Use the SSA-1207-BK for:

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  all claims for disability insurance benefits (DIB),

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  title II childhood disability benefits (CDB), and disabled widows(ers) benefits (DWB), including surviving divorced spouses, and

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  disabled/blind individual (DI/BI) and disabled/blind spouse (DS/BS)-title XVI when the medical improvement review standard (MIRS) will be used.

The DHO will document the DHO decision in the “Analysis of Evidence and Findings of Fact” section of the SSA-1207-BK or SSA-1207-BK-OP1.

Use the SSA-1207-BK for:

If the decision is fully favorable, the DHO’s discussion of the evidence and rationale does not have to proceed past the point the claim is allowed.

Use the SSA-1207-BK-OP1 in cases where MIRS is not applicable, e.g., initial claims escalated to the reconsideration level, reconsiderations of adverse reopening, and Age 18 Redeterminations. (For cases where MIRS does not apply, see DI 28005.001D.2. For information on age 18 redetermination cases under P.L. 104-193, see DI 33025.075.)

NOTE: For Title XVI disabled or blind children, use form SSA-1209 (Disability Hearing Officer’s Decision, Title XVI Disabled Child (DC) Continuing Disability.

Use the reverse side of each page of the paper forms or attach an additional sheet of paper if there is insufficient space for addressing a particular issue. Be sure to refer the reader to the location of a continuation. For example, if item 2 continues on the reverse side of the page, show “See reverse side of this page.” On the reverse side of the page, show “Continuation of item 2.”

For electronic forms where additional space is needed, continue text on the continuation page at end of forms SSA-1207-BK and SSA-1207-BK-OP1.

Based on the claimant’s testimony, provide a brief description of why the claimant believes they are disabled. Avoid writing, “Can't work.” Instead, attempt to explain the basis for the claimant's appeal. The following examples are guides for completing this section of the form:

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  EXAMPLE 1

  Claimant says they have constant back pain that they describe as “agony.” They testified that they have problems with both legs including their knees and ankles. The claimant says their legs give out and that they are unable to walk about half of the time. Sitting also causes pain. Claimant says they cannot use their left shoulder. They also have pain and burning and stomach trouble from two hernia repairs.

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  EXAMPLE 2

  The claimant states that their disability is due to their heart condition and arthritis; but they also have breathing problems, allergies, and sinus problems. The claimant wears a brace on the right knee all of the time and often wears a cervical collar. The claimant has stiffness and a lot of pain. Their ankles and knees give out and they have constant pain in their hands. Their hands swell and get stiff. The hands get so stiff at times, that they are unable to button their shirt. Riding in a car bothers them a lot because of the vibration. In the last two months, their condition has worsened. Fluid builds up around their heart and they get angina attacks. If they do anything much, they gets so hoarse they cannot talk.

Briefly identify and summarize the testimony of all witnesses. Use the “Disability Hearing Officer's Report of Disability Hearing” for guidance since the form contains a section for recording the testimony of witnesses. Use the following examples as a guide for completing this section of the form:

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  EXAMPLE 1

  Mrs. X, the claimant's relative, testified that they are with the claimant every day. The relative cooks and cleans for the claimant. The relative says that the claimant is constantly in bed and taking medicine. Mrs. X believes it is impossible for the claimant to work. They have seen the claimant's legs give out.

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  EXAMPLE 2

  Mrs. Y, the claimant's spouse, states that the claimaint has trouble walking and getting up and down. The claimant cannot sleep at night and cannot ride in a car. The claimant gets nauseated and cannot eat. When they eat, they have a problem opening their jaws. The spouse does all the errands and all the work around the house because the claimant's pain is so bad. The claimant used to be able to out walk anybody, but they cannot now. They cannot do anything anymore. The claimant cannot even visit relatives. The spouse knows the claimant is sick because the claimant would prefer working 2-3 jobs instead of not working any.

