TN 49 (08-08)

DI 11010.205 Completing the Paper SSA-831

The following section contains FO procedure for completing the paper SSA-831 (Disability Determination and Transmittal) in disability claims that are Electronic Disability Collect System (EDCS) exclusions or limitations (Certified Electronic Folder (CEF) Exclusions and Limitations - DI 81010.030).

NOTE: Complete Substantial Gainful Activity (SGA) denials in EDCS unless the case is an exclusion. See Using Form Attestation for Work Activity Reports (DI 81010.120) and Processing Field Office (FO) Determinations (DI 81010.140C) for instructions on processing SGA denials electronically.

A. How to complete items 1-19

1. Item 1 - destination

Check the ODO block if the current claim is being transmitted to ODO. If the claim is being transmitted to the PSC, line through ODO and enter PSC/DPB. Check the “OIO” block if the claimant's address is outside the 50 States, District of Columbia, Puerto Rico, American Samoa, Guam, the Northern Mariana Islands and U.S. Virgin Islands. Check the “DDS” block in all other cases.

2. Item 2 - DDS code

For cases to be forwarded to a Disability Determination Services (DDS), show the appropriate 3 digit DDS code listed in the Detailed Office/Organization Resource System (DOORS).

3. Item 3 - filing date

Show the actual month, day, and year of filing of the current application. The only exception to this rule is when an earlier filing date (i.e., protective filing) is established based on a written or telephone request for benefits, see Protective Filing (GN 00204.010), in which case show the earlier date. If there are two or more current applications, show the earliest filing date.

4. Item 4 - SSN

Enter the Social Security Number (SSN) of the individual on whose E/R the benefits are being claimed. This is the primary SSN even though the individual has multiple SSNs and may have used another SSN at the field office (FO) interview or when he/she filed a prior claim. In CDB and DWB (including Medicare only) claims, also show the claim symbol e.g., HC1, W, E, and D. In End Stage Renal Disease (ESRD) claims, enter the spouse's or parent's SSN if the ESRD claimant is receiving benefits on that SSN. In all other ESRD cases, use the claimant's SSN.

5. Item 5 - name and address of claimant

Enter the name and mailing address of the claimant. If a proper applicant, see Proper Applicant - GN 00204.003, has filed on behalf of the claimant, enter the applicant's name for the appropriate legend followed by the word “for”, and then the claimant's name, and applicant's mailing address. Enter names exactly as shown on the claim. If two or more proper applicants have filed on behalf of the claimant the name and address entries for the applicant should be for whichever of the applicants is the preferred payee. See Payee Preference Lists - GN 00502.105.

In situations involving a disability application filed after the claimant's death, show the applicant's name followed by “On behalf of (claimant's name) Dec'd.” If the SSA-831 is for the deceased parent of a child filing on a grandparent's ER, enter the name only of the disabled parent.

6. Item 6 - WE's name

Number Holder’s (NH's) Name, complete for CDB and DWB claims involving a DIB NH. This item is not completed in DIB Cases.

7. Item 7 - type claim (Title II)

Check the appropriate block as follows:

Acronym

Definition

DIB

Disability Insurance Benefits

FZ

Freeze Only

DWB

Disabled Widow(er)'s Benefits

CDB-R

Childhood Disability Benefits (RSI NH)

CDB-D

Childhood Disability Benefits (DIB NH)

RD-R

End Stage Renal Disease - Claimant receiving RSI benefits on spouse's or parent's SSN

RD-D

End Stage Renal Disease - Claimant receiving auxiliary benefits on the SSN of a spouse or parent entitled to DIB

RD

End Stage Renal Disease - Claimant receiving monthly benefits on own SSN or not receiving monthly benefits

P-R

Disability determination for parent-child filing on earnings record of grandparent (RSI NH)

P-D

Disability determination for parent-child filing on earnings record of grandparent (DIB NH)

MQGE

Medicare for Qualified Government Employees

8. Item 8- type claim (Title XVI)

Check the appropriate block.

9. Item 9- Date of Birth (DOB)

Show the established month, day, and year of birth (e.g., 3/17/49). If the date of birth has not been established, use the DOB by which the claimant is the oldest.

