TN 2 (04-05)

DI 26530.055 Personalized Disability Explanation Preparation Guide Form

(Typist: Type information checked and entered. Do not type instructions in parenthesis.) (Examiner: Check information and enter paragraph numbers as appropriate. Also, line through “s” or multiple words which are not to be part of sentence.)

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The following reports was/were used to decide your claim. (Initial)

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The following reports was/were used to decide your claim in addition to those listed on our previous notice. (Recon - added medical evidence)

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Since no additional evidence was submitted, the reports listed in our previous notice was/were used to decide your claim (Recon - no added medical evidence.)

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We were unable to obtain any evidence needed to evaluate your claim (Initial-no medical evidence).

 

Medical evidence that was submitted with your claim (claimant, attorney or third party submitted medical evidence with the claim from multiple sources, or multiple reports from various sources that can't clearly be identified.)

 

(Show name of medical source and date of report.)

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Additional reports were not obtainable, however, the ones shown above had enough information to evaluate your condition. (Sufficient medical evidence - not all reports obtainable.)

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(Optional for partially favorable allowances) The determination on your claim was made by an agency of the State. It was not made by your own doctor or by other people or agencies writing reports about you. However, any evidence they gave us was used in making this determination. Doctors and other people in the State agency who are trained in disability evaluation reviewed the evidence and made the determination based on Social Security law and regulations.

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(In denial determinations enter the decision paragraph(s) as indicated in the charts in DI 26530.025-DI 26530.050.)

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You said that you are unable to work because:

 

(Enter impairments evaluated. Exercise care not to offend or upset the claimant.)

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We have evaluated blindness-related impairments only because you do not meet the earnings requirements for non-blind disability benefits.

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The medical evidence shows:

 

(Enter what the medical evidence shows.)

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Based on your description of the job you performed as a   (1)   for the past   (2)   years, we have concluded that you have the ability to do this job. (Fill-ins: (1) job title, (2) no. of years.)

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We realize that your condition keeps you from doing   (1)   , but it does not keep you from doing   (2)   . Based on your age   (3)   , education   (4)   , and past work experience you can do other work. (Fill-ins: (l) Use “any of your past jobs” or for those claimants who haven't worked, use “some types of work,” (2) specify the claimant's capacity to do other work which is less demanding (refers to exertion, mental, skill level) or requires less physical effort in general terms, e.g., lighter work, (3) age, (4) education.)

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Add a concluding statement, if applicable, for the