WPC 0F`Mws 1Nd OؙIDYr%ϽIB/@;l\Dd?u߄1OnZ0dkDjhB!TÞRʐy zL^5xQZ)ȉ]}*!Ykzpۖ'%%gotGW cbK^{J햱ϰ,Fg +ia;C=t\F\Y 4iUA`,"&;3XƒO(%% (      :     4      B.0  Effectofapplicant'sdisability:Describeintermsof: 1'0 %% 1?lX9,X9,X?0  1.0%%Mobilityandlimitationofordinaryphysicalactivities: (* %% (  |    &   x  0  2.0%%Dependenceonothersforhelporservice: (r%% (     n   h 0  3.0%%Appliancesorprosthesesnecessary(forexample:hearingaid,crutches,artificiallimb,etc.) (%% (  d    ^    0  4.0%%Attitudeandadjustment:(Whatcanapplicantdowithremainingcapacities?) (Z %% (  !T   "    P$!   %J# BlX9,lX9,XBC.0  Mentalability:Evaluatebrieflyfromyourobservation,notinganyunusualbehaviorand,ifpertinent,include &$ applicant'sabilitytoread,write,handlefinances,participateininterview,understandandfollowdirections,etc. ('Z%%% (  )&   V*'    +P)!   ,*"   L.+#    PageIof7Pages /F-$ ThisformsupersedesFormDDSMA10b,874. "\0.% "*ld!d(#dd (#X%X%l,dd ,,dd ,Xdd ,,dd ,Xdd ,,dd ,Sdd ,dd ,dd +  /[XX / @  X$X(I.SOCIALINFORMATION(continued)#(XX$# =3$d[  =D.0  Ifcurrentlyemployed,stateindetailthetypeofwork,theamountandkindofphysicalactivityinvolved,the < supervisionrequired,andaveragemonthlyearningsandhoursworked.Istheworksubsidized,requiredbySRS,or  sheltered? /%`%%  /       \     V         R      L          H     B         >    8   %   %E.0  DisabilityBenefits:HastheapplicanteverfiledforSocialSecurityorSupplementalSecurityIncomedisability 4 benefits? 4*%%  4 'D ' 'D ' 'D ' 'D ' 'D ' 'D 'DateFiled 'D 'DateClaimAllowed 'D 'DateClaimDenied 'D 'OASDI: ([> ( -#>[ -No !> ! -#>  -Yes '>! ' %[>" % +[>#[ + +[>$[ + 1'>%[ 1 * &  *SSI: ([:' ( -#:([ -No ([[:) ( -#:*[[ -Yes ':+ ' %[:, % <    h +[:-[ + +[:.[ + 1':/[ 1Indicateanyreasonfordenialofclaim(orattachdocumentationofdenial): %40  %   1    0"2    #*!3    $|"4    &    x' %6    (r&7    *'8    n+)9    ,h*:    .+;   % d/ -<  %@BB"Page2of7Pages%0^.= !   %*d "ddd ,dd ,Xdd X,dd ,Xdd X,dd ,Sdd Sdd dd X%X%,Zdd ,Zdd ,dd ,Zdd ,Zdd ,Qdd ," dd ,; dd ,^dd +  /[XX /  II.MEDICALHISTORY =3$d [  =Listthename,addressandtelephonenumberof  theDOCTORWHOHASCLAIMANT'SMEDICALRECORDS. * | *K  Ifclaimanthasnodoctor,  checkhere: %[|0 %^ 8['|[ 8 D[3$&[ D =3$& [ =Name .$x   .AreaCodeandTelephone ,[x   , 2[!r [ 2 4*r [ 4Address(Street,City,State,Zip) ,[   , 4*n  [  4ReasonsforVisits ,[ h   , 4* [  4TypeofTreatmentReceived ,[d   , 4*^[  4B.HasclaimantseenANYOTHERDOCTORsincehisillnessorinjurybegan? *   * %[Z % 1'Z[ 1Yes ([Z ( -#Z[ -No +!Z +NoIf''Yes,''showthefollowing: .$Z .Name .