of Montezuma
Hospice of Montezuma CNA/HHA Physical Demands JOB SUMMARY Under the supervision of a licensed nurse the Certified Nurse Aid has responsibility for transportation to and direct patient care for those assigned
Self-Evaluation for Compliance with Section 504 Accessibility Requirements for Persons with Disabilities
OREGON COMMUNITY DEVELOPMENT BLOCK GRANT PROGRAM Self-Evaluation for Compliance with Section 504 Accessibility Requirements for Persons with Disabilities Note: This self-evaluation must cover all programs
Ergonomics. Best Practices Lifting Tips and Techniques (EOHSS)
Ergonomics Best Practices Lifting Tips and Techniques Environmental and Occupational Health Support Services Environmental and Occupational Health Support Services (EOHSS) Ergonomics: Agenda Ergonomics
JOB TASK ANALYSIS. Stanislaus County. Therapist Aide. CEO-Recruitment Unit
JOB TASK ANALYSIS Employer: Occupation: Company Contact: Stanislaus County Therapist Aide CEO-Recruitment Unit Date: July 2001 Analysis Provided By: Lyle Andersen, PT, CWCE Andersen & Baim Physical Therapy,
Proposed Data Collection Submitted for Public Comment and. AGENCY: Centers for Disease Control and Prevention (CDC),
This document is scheduled to be published in the Federal Register on 03/06/2019 and available online at https://federalregister.gov/d/2019-04011, and on govinfo.gov BILLING CODE: 4163-18-P DEPARTMENT
Respiratory Questionnaire
Respiratory Questionnaire Date: Name: SS#: Sex: M F Height: Weight: DOB: Age: Employer: Department: Job Title: Phone # where you can be reached regarding this questionnaire (include area code): What is
Sports and Spine Physical Therapy
Sports and Spine Physical Therapy PATIENT MEDICAL HISTORY Name: Referring Physician: How did you hear about Sports & Spine Physical Therapy? First date of pain: Have you had surgery for this injury? Yes
Office Ergonomics: Best Practices and Results. Mike Lampl, MS, CPE Ohio Bureau of Workers Compensation (BWC)
Office Ergonomics: Best Practices and Results Mike Lampl, MS, CPE Ohio Bureau of Workers Compensation (BWC) www.ohiobwc.com Analysis of Injury Data Nineteen organizations received safety grants to incorporate
Office Ergonomics and Workstation Analysis
Office Ergonomics and Workstation Analysis Ergonomics is the study of the relationship between people and their environment. In the workplace, ergonomics is the science of designing or redesigning the
Ergonomics. For additional assistance, contact the Occupational Safety office to schedule an evaluation.
Ergonomics 1. Purpose: Virginia Commonwealth University Department of Safety and Risk and Risk Management (SRM) developed this program to improve the health and happiness of it s employees by assisting
Plaintiff, Case # 17-CV-518-FPG INTRODUCTION. seeking review of the final decision of the Acting Commissioner of Social Security that denied her
Bryant v. Berryhill Doc. 13 UNITED STATES DISTRICT COURT WESTERN DISTRICT OF NEW YORK LINDA MARIE BRYANT, v. Plaintiff, Case # 17-CV-518-FPG DECISION AND ORDER NANCY A. BERRYHILL, DEPUTY COMMISSIONER OF
Welcome to Carefree Chiropractic! Please take your time completing the following information so we can serve you to the best of our ability.
