SSA - POMS: DI 22511.007 - Evidence about Functioning

A. Policy – How we use evidence

We use medical and non-medical evidence to assess a claimant's functioning at multiple steps of the sequential evaluation process. However, only objective medical evidence from an acceptable medical source can establish a medically determinable impairment (MDI), see DI 24501.020.

Once the objective medical evidence establishes an MDI, we will consider non-medical and other evidence about the claimant's functioning to determine:

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Impairment severity (see DI 24505.000);
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Whether the MDI(s) meets the duration requirement, see DI 25505.000;
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The persistence and limiting effects of a claimant's symptoms, see DI 24501.021;
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Whether the MDI(s) meets or medically equals the criteria of a listed impairment, as applicable. For information on medical evaluation at step three of the sequential evaluation process, see DI 24508.000. For the introductory texts of listed impairments, see DI 34001.000; and
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The claimant's residual functional capacity (RFC), see DI 24510.000.

B. Sources of evidence about functioning

Evidence is anything the claimant or anyone else submits to us or that we obtain that relates to their claim for disability benefits (see DI 22505.001). The SSA-3368-BK (Disability Report – Adult) and