$T .AreaCodeandTelephoneName ,[T , 2[![ 2 4*[ 4Address(Street,City,State,Zip) ,[P  , 4*J [  4HowOftenDoesClaimantSeeHim? * ! *DateClaimantFirstSawHim? +!" +DateClaimantLastSawHim? %# %  F$   F%  +[ F& +ReasonsforVisits 4*$@'[  4 ([ (  (TypeofTreatmentReceived ;t*$<)[  ; 4* 6*t  4IftheclaimanthasseenOTHERDOCTORSsincehisillnessbegan,listtheirnames,addresses,datesandreasonsfor !+ visitsunder''Remarks,''Page7. 5[[$"F ,  5 =3$#!-[[  =C.0  HasclaimantbeenHOSPITALIZEDortreatedataCLINICforhisillnessorinjury? 4*B%".%%  4 %[&<$/ % -#&<$0[ -Yes '&<$1 ' %[&<$2 % -#&<$3[ -No +!&<$4 +Yesif''Yes,''showthefollowing: ,[&<$5 , 4*'%6[  4NameofHospitalorClinic .$8)&7 .PatientorClinicNumber %8)&8 %  *2(9  ([ *2(: (Address(Street,City,State,Zip) 4*$+);[  4  .-*<    .(,=   ([ /z->  (_@BB"Page3of7Pages4*($1.? " [  4*d #dZdd ZZdd Zdd Zdd ZZdd ZQdd Q" dd " ; dd ; ^dd ^X%X%,Zdd ,Zdd ,dd ,Zdd ,Zdd ,Qdd ,dd ,dd ,3dd ,3dd ,3dd +  (XX (@ II.MEDICALHISTORY(continued) 1[$d  1Wasclaimantaninpatient?(Stayedatleastovernight) 9/$[  9 %[h % -#h[ -Yes 'h ' %[h % -#h[ -No +!h +If''Yes,DatesofAdmissions: * h  * 'h " ' 'h " ' 'h " ' 'b  ' 'b ' 'b ' 'b ' 'b ' +!b +DatesofDischarge: 1[[ b 1 =[[,!b"[[ = =[[,!b"[[ = :0!b"[[ :WasclaimantanOutpatient? *    * %[^  % -#^ [ -Yes '^  ' %[^  % -#^ [ -No +!^  +If''Yes,DatesofVisits: 1[ ^  1 =[,!^ "[ = =[,!^  "[ = :0!^ !"[ :ReasonforHospitalizationorClinicVisits ,[ X"  , 4* #[  4TypeofTreatmentReceived ,[T $  , ;t*N %[  ;Ifclaimanthasbeeninotherhospitalsorclinicsforhisillnessorinjury,listthenames,addresses,patientorclinic  & numbers,datesandreasonsforhospitalizationorclinicvisitsunder''Remarks,''Page7. =3$^'t  =D.0  HasclaimantbeenseenbyOTHERAGENCIESforhisinjuryorillness?(VA,Workmen'sCompensation, ( VocationalRehabilitation,MentalHealthCenter,StateInstitution,etc.) 4*n)%%  4 %[* % -#+[ -Yes ', ' %[- % -#.[ -No +!/ +If''Yes,showthefollowing: ,[0 , 4*j1[  4NameofAgency .$d2 .ClaimNumber ,[d3 , 2[!4[ 2 4*5[ 4Address(Street,City,Town,Zip) ,[`6  , 4*Z7[  4DatesofVisits ,[8  , 7-V9[  7TypeofTreatmentorExaminationReceived >[-$P:  > 4*;[  4   III.INFORMATIONABOUTYOUREDUCATION .$L!<   .M=A.0  Whatisthehighestgradeofschoolthatyoucompletedandwhen? 6[%"N =%%  6 4*#!>[  4B.0  Haveyougonetotradeorvocationalschoolorhadanytypeofspecialtraining? 4*J%"?%%  4 %[&D$@ % -#&D$A[ -Yes '&D$B ' %[&D$C % -#&D$D[ -No +!&D$E +If''Yes,''show: .