Welcome to Carefree Chiropractic! Please take your time completing the following information so we can serve you to the best of our ability. Patient Information Title: Mr. Mrs. Miss Ms. Dr. (circle one)
Ergonomics: Why do workers get injured? Presented by: Steve Bilan Ergonomic Specialist
Ergonomics: Why do workers get injured? Presented by: Steve Bilan Ergonomic Specialist What do you know about Ergonomics? Ergonomics is the study of designing equipment and devices that fit the human body,
Respiratory Fitness Questionnaire
Part A, Section 1 and 2 (for full-face and SCBA respirators) Company Name: 1. Date: Part A. Section 1. (Mandatory) The following information must be provided by every employee who has been selected to
Agency Information Collection Activities; Submission for Office of Management and
This document is scheduled to be published in the Federal Register on 02/19/2019 and available online at https://federalregister.gov/d/2019-02596, and on govinfo.gov 4164-01-P DEPARTMENT OF HEALTH AND
Where Small Voices Can Be Heard
Job Title: Forensic Interviewer Reports To: Program Director Starting Salary: $34,000 - $38,000 Work Hours: Full Time FLSA: Professional Exemption/Salaried Classification: 8864 Social Services Where Small
Risk assessment of physical workload situations
Risk assessment of physical workload situations Detailed instructions for the application of the Key Indicator Method Manual Handling Operations (KIM MO) Published by the Federal Institute for Occupational
ORPAT VALIDATION STUDY FOR CORRECTIONS OFFICER
ORPAT VALIDATION STUDY FOR CORRECTIONS OFFICER Authored By: Rick Gardner Senior Research Analyst Date: 2006 ORPAT VALIDATION Introduction The Oregon Physical Abilities Test (ORPAT) was originally developed
The following guidelines are applicable to office workers who sit at a desk and/or work on computers.
STANDARD OPERATING PROCEDURES (SOP) FOR COMPUTER WORK, DESK TOP General Guidelines-Best Practices: The following guidelines are applicable to office workers who sit at a desk and/or work on computers.
Office of Human Resources. Forensic Scientist II CE0412
Office of Human Resources Forensic Scientist II CE0412 General Statement of Duties Performs full performance level forensic work including applying the physical sciences to the investigation of crimes,
Appendix A: Repetitive Motion Injuries (Cal/OSHA Standard)
20.16.1 Appendix A: Repetitive Motion Injuries (Cal/OSHA Standard) 5110. Repetitive Motion Injuries. (a) Scope and application. This section shall apply to a job, process, operation where a repetitive
[HAC ADVOCACY MANUAL]
![[HAC ADVOCACY MANUAL]](/thumbs/95/122979260.jpg "[HAC ADVOCACY MANUAL]")
2016 Charles Bruce, Esq. [HAC ADVOCACY MANUAL] Best Practices and Policies for delivering Pro Bono legal services consistent with the mission and values of the Homeless Action Center. Table of Contents
BILL TO: Comprehensive Health Services, Inc Parkridge Blvd, Suite 200 Reston, VA (703) or (800)
DHS FITNESS TESTING INSTRUCTIONS NOTE: Failure to comply with these instructions will result in a delay of the candidate s application process and may ultimately deter payment to your facility. 1.) 2.)
Principal, Deaf and Hard of Hearing Program Class Code: 1450 Work Days: 220
Orange County Department of Education Human Resources Department Certificated Management Class Specification Principal, Deaf and Hard of Hearing Program Class Code: 1450 Work Days: 220 GENERAL PURPOSE
ADMISSIONS POLICIES ADMISSIONS CRITERIA
ADMISSIONS CRITERIA ADMISSIONS POLICIES The Louisiana College PTA program selects a maximum of 24 students each year to enroll in the technical education component of the program. To ensure that the PTA
OPNAVINST G 30 Dec 05
Appendix 23-B Computer Workstation Checklist The computer workstation checklist is one method available for performing computer workstation assessments. The checklist is designed to be printed as two double-sided
SPORTS AND SPINE PHYSICAL THERAPY, INC. PATIENT MEDICAL HISTORY
SPORTS AND SPINE PHYSICAL THERAPY, INC. PATIENT MEDICAL HISTORY Name: Referring Physician: How did you hear about Sports and Spine Physical Therapy? First date of onset of pain: Have you had surgery for
b. Entities that lease or rent space for their events but have no permanent public office or facility must also follow Title III of the ADA.
