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)
|