$&D$F .Thetypeoftradeorvocationalschoolortraining ,['%G  , 4*@)&H[  4Approximatedatesyouattended ,[*:(I  , 4*+)J[  4Howtheschoolingortrainingwasusedinanyworkyoudid %6-*K  % ([ .0,L  (@BB"Page4of7Pages 4*(/-M ! [  4**d "dZdd ZZdd Zdd Zdd ZZdd ZQdd Qdd dd 3dd 33dd 33dd 3X%X%*,dd ,dd ,dd ,dd ,dd ,3dd ,dd ,dd ,dd ,dd +  /[XX / @  III.INFORMATIONABOUTTHEWORKYOUDID(continued) =3$d[  =Listalljobsyouhavehadinthepast15yearsbeforeyoustoppedworking,beginningwithyourusualjob.Normally,this  willbethekindofworkyoudidthelongest.(Ifyouhavea6thgradeeducationorlessanddidonlyheavyunskilled | laborfor35yearsormore,listallofthejobsyouhavehadsinceyoubegantowork.Ifyouneedmorespace,listunder : ''Remarks,''Page7. P  1[[[   1@??JOBTITLE ` (Besuretobeginwith   yourusualjob.) A[[[0!  [[[ A  TYPEOFBUSINESS D[[[3$   [[[ D@';DATESWORKED `  @%;(MonthandYear)   FromTo @[[[/$ [[[ @  DAYS ` PER   WEEK C[[[[0!  [[[ CI@''BK!RATEOFPAY ` @99=K!(Perhour,day,week,   @zzAK!month,year) 8[)$ [[[[ 8 0[!. [ 0 /[ . [ / ,[. [ , ,[. [ , 4[[!. [ 4 ,[[. [[ , -[[ ( [[ - ,[[ ( [[ , )[[ ( [[ ) )[[ ( [[ ) 1[[[ ( [[ 1 ,[[ ( ![[[ , -[[ z "[[ - ,[[ z #[[ , )[[ z $[[ ) )[[ z %[[ ) 1[[[ z &[[ 1 ,[[ z '[[[ , -[[$ ([[ - ,[[$ )[[ , )[[$ *[[ ) )[[$ +[[ ) 1[[[$ ,[[ 1 ,[[$ -[[[ , -[[v.[[ - ,[[v/[[ , )[[v0[[ ) )[[v1[[ ) 1[[[v2[[ 1 ,[[v3[[[ , -[[p4[[ - ,[[p5[[ , )[[p6[[ ) )[[p7[[ ) 1[[[p8[[ 1 ,[[p9[[[ , -[[:[[ - ,[[;[[ , )[[<[[ ) )[[=[[ ) 1[[[>[[ 1 .[[[?[[[ . /[[[l@[[[ / .[[[lA[[[ . +[[[lB[[[ + +[[[lC[[[ + 1[[[[lD[[[ 1 4*lE[[[[ 4ProvidethefollowinginformationforyourusualjobshowninItemA,Line1. .$fF  .Inyourjobdidyou: .$G .Usemachines,toolsorequipmentofanykind? $H $ -#I -Yes !J ! -#K -No +!L + .$b M .Usetechnicalknowledgeorskills? '[b N ' -#b O[ -Yes $[b P $ -#b Q[ -No +!b R + .$\S .Writematerial,completereports,orperform \T similarduties? 0[#rU 0 6,!\V[ 6Yes -[ rX - 6,!\Y[ 6No +!r[ + .$l\ .Havesupervisoryresponsibilities? +[[l] + -#l^[[ -Yes ([[l_ ( -#l`[[ -No +!la + 1[$b  1C.0  Describeyourbasicduties(Explainwhatyoudidandhowyoudidit.)below.Also,explainall''Yes''answersby hc givingaFULLDESCRIPTIONofthetypesofmachines,tools,orequipmentyouusedandtheexactoperationyou &d performed,thetechnicalknowledgeorskillsinvolved,thetypeofwritingyoudid,andthenatureofanyreports,and e thenumberofpeopleyousupervisedandtheextentofyoursupervision. >4. Jf%%[  >  !g    F# h    $@"i    %#j    <'$k    (6&l    )'m    2+(n    ,,*o   #[ -~+p  # 4*(/,q[  4  Page5of7Pages%z0".r     %Ї*d ddd dd dd dd dd 3dd 3dd dd dd dd X%X%,dd ,wdd ,dd ,dd ,dd ,dd ,dd ,dd ,dd ,dd ,dd ,dd ,dd ,dd ,dd ,dd ,dd ,.dd +  /[XX /III.INFORMATIONABOUTTHEWORKYOUDID(continued) =3$d"[ =  D.0  Describethekindandamountofphysicalactivitythisjobinvolvedduringatypicaldayintermsof: 4*%% 4 G=h  ?1.?G1. J@1h3  ?1. ? JWalking .$h .Walking(Circlethenumberofhoursadayspentwalking.) 