To Whom it May Concern: The National Association of the Deaf (NAD) seeks to ensure that all theaters, concert halls, or other places of exhibition or entertainment understand their legal obligations with
RIDGEVIEW MEDICAL CENTER PHYSICAL DEMANDS / POTENTIAL EXPOSURES
RIDGEVIEW MEDICAL CENTER PHYSICAL DEMANDS / POTENTIAL EXPOSURES A. DEPARTMENT: Various Departments JOB TITLE: Health Care Clinical 2 JOB PURPOSE: Provide Health Care Services to ambulatory SHIFTS: Day
Social Security No. Date of Birth Sex Male Female Height Weight lbs Occupation Marital Status
Workers Compensation Intake Form File Number (Office Use) Patient Information: Today s Date Home Phone Name Cell Phone I prefer to be called Preferred Contact Home Cell Email Social Security No. Date of
ERGONOMIC CHECKLIST. Area: Date of Survey: Assessors Name: BODY PART RISK FACTORS NECK/SHOULDER ELBOW HAND/WRIST Carpel tunnel
ERGONOMIC CHECKLIST Area: Date of Survey: Assessors Name: Job Description Job Risk priority as per Risk Assessment ( X applicable column) H H-M M M-L L ERGONOMIC FACTORS Repetition BODY PART RISK FACTORS
The Whole Child Approach of the Social Security Administration:
THESE ARE THE FORMS I USE THIS IS NOT LEGAL ADVICE AND INTENDED TO SUPPLEMENT YOUR PARTICULAR FACTUAL SITUATION ONLY It is crucial you educate yourself on the Social Security Regulations that define and
YES YES YES YES NO NO NO NO YES YES YES YES YES YES YES YES YES YES YES YES NO NO NO NO NO NO NO NO NO NO NO NO YES
respirator. 1. Do you currently smoke tobacco, or have you smoked tobacco in the last month? 2. Have you ever had any of the following conditions? A. Seizures (fits) B. Diabetes (sugar disease) C. Allergic
ERI Safety Videos Videos for Safety Meetings. ERGONOMICS EMPLOYEE TRAINING: Preventing Musculoskeletal Disorders. Leader s Guide 2001, ERI PRODUCTIONS
ERI Safety Videos Videos for Safety Meetings 2120 ERGONOMICS EMPLOYEE TRAINING: Preventing Musculoskeletal Disorders Leader s Guide 2001, ERI PRODUCTIONS ERGONOMICS EMPLOYEE TRAINING: Preventing Musculoskeletal
North Jersey Physical Therapy Medical History Questionnaire. Name: Date of Birth: Age: Occupation: Currently working?:
Today s Date: North Jersey Physical Therapy Medical History Questionnaire Name: Date of Birth: Age: Occupation: Currently working?: How did you hear about our practice: Referring Physician (full name &
Maine. Video Display Terminal Law. Training Program SAFE345
Maine Video Display Terminal Law Training Program By the end of this presentation you will be able to: Identify the elements of the law Identify the training requirements Define ergonomics and its benefits
PHYSICAL DEMANDS EVALUATION FOR MINING APPRENTICESHIP PROGRAM. Job Title: Industrial Electrician Apprentice
PHYSICAL DEMANDS EVALUATION FOR MINING APPRENTICESHIP PROGRAM A. JOB DEMANDS: Job Title: Industrial Electrician Apprentice 1. Hours worked: Regular: 12 hours Overtime: maximum 3 of 4 days off Tours/Sets:
Due Process Hearing Request Information Sheet and Model Form
Oregon Department of Education Office of Learning/Student Services 255 Capitol Street NE Dispute Resolution Section Salem, OR 97310-0203 (503) 947-5689 Due Process Hearing Request Information Sheet and
WARM UP AND WARM DOWN ROUTINE: warm up and warm down routines should be performed before and after exercising.