NOTE: The first paragraph is pre-printed and states that we reviewed and considered all relevant evidence (in the claims folder and addressed at the hearing). This prompts the DHO to analyze the relevant evidence and make findings of fact based on their analysis of the evidence.

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  Be sure this section contains all findings required for making your determinations in the SSA-1207-BK and SSA-1207-BK-OP1.

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  State your findings of fact and cite the doctor's report(s) used in making the finding when there is no conflict or inconsistency in the medical evidence.

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  If there is no conflict in the evidence, assess the vocational factors and state the finding. For example, “Claimant is 43 years old.”

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  Explain how you resolved conflicts or inconsistencies in the evidence and how you reached your finding. For example, if two medical reports conflict as to the nature of the impairment, you must assess the reports for their probative value and make a finding on the nature of the impairment. You may also consider lay evidence such as a claimant's appearance and testimony and witness testimony when making the finding. Make sure you properly consider medical opinions according to DI 24503.025 and DI 24503.035.

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  Explain how you considered evidence from medical sources, nonmedical sources, and DDS medical and psychological consultants about the nature and severity of an individual’s impairments. The DHO is not bound to agree with this evidence.

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  Analyze and make a finding on any related issues indicated in the “Other Issues” portion of the decision.

Be sure to attach to the decision Form SSA-887, (Summary of Evidence). This is important because the Summary of Evidence and the documentary description of evidence the claimant submits at the hearing constitute relevant evidence used to make a decision.

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  Check the appropriate block in item 1.

  NOTE: This first review step of the sequential evaluation is pre-printed on both forms. The FO determines if the claimant is engaging in substantial gainful activity (SGA). The decision is not within the DHO's authority. However, if the FO determines that the claimant is engaging in SGA and needs a medical decision for possible establishment of an extended period of eligibility (EPE), the DHO is responsible for making the medical determination.

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  Use the findings of fact made in the previous section of the decision form to complete the remaining items on the forms. Refer to a particular finding without restating it when appropriate.

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  Complete only those items that are relevant to the claim(s). Mark N/A for items which do not apply.

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  Remember, the regulations give the DHO authority to make binding decisions on whether the impairment(s) equals a listed impairment. However, since the assessment of a physician designated by the Commissioner on this issue must be part of the evidence in the claims folder, be sure it is included and evaluated.

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  Share the physician’s assessment with the claimant per DI 33015.035 if, after considering the assessment, you decide that an unfavorable determination must be made.

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  Make sure the evidence of record consists of a psychiatric review technique form (PRTF) that has been completed and signed by a medical consultant in all mental impairment cases.

For Title XVI blindness cases, follow the CDR evaluation process in DI 28005.090.

Write the determination in the blank space under “Are there other issues relating to this determination” on page 8 of the SSA-1207-BK.

NOTE: If the determination is that the individual is not statutorily blind, make a determination using the pre-printed evaluation process on the form, because a visual impairment may not meet the statutory blindness definition, but may be disabling.

To make a determination regarding any related issues that were raised, use the blank space under “Are there other issues relating to this determination” on page 8 of the SSA-1207-BK.

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  Check the appropriate block. Make sure the individual meets insured status at the time any new period of disability is established. Before establishing a new period of disability in title II cases, make sure a new application is filed. Contact the FO and request the FO to secure a title II application on a priority basis if the claimant is establishing a new period of disability and a new application is not in the claims folder.

  NOTE: In title XVI cases, we do not need a new application to establish a new period of disability.

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  If a new period of disability or a later cessation date is established, provide the basis for the conclusion in the “Analysis of Evidence and Findings of Fact” and the “Determination of Disability” sections. In the blank space provided, write your conclusions on any related issues addressed at the hearing.

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  Sign the form.

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  Prepare an

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    SSA-831-U3 (Disability Determination and Transmittal),

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    SSA-832-U3 (Cessation or Continuance of Title XVI) or

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    SSA-833-U3 (Cessation or Continuance of Disability or Blindness Determination and Transmittal)