10. Item 10- prior action

Check the “PD” block when the last determination for the same type of benefit was a denial. Check the “PT” block when the last determination for the same type of benefit was a termination of entitlement. Include the prior disability file, if in the FO or required as shown in Impairment-Related Work Expenses (IRWE) Paid 12/01/80, and Later (DI 11010.180) and complete information on a SSA-3367 (Disability Report-Field Office), Item 7.

11. Item 11 - remarks

Document the following:

  • Gender

  • Phone number

  • Capability Development Needed

  • Study List Code

  • Litigation Code

For instructions on documenting prisoner cases, see DI 10105.094.

Complete items 11A and 11B (the blocks do not need to be checked) with code 01 in 11A and an impairment number from Field Office (FO) Procedures for Processing Presumptive Disability (PD) AND Presumptive Blindness (PB) Cases DI 11055.240D.1.a. in 11B.

12. Item 12 - FO address/FO code

Enter the City, State, ZIP code and FO code, as well as the local address (street number and name or P.O. Box), in all cases.

13. Item 13 - FO representative

The FO employee who transmits the case should enter his/her name and title in this block.

14. Item 14 - date

Enter the date the file is transmitted to the DDS, ODO, DPB or OIO.

15. Item 16 - diagnosis

Enter “None established” for Substantial Gainful Activity (SGA) denials.

16. Item 19A - claimant not disabled through date of current determination

Check this block when the insured status or prescribed period requirement continues to be met through the date of the current determination.

17. Item 19B - claimant not disabled through (date)

Check this block when the prescribed period ended or the insured status requirement was last met prior to the date of the current determination. Enter the date the insured status or prescribed period requirement is last met.

18. Item 19C - before age 22

Complete this item for CDB cases.

B. How to complete item 20 – vocational background

1. Item 20 - vocational background

Complete this item in DIB, DWB, DWB Medicare Only, Freeze and CDB cases. Show both the claimant's occupation and the industry. Enter the 2-digit occupation code from the list below which most closely approximates the determined occupation. Follow the code with a dash and then enter the approximate 2-digit industry code from the list below most closely approximating the determined industry. If a CDB has never had an occupation, enter “NONE.”

Occupation Codes (Item 20 of SSA-831)

PROFESSIONAL TECHNICAL, AND MANAGERIAL OCCUPATIONS

01

Occupation in architecture, engineering, and surveying

02

Occupation in mathematics and physical sciences

04

Occupation in life science

07

Occupation in medicine and health

09

Occupation in education

10

Occupation in museum, library, and archival sciences

11

Occupation in law and jurisprudence

12

Occupation in religion and theology

13

Occupation in writing

14

Occupation in art

15

Occupation in entertainment and recreation

16

Occupation in administrative specializations

18

Managers and officials

19

Other professional, technical, and managerial occupations

CLERICAL AND SALES OCCUPATIONS

20

Stenography, typing, filing, and related occupations

21

Computing and account-recording occupations

22

Production and stock clerks and related occupations

23

Information and message distribution occupations

25

Sales occupation, services

26

Sales occupation, consumable commodities

27

Sales occupation, commodities other than consumable

28

Other clerical occupation

29

Other sales occupation

SERVICE OCCUPATIONS

30

Domestic service occupations

31

Food and beverage preparation and service occupation

32

Lodging and related service occupation

33

Barbering, cosmetology, and related service occupation

34

Amusement and recreation service occupation

35

Other personal service occupation (e.g., hostesses, stewards, hospital attendants, practical nurses, etc.)