WARM UP AND WARM DOWN ROUTINE: warm up and warm down routines should be performed before and after exercising. 1. 1. Stand with your feet 30cm apart, hold the Bullworker inner grips with your arms extended
Patient Profile. Full Name: Address: Work Phone: Date of Birth: Social Security #: (Circle One) Full Time / Part Time. Emergency Contact: Number:
Patient Profile Full Name: Address: City: State: Zip Code: Home Phone: Cell Phone: Work Phone: Date of Birth: Social Security #: Email Address: Employer: (Circle One) Full Time / Part Time Emergency Contact:
RIDGEVIEW MEDICAL CENTER PHYSICAL DEMANDS / POTENTIAL EXPOSURES
RIDGEVIEW MEDICAL CENTER PHYSICAL DEMANDS / POTENTIAL EXPOSURES A. DEPARTMENT: Various Departments JOB TITLE: Health Care Clinical 3 JOB PURPOSE: Provide patient care in a hospital inpatient or SHIFTS:
[HAC ADVOCACY MANUAL]
![[HAC ADVOCACY MANUAL]](/thumbs/95/122979563.jpg "[HAC ADVOCACY MANUAL]")
2018 Charles Bruce, Esq. [HAC ADVOCACY MANUAL] Best Practices and Policies for delivering Pro Bono legal services consistent with the mission and values of the Homeless Action Center. Table of Contents
Gordley Family Chiropractic Clinic Patient Introduction Card. First Name MI Last Name Date Address Married Single Mailing Address City State Zip Code
Gordley Family Chiropractic Clinic Patient Introduction Card First Name MI Last Name Date Address Married Single Mailing Address Phone City State Zip Code Birth Date Social Security Number Employed By
Working with Your Local Hearing Office
8th Circuit Social Security Disability Working with Your Local Hearing Office Presented By 3:45 p.m.-4:45 p.m. Hon. John Sandbothe, ALJ SSA Office of Disability Adjudication and Review West Des Moines,
Advanced EMT (AEMT) Program Application
Advanced EMT (AEMT) Program Application Thank you for your interest in the Advanced EMT course. This course is presented in two formats; a blended format which includes the online component through Desire2Learn
ESD 113 Sound to Harbor Head Start/ECEAP Procedure 620 Page 1 of 6 HEALTH SCREENINGS PROCEDURE. Health Section
Page 1 of 6 HEALTH SCREENINGS PROCEDURE 1. Head Start children will be screened within 45 days of enrollment and ECEAP children will be screened within 90 days of enrollment. ECEAP children at Head Start
Strains and Sprains. Signs and Symptoms of MSI
Strains and Sprains Strains and sprains (known as musculoskeletal injuries) are the most common type of workrelated injury. Musculoskeletal injury (MSI) is a term used to describe an injury of the muscles,
PHYSICIAN S REPORT SPECIAL NEEDS Patient s Name: Date of Birth:
Guiding Eyes for the Blind 611 Granite Springs Road, Yorktown Heights, New York 10598 PHONE 914 243-2216 admissions@guidingeyes.org FAX 914 243-2232 PHYSICIAN S REPORT SPECIAL NEEDS Patient s Name: Date
CLINICAL PSYCHOLOGIST I/II
THE COUNTY OF SHASTA http://agency.governmentjobs.com/shasta/default.cfm INVITES APPLICATIONS FOR CLINICAL PSYCHOLOGIST I/II CLINICAL PSYCHOLOGIST I: $5,172 - $6,601 APPROX. MONTHLY / $29.84 - $38.09 APPROX.
FCE JSA EJA. When is your patient safe to return to work? Introduction. The Industrial Rehabilitation System. Work Conditioning.
When is your patient safe to return to work? Introduction Presented by: Jonathan Reynolds, PhD, PT Bloswick, 2000 INJURY FCE JSA EJA Physician Chiropractor Physical Therapist Occ. Therapist CASE RESOLUTION
Risk Management Department. Office Ergonomics
Risk Management Department Office 1 Introduction In order to prevent injuries, reduce stress and improve work productivity, APS has developed this training to provide you the knowledge to help yourself
a. Preferred lift b. Floor to knuckle lift c. Knuckle to shoulder lift d. Shoulder to overhead lift e. Bimanual carry f. Push/pull
TITLE/ DESCRIPTION: Work Capacity Evaluation DEPARTMENT: Rehab Services PERSONNEL: PT, Work Hardening Specialist, Clerical EFFECTIVE DATE: 3/00 REVIEWED: 6/00 6/17 REVISED: PURPOSE of WCE A. Establish