OAO staff will prepare an examination of evidence document
similar to the following for use by the FO:
EXAMINATION OF EVIDENCE
| In the case
of _______________________________ (Claimant) | Claim for _______________________________ (Social
Security Number) | 
| _______________________________ (Wage
Earner) | _______________________________ (Social
Security Number) | 
DESCRIPTION OF ADDITIONAL EVIDENCE
[List Additional Evidence Here]
Claimant to check any applicable statements:
___ I examined the above listed evidence and have no comments
to make.
___ I examined the above listed evidence and have noted comments
on the attached documents.
___ I have no further evidence to submit.
___ I am submitting the following evidence:
___ I do not wish the evidence to be forwarded to my medical
source.
___ I wish the evidence to be forwarded to my medical source
for comments.
The name and address of my medical source is:
[Add the following options as applicable per the instructions
in Hearings, Appeals and Litigation Law manual HA 01320.016]
[___ I do not wish to request a supplemental hearing to discuss
this evidence.]
[___ I wish to request a supplemental hearing to discuss this
evidence.]
[___ I do not wish to question, either orally or in writing,
the author(s) of this (these) report(s).]
[___ I wish to question, either orally or in writing, the
author(s) of this (these) report(s).]
| ____________________________________ | __________________ | 
| (Signature) | (Date) | 
The claimant did not respond to our 10-day letter.
| ____________________________________ | __________________ | 
| (Signature/Title of Social
Security Employee) | (Date) |