Identification Number:
DI 22511 TN 4
Intended Audience:See Transmittal Sheet
Originating Office:ORDP ODP
Title:Documenting and Evaluating Mental Impairments
Type:POMS Transmittals
Program:All Programs
Link To Reference:
 

PROGRAM OPERATIONS MANUAL SYSTEM
Part DI – Disability Insurance
Chapter 225 – Case Development Procedures
Subchapter 11 – Documenting and Evaluating Mental Impairments
Transmittal No. 4, 03/18/2021

Audience

PSC: DE, DEC;
OCO-OEIO: CR, ERE, FCR, FDE, RECONE;
OCO-ODO: DE, DEC, DS, RECONE;
ODD-DDS: ADJ, DHU;

Originating Component

ODP

Effective Date

Upon Receipt

Background

This is a Quick Action Transmittal. These revisions do not change or introduce new policy or procedure.

Summary of Changes

DI 22511.011 Contacting Claimants and Collateral Sources

We are updating this POMS section for consistency with the changes to the mental disorders listings in 2016, the medical evidence policy in 2017, and the failure to cooperate-insufficient evidence policy in 2020. We are updating and removing outdated cross-references. In addition, we are making non-substantive language changes for usability and consistency within the POMS section.

Conversion Table
Old POMS ReferenceNew POMS Reference
DI 22511.011DI 22511.011

DI 22511.011 Contacting Claimants and Collateral Sources

A. Policy

Many factors can make an impact on the method selected for developing claimant and collateral evidence (e.g., geographical location, access to telephone, work schedules, etc.). The manner in which such evidence is obtained must be left to the adjudicator's discretion.

B. Procedure -- General

There may be instances in which field office (FO) assistance is necessary to contact a potential collateral source or to recontact the claimant (e.g., when a face-to-face contact is needed). In such instances, the Disability Determination Service (DDS) should request the FO to make the contact. However, DDS should request FO assistance only after they have been unsuccessful in contacting the source.

To ensure complete responses and to minimize follow up contacts, the DDS should furnish the FO a list of specific questions to be asked of the source. The FO should be advised as to what type(s) of attempts the DDS has made to obtain the needed evidence. This will alert them to methods either to try or avoid.

C. Procedure -- Claimant Contact Techniques

1. General

Contact with the claimant should focus on those activities that he or she actually performs or can no longer perform due to the alleged impairment. The SSA-3373 asks questions requiring descriptive information about the claimant's activities and socialization that will permit judgments about the quality, effectiveness, independence, appropriateness, and sustainability of those activities and relationships. The SSA-3373 is not intended to address all situations. If a DDS, after reviewing responses on the SSA-3373, determines that additional information is necessary to fully evaluate a claimant's limitations in the ability to function, the DDS may use impairment-specific or case-specific questions to develop the additional information.

Verbatim quotes from the claimant are the preferred method of documentation whenever possible. For example, it is much more revealing to know that exact change has to be given to a claimant for car fare and lunch than to state that the claimant has difficulty with elementary mathematical concepts. Describing an episode in which the claimant could not make change and so either lost money or became confused or upset would be even more revealing.

2. Preparing For the Contact

Before contacting the claimant, thoroughly review the information already contained in file. This preparation will enable the adjudicator to ask pertinent questions which can resolve inconsistencies or clarify ambiguities.

3. Contacting the Claimant

a. General

When possible, questions that supplement or clarify information obtained on the SSA-3373 should be open-ended. Encourage the claimant to take the lead to provide a narrative response. Avoid leading questions such as, “You can't drive much with your bad back, can you?”

Techniques such as prompting or recasting a significant statement of the claimant's into a question are useful in eliciting details from the claimant. For example, if the claimant says, “I am too nervous to drive anymore,” the response might be “You cannot drive your car anymore? Why not?” or “Tell me about it.”

When the claimant has had an adequate opportunity to explain his or her functions and limitations, more structured questioning may be used. However, the opening moments of the contact may reveal situations that may require a different approach. For example, if the claimant seems depressed, under-productive or too anxious to focus on a narrative response, questions may need to be more directive. Similarly, if the claimant exhibits hyperactive behavior, he or she may respond with too much information, and the questions may need to be more restrictive to control the responses.

Remember that the areas of mental functioning (i.e., paragraph B criteria of the mental disorders listings) to be assessed are:

  • Understand, remember, or apply information,

  • Interact with others,

  • Concentrate, persist, and maintain pace, and

  • Adapt or manage oneself.

Physical impairments also affect these areas of functioning. We look at how a claimant's physical and mental impairments restrict his or her ability to function in each of the areas. For example, in the area of interacting with others, the claimant needs to describe how his or her impairment(s) affects the effectiveness, independence, appropriateness, and sustainability of his or her ability to function with others.

b. Focus on Selected Activities

Instead of trying to document all of the claimant's activities, select at least two of the activities he or she is currently performing. Choose activities that involve sufficient complexity so that a full description of the activities will permit evaluation of the qualities previously described. Complexity can be viewed in terms of relating to people, places, dates, and things. For example, does the activity involve interaction with other people? Does the activity take place at home, or must the claimant travel to perform the activity? Does the activity require calculation or reading and understanding instructions? Does the activity require the use of tools, devices, or appliances?

When possible, the adjudicator should choose to evaluate activities that are known to him or her. It is easier to evaluate quality and appropriateness if the adjudicator knows how the activity is customarily performed. This can also be a useful communications tool, as the enthusiasm of a shared interest may encourage the claimant to be more expansive.

Generally, activities fall into categories, such as:

  • Self-care (e.g., grooming, cleanliness, and dressing).

  • Home maintenance (e.g., cleaning, cooking, and shopping).

  • Social/religious (e.g., church attendance, family gathering, organizations, parties, etc.).

  • Economic (e.g., paying bills and taxes, budgeting income and expenses, etc.).

  • Hobbies (e.g., woodworking, sewing, photography, playing cards, etc.).

 

 

 

 

 

c. Specific Questions

There is no set list of questions to be used when claimant contacts are needed to clarify or supplement the SSA-3373. Instead, assess each individual case situation and determine the best questions to ask to know how, when, why, and what the claimant does and what, if any, problems have been noted and can be described.

There are many conditions, both physical and mental, that may limit function. In addition, medications or combinations of medications and side effects of various medications may also limit a claimant's ability to function. Therefore, if possible, ask questions that permit one to contrast the claimant's performance of an activity before and after the onset of his or her disability.

D. Procedure -- Collateral Source Contact

1. General

The SSA-3380 is used to collect information about a claimant's ability to perform the activities of daily living from third parties familiar with the claimant's ability to function, such as family members, caregivers, neighbors, friends, clergy, and employers. The SSA-3380 is not required in all cases. For more information on contacting nonmedical sources, see DI 22511.007E.

The SSA-3380 is not intended to address all situations. If a DDS, after reviewing responses on the SSA-3380, determines that additional information is necessary to fully evaluate a claimant's limitations in the ability to function, the DDS may use impairment-specific or case-specific questions to develop additional information. As with claimant contact, when contacting collateral sources, there is no set list of questions which is appropriate to clarify or supplement information obtained on the SSA-3380. The diverse nature of impairments and their functional manifestations, plus the variability of the relationship with collateral sources, all require an individual case-by-case approach.

2. Initiating the Contact

The collateral source should be told that the contact is related to an application for Social Security benefits and that the information will be used as evidence in the claim. The claimant's right to privacy should be guarded. If a mental impairment has been alleged, that fact should not be divulged. For more information on technical requirements when securing collateral evidence, see DI 22511.013.

Ask the individual to describe his or her relationship with the claimant. For example, does the individual live with the claimant or, if not, how often and under what circumstances does the individual see the claimant? Understanding the source's relationship with the claimant will help to determine the nature and depth of evidence he or she can furnish.

3. Guidelines For Collateral Source Contacts

Encourage the collateral source to tell in his or her own words what is known about the claimant's function in a specific activity. Questions should be restricted to the topic in which the respective source's evidence is needed.

For example, if the claimant attends church and the contact is a member of the clergy and indicates that he or she sees the claimant at services, questions about the frequency of attendance, degree of participation in services, and any problems during services might be explored. The member of the clergy might be asked if the claimant serves on any church committee, and if so, how he or she performs that function.

If the source is a neighbor with only casual contact with the claimant, inquiry about house and yard maintenance or participation in civic associations might be appropriate.

Remember, it is not the specific activity that is important, but a description of the quality, effectiveness, appropriateness, sustainability and independence of participation in that activity that is significant. Encourage the source to describe what he or she has observed about the claimant in a given activity, but not to speculate or draw conclusions in areas outside personal knowledge or expertise. Stress the need for quality, rather than the quantity, of the information elicited during the contact.

E. Procedure -- Mail Requests to the Claimant or Collateral Source

1. Request to Claimants

When requesting information from the claimant by letter, follow the policy and procedures in DI 23007.005 and DI 22505.014.

2. Request to Collateral Sources

When requesting information from collateral sources by letter, make a reasonable effort to obtain the requested information. When the collateral source does not respond within 10 calendar days from the date of the initial, written request, follow up once by telephone or letter. Give the collateral source 10 additional calendar days to respond.

The file must be documented to show that a reasonable effort has been made to obtain the requested evidence.


DI 22511 TN 4 - Documenting and Evaluating Mental Impairments - 3/18/2021