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In Item 16B, for both allowances and denials, determine and enter the secondary diagnosis
(i.e., the most significant diagnosis following in severity the primary diagnosis).
In the space provided, enter the ICD-9-CM code number applicable to the secondary
diagnosis. Entry of a secondary diagnosis is required in all cases where one exists.
Thus, if there is no secondary diagnosis, write “None” in the space provided for that diagnosis.
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| Item 17 |
(Diary), complete per instructions in DI 26510.020. Follow instructions in DI 26525.000 for determining when a medical improvement expected (MIE) diary is needed.
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| Item 18 |
(Case of Blindness as Defined in Section 1614(a)(2)(216(i)), check block “A” or “B” as appropriate (DI
24000.000 and DI 26000.000.)
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| Item 20 |
(Vocational Background), complete this item in DIB, freeze, and CDB cases. This block
should reflect vocational background data regarding the beneficiary/recipient's customary
occupation or, if not determined, the longest full-time occupation in the 15-year
period prior to current adjudication. Show both the individual's occupation and the
industry. Enter the 2 digit occupation code from DI 40105.005C., Exhibit 3, most closely approximating the determined occupation. Follow this code
with a dash and then enter the appropriate 2 digit industry code from DI 40105.005C., Exhibit 4, most closely approximating the determined industry. If a CDB has never
had an occupation enter “None.” If there is no vocational information in the file, and it is not needed, enter “unknown.”
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| Item 24 |
(MOB Code), secure from the prior SSA-831-U5. |
| Item 25 |
(Revised Det.), place a check in the block. |
| Item 25A |
(Adjudicative Level), check appropriate block |
| Item 26 |
(List No), The revised SSA-831-U5 provides spaces for up to six listing numbers in
item 26, thus eliminating use of item 34 for entry of other listing codes. Complete
per instructions in DI 26510.070.
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| Item 27 |
(Rationale), enter the following statement only: “Decision of Administrative Law Judge (Name of ALJ) on (Date of Decision).” |
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A box has been added to item 27 to indicate whether an Appendix 2 Vocational Rule
has been met. In the space following, cite the rule, e.g., “202.03.” (See DI 25020.000 for processing instructions.)
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| Item 28 |
(Period of Disability/Etc.), complete this item in a DIB “open period” or “closed period” allowance. |
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1. Since insured status and an effective application are requirements for a period
of disability, check blocks “A” and “C”, then enter in “C” the date on which all requirements for entitlement are first met.
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2. If the earnings requirement is met after the onset date established by the ALJ
decision, complete Block “C” showing the first day of the quarter in which insured status is met. Show an asterisk
*after Block “C” and in item 34 enter the following explanatory remark, “*, date insured status is first met.” Prepare an SSA-567 referring the file after payment to a reconsideration examiner
for preparation of a memorandum to OHO requesting the ALJ to amend his/her decision
based on the date insured status is first met.
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3. If disability is found to be continuing, check Block “D.” |
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4. If disability is found to have ceased, check Block “E” and enter the year with the last day of the second month following the cessation
date in item 15B.
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5. If a second period of disability is being established, the first period of disability
(and benefit entitlement) will continue through the last day of the second month following
cessation of disability; a second period can begin no earlier than the first day thereafter.
If the established onset date shown in item 15 falls within this 2-month period, Block
“C” should be completed with the first day of the month after the prior period of disability.
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A disability ceases June 15, 1978, and the corresponding period of disability ends
August 31, 1978. It is determined that the claimant is entitled to a second period
of disability based on an onset of August 8, 1978. In this situation, Block C should
show the second period of disability as beginning on September 1, 1978. Also, include
this remark in item 34, “Dates in items 15 and 28 differ—new period of disability established after cessation.”
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| Item 29 |
(Ltr. Para. No), enter “C13” for ALJ and AC decisions and any other appropriate paragraphs.
(See NL 00601.010 for award notices and NL 00705.030 and NL 00708.100 for closed period of disability awards.)
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| Item 34 |
(Remarks) |
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1. Enter “This revises the determination of (date of reconsideration SSA-831-U5).” Cross refer the reconsideration determination by entering a remark on that SSA-831-U5,
“See revised determination of (date of current SSA-831-U5).”
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3. Enter any other applicable remarks regarding capability, earnings discrepancies,
WC, no waiting period, multiple SSN's etc.
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| Items 34A and 34B |
(Multiple Impairments Considered) Check block A in item 34 in all cases where multiple
impairments were considered in the determination, and the combination of nonsevere
impairments results in a determination of a severe impairment. Check block B if the
combination of nonsevere impairments results in a determination of a nonsevere impairment.
(See DI 24505.005).
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NOTE: Those DDS in States currently affected by court decisions prohibiting the use of
the nonsevere concept; e.g., Illinois (Johnson case), New York (Dixon case), Alaska,
American Samoa, Arizona, California, Guam, Hawaii, Idaho, Montana, Nevada, Northern
Marianas, Oregon, and Washington (Smith case), should follow existing instructions
with respect to the nonsevere concept, and they SHOULD NOT complete either block 34A
or B.
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| Item 36 |
(Revised Det. Codes) |
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If the prior decision was a denial, enter “D.” If the prior decision was an allowance enter “A.” Following this: If a prior application is reopened enter “9.” If a prior application is not reopened enter “5.” |
| Item 37 |
(SSA Representative) (Section) will show the signature and modular processing branch
of the individual preparing the form.
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The SSA adjudicator or reviewer should sign in item 37 and in the “SSA CODE” block, identify his/her component by entering the appropriate code from the following
list:
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