5+h # 50 G=h #   ?1?G1 RH'h  ?1 ?  @2@R2 RH'h   @2 @  @3@R3 RH'h   @3 @  @4@R4 RH'h   @4 @  @5@R5 RH'h   @5 @  @6@R6 RH'h   @6 @  @7@R7 RH'h  @7 @   @8 @R8 <2'h   @8  @ < G=b  @2.@G2. J@1b3  @2. @ JStanding .$b .(Circlethenumberofhoursadayspentstanding.) 5+b # 50 G=b #   ?1?G1 RH'b  ?1 ?  @2@R2 RH'b  @2 @  @3@R3 RH'b  @3 @  @4@R4 RH'b  @4 @  @5@R5 RH'b  @5 @  @6@R6 RH'b  @6 @  @7@R7 RH'b  @7 @   @8 @R8 <2'b   @8  @ < G=   @3.@G3. J@1 3  @3. @ JSitting .$  .(Circlethenumberofhoursadayspentsitting.) 5+   # 50 G= ! #   ?1?G1 RH' "  ?1 ?  @2@R2 RH' #  @2 @  @3@R3 RH' $  @3 @  @4@R4 RH' %  @4 @  @5@R5 RH' &  @5 @  @6@R6 RH' '  @6 @  @7@R7 RH' (  @7 @   @8 @R8 <2' )   @8  @ < G=^ *  @4.@G4. J@1^ +3  @4. @ JBending .$^ , .(Circlehowoftenadayyouhadtobend.) * ^ - * '^ . ' '^ / ' '^ 0 ' '^ 1 ' '^ 2 ' '^ 3 ' '^ 4 ' '^ 5 'Ѐ '^ 6 ' ' X7 ' +! X83 + *  X9 *Never ' X: 'Occasionally +! X; +Frequently *  X< *Constantly +! X= + v     *  X>  * ' ? ' +! @3 + ! A !   B    C    D Ѐ "  E " v     *  F  * G=T G  @5.@G5. J@1T H3  @5. @ JReaching * T I *Never 'T J 'Occasionally +!T K +Frequently * T L *Constantly +!T M + * T N  * 'N O ' +!N P3 + !N Q ! `   N R   N S   N T  " N U " v     * N V  * G= W  @6.@G6. J@1 X3  @6. @ JLiftingandCarrying *  Y * 'JZ ' +!J[3 +Describebelowwhatwasliftedandhowfaritwascarried: * J\ * 'D] ' "D^3 " ! D_ ! '` ' "a3 " ! b ! '@c ' "@d3 " ! @e ! ':f ' ":g3 " ! :h ! 'i ' +!j3 +Checktheheaviestweightliftedandtheweightfrequentlyliftedand/orcarried: * k * '6l ' '6m ' +!6n +HEAVIESTWEIGHTLIFTED * 6o * '6p ' +!6q +WEIGHTFREQUENTLYLIFTED/CARRIED * 6r  * '0s ' %[0t % 1'0u[ 110lbs. * 0v * %[0w % 1'0x[ 1Upto10lbs. * 0y  * 'z ' %[{ % 1'|[ 120lbs. * } * ~  "  "Upto25lbs. *   * ', ' %[, % 1',[ 150lbs. * , * %[[, % 1',[[ 1Upto50lbs. * ,  * '~& ' %[~& % 1'~&[ 1100lbs. * ~& * ~&  " ~& "Over50lbs. * ~&  * 'x ' 'x ' +!x + * x * %[[x % 1'x[[ 1Over100lbs. %x  %  "!   t"    #n!   %"   j&$   'd%   )&   `*(   +Z)   -*  #[ V.+ # 4*/P-[ 4  Page6of7Pages%0.  #  %!Y !ww !  * d$ddd wdd wdd dd dd dd dd dd dd dd dd dd dd dd dd dd dd .dd .X%X%, dd , dd , dd +  /[XX / @CC$X$X(IV.REMARKS#(XX$m# =3$d[ =Seethissectionforadditionalspacetoansweranypreviousquestionsandtoexplainanyothersocialfactorswhichyou < feelshouldbeconsideredindeterminingifdisabilityexists. % %  L   F      B     <        8    2        .    (   z   $   v   p      l   f      b     \   "   X#!   $R"   %#   N'$   (H&   )'  [ D+(   +[,>*![ + <    h  $  | +[,>*"[ + -#,>*#[ -SocialWorker '-+$ 'Date '-+% 'SupervisororDirector 0&-+& 0@BB"Page7of7Pages* :/,'  !  *@*