36

Apparel and furnishings service occupation

37

Protective service occupation

38

Office service occupation

39

Other non-personal service occupation

AGRICULTURAL, FISHERY, FORESTRY, AND RELATED OCCUPATIONS

40

Plant farming occupation

41

Animal farming occupation

44

Fishery and related occupation

45

Forestry occupation

46

Hunting, trapping, and related occupation

47

Other agricultural, fishery, forestry and related occupation

PROCESSING OCCUPATIONS

50

Occupation in processing of metal

51

Ore refining and foundry occupation

52

Occupation in processing of food, tobacco, and related products

53

Occupation in processing of paper and related materials

54

Occupation in processing of petroleum, coal, natural and manufactured gas, and related products

55

Occupation in processing of chemicals, plastics, synthetics, rubber, paint, and related products

56

Occupation in processing of wood and wood products

57

Occupation in processing of stone, clay, glass, and related products

58

Occupation in processing of leather, textiles, and related products

59

Other processing occupation

MACHINE TRADES OCCUPATIONS

60

Metal machining occupation

61

Metalworking occupation

62

Mechanics and machinery repairers

64

Paper working occupation

65

Printing occupation

66

Wood machining occupation

67

Occupation in machining stone, clay, glass, and related materials;

68

Textile occupation

69

Other machine trades occupation

BENCHWORK OCCUPATIONS

70

Occupation in fabrication, assembly, and repair of metal products

71

Occupation in fabrication and repair of scientific, medical, photographic, optical horological, and related products

72

Occupation in assembly and repair of electrical equipment

73

Occupation in fabrication and repair of products made from assorted materials

74

Painting, decorating, or related occupation

75

Occupation in fabrication and repair of plastics, synthetics, rubber and related products

76

Occupation in fabrication and repair of wood products

77

Occupation in fabrication and repair of sand, stone, clay, and glass products

78

Occupation in fabrication and repair of textile, leather, and related products

79

Other bench work occupation

STRUCTURAL WORK OCCUPATIONS

80

Occupation in metal fabricating

81

Welder, cutter, or related occupation

82

Electrical assembling, installing, and repairing occupation

84

Painting, plastering, waterproofing, cementing, or related occupation

85

Excavating, grading, paving or related occupation

86

Construction occupation

89

Other structural work occupation

MISCELLANEOUS OCCUPATIONS

90

Motor freight occupation

91

Transportation occupation

92

Packaging and materials handling occupation

93

Occupation in extraction of minerals

95

Occupation in production and distribution of utilities (e.g., energy, water, sewage)

96

Amusement, recreation, motion picture, radio and television occupations not included in the preceding

Industry Codes (Item 20 of SSA-831)
AGRICULTURE, FORESTRY, FISHING, HUNTING AND TRAPPING

01

Agriculture production crops

02

Agriculture production livestock

07

Agriculture services

08

Forestry

09

Fishing, hunting, and trapping

MINING AND COAL AND GAS EXTRACTION (INCLUDING URANIUM)

10

Metal mining

11

Anthracite mining

12

Bituminous coal and lignite mining

13

Oil and gas extraction

14

Mining and quarrying of nonmetallic minerals, except fuels

CONSTRUCTION

15

Building construction – general contractors and operative builders

16

Construction other than building construction – general contractors

17

Construction - special trade contractors (e.g., plumbing, heating, electrical, carpentry, etc.)

18

Other construction

MANUFACTURING

20

Food and kindred products

21

Tobacco manufactures

22

Textile mill products

23

Apparel and other finished products made from fabrics and similar materials

24

Lumber and wood products, except furniture

25

Furniture and fixtures

26

Paper and allied products

27

Printing, publishing, and allied industries

28

Chemicals and allied products

29

Petroleum refining and related industries

30

Rubber and miscellaneous plastics products

31

Leather and leather products

32

Stone, clay, glass and concrete products

33

Primary metal industries

34

Fabricated metal products, except machinery and transportation equipment

35

Machinery, except electrical

36

Electrical and electronic machinery, equipment, and supplies

37

Transportation equipment

38

Measuring, analyzing, and controlling instruments, photographic, medical, and optical goods; watches and clocks

39

Other manufacturing industries

NONMANUFACTURING

40

Railroad transportation

41

Local and suburban transit and interurban highway passenger transportation

42

Motor freight transportation and warehousing

43

U.S. postal service

44

Water transportation

45

Transportation by air

46

Pipe lines, except natural gas

47

Transportation services

48

Communication

49

Electric, gas, and sanitary services

50

Wholesale trade – durable goods

51

Wholesale trade – nondurable goods

52

Building materials, hardware, garden supply, and mobile home dealers

53

General merchandise stores

54

Food stores

55

Automotive dealers and gasoline service stations

56

Apparel and accessory stores

57

Furniture, home furnishings and equipment stores

58

Eating and drinking places

59

Miscellaneous Retail

60

Banking

61

Credit agencies other than banks

62

Security and commodity brokers, dealers, exchanges, and services

63

Insurance companies

64

Insurance agents, brokers, and service

65

Real estate

66

Combination of real estate, insurance, loans, law offices

67

Holding and other investment offices

70

Hotels, rooming houses, camps, and other lodging places

72

Personal services

73

Business services

75

Automotive repair, services, and garages

76

Miscellaneous repair services

78

Motion pictures

79

Amusement and recreation services, except motion pictures

80

Health services

81

Legal services

82

Educational services

83

Social Services

84

Museums, art galleries, botanical and zoological gardens

86

Membership organizations

88

Private households

89

Miscellaneous services

91

Executive, legislative, and general government, except finance

92

Justice, public order, and safety

93

Public finance, taxation, and monetary policy

94

Administration of human resources programs

95

Administration of environmental quality and housing programs

96

Administration of economic programs

97

National security and international affairs

99

Non-classifiable establishments

Show in the “Occ. Yrs.” block the number of years that the claimant worked in the principal occupation, if determined, or, if not determined, in the longest full-time occupation. When such information is not reflected on the SSA-3368 (Disability Report - Adult) and/or SSA-3369 (Work History Report), it may appear elsewhere in the file. Where there are broken periods of employment in that occupation, determine the total number of years the claimant was employed or available for employment in the shown occupation. If the number of occupational years is unknown, enter “unk.”

In the “Ed. Yrs.” block, enter the highest grade of school completed by the individual, including any part-time and night courses. Use “12th grade” to indicate completion of high school, “13th grade” for one year of college, etc. Also, enter the type of school and number of years completed in specialized schools, such as nursing school, accounting school or ungraded vocational school. If the number of years of education is unknown, enter “unk.”

C. How to complete item 22 – reg basis code

For DIB/DWB claims use the following chart:

Situation

Entry

DIB/DWB claim—insured status or prescribed period last met on or after date of current decision.

“N1-1520(b)”

DIB/DWB claim—prescribed period ended or insured status last met prior to date of current decision.

“N2-1520(b)”

For CDB claims, use the following guide:

If the individual is engaging in SGA:

  1. Is the SGA determination prior to age 22? If yes, use code N1. If no go to step b.

  2. Does the CDB have any prior CDB entitlement? If no, use N2. If yes, go to step c.

  3. Was the prior CDB entitlement terminated due to SGA? If yes, use N1. If no, go to step d.

  4. Is the SGA determination being made within the 84-month re-entitlement period? If yes use N1. If no, use N2. (Assumption that the prior entitlement was terminated due to medical recovery.)

D. How to complete items 26-29

1. Item 26 - list No.

See Disability-Related List Codes (Active) - DI 33530.005.

2. Item 27 - rationale

See Background - DI 26516.001.

3. Item 29 - LTR. /PAR. No.

Complete this item in accordance with Preparing Notices in Disability Claims - DI 11010.345.

E. How to complete items 37-38

1. Item 37 - SSA representative

The claims representative signs his or her name.

2. Item 38 - date

Enter the date the SSA-831 is signed.

F. FO remarks

When preparing a case to be sent to DDS, keep in mind the following situations requiring specific remarks:

  • Always enter the telephone number (including the area code) where the claimant can be reached. If the claimant gives an address that is general delivery, a hospital or an institution, enter the claimant's home address or the address of a friend or relative who would know the whereabouts of the claimant.

  • If the claimant's mailing address is in one State, and he/she resides in another State, enter “Resides in (name of State).” Show the county if the DDS indicates a need for this information. The case is sent to the DDS servicing the claimant's residence address.

  • Enter alleged onset date.

  • Enter the reason a DDS determination is needed.

The “Remarks” portion is used to alert the DDS or of special situations. The following are some of the principal notations:

1. DIB transmittal to DDS delayed for E/R

If a DIB claim is transmitted to the DDS prior to FO receipt of the ER, enter “DLI (date).” Also, if the DIB claimant alleges a visual impairment and is fully insured only, enter the remark “Fully insured only.”

NOTE: Do not forward initial materials for a disability determination if there is any doubt as to whether the claimant meets a non-disability requirement (e.g., insured status or prescribed period requirement). In cases delayed pending resolution of a non-disability requirement, do not forward the application, E/R or other non-disability material to the DDS. Send only the material pertinent to the disability determination when the issues are resolved.

2. Concurrent DWB-DIB

If concurrent DWB-DIB claims are being processed, cross refer as follows; enter on the SSA-831 (Disability Determination and Transmittal) “Also filing as disabled widow(er) on (SSN)”, and enter on the DWB SSA-831 “Also filing for DIB on (SSN).”

3. DWB claimant is DIB beneficiary

If a DWB claimant is already receiving DIB, enter “Widow(er) entitled to DIB on (SSN).”

4. Concurrent Title II-Title XVI

If either of the following situations is applicable, enter the appropriate remark: “Title XVI initial (or reconsideration) filed (date), pending in DDS.” or “Prior Title XVI denial (or cessation) (date).”

5. CDB/DIB - same SSN

In cases involving a disabled claimant and a disabled child auxiliary living in different jurisdictions, cross-refer each SSA-831 by entering “(CDB or DIB) application for (name of claimant or disabled child) forwarded to (DDS, ODO, DPB, DRS, or OIO) on (date).”

6. DIB/CDB - different SSNs

When a disabled child has disability insured status on his or her own SSN and has filed disability application in addition to the auxiliary claim, enter on the SSA-831 associated with the DIB claim, “See (parent's name) (parent's SSN) for CDB claim.”

7. No waiting period case

If the claim is a no waiting period case, enter “no waiting period.” (See When No Waiting Period Is Required DI 10105.075 for the definition of a no waiting period case.)

8. Visual impairment alleged

Enter “Alleges visual impairment” when a visual impairment is alleged.

9. Claimant does not want to pursue claim

Enter “Claimant does not want to pursue claim” if the claimant does not want to complete development (Claimant Cannot be Contacted. Whereabouts Unknown or Claimant Does not Wish to Pursue Title II Claim - DI 11010.045). In an ODO case, enter “No medical evidence for reasons beyond claimant's control” if the claimant is unable to proceed with the claim.

10. DIB after death

In cases involving a disability application filed after the claimant's death, show the date of death; i.e., “Date of death (date).”

11. Claimant also filed RIB or Survivor claim

If the claimant filed a RIB or non-disability survivor's claim, enter “Application for RIB or survivors benefits.”

12. Foreign language notice required

If a foreign language notice is required, enter “foreign language notice required,” using the appropriate language in place of “foreign language.”

13. Braille notice requested

See details in Procedure for the Braille Special Notice Option for the Blind or Visually Impaired (NL 01001.120).

14. Homeless - no permanent address

Enter “Homeless - no permanent address” when the claim is for a homeless individual.

15. Possible application of Res Judicata

When a subsequent Title II disability claim is being transmitted in accordance with Initial Title II Technical Denials and Claims Not Requiring a Disability Determination - DI 11010.075, enter: “Prior claim attached. Review for application of res judicata." If the prior claim could not be located, enter: “Prior claim not located - Substantive determination necessary.”

16. Applying FO adoption

When a subsequent Title II or Title XVI disability claim is being sent to DDS per FO Adoption Decision -DI 11011.005, enter “FO unable to adopt prior decision.”

17. MSSICS limitation

Indicate the reason for the limitation and claim type.

18. Amyotrophic Lateral Sclerosis (ALS) — Medicare waiting period waived

Public Law 106-1554 amended section 226 of the Social Security Act to waive the 24 month waiting period for Medicare coverage for disabled individuals medically determined to have ALS. The date of Medicare entitlement is the date of entitlement to disability insurance benefits or 07/01, whichever is later. This applies to new and current claims.

G. How to complete item 28 on the paper SSA-831

When the DDS makes a final determination resulting in an allowance on a Title II DIB or Freeze claim, the FO must complete certain blocks and dates in item 28 if a paper SSA-831 exists. The DDS always checks blocks A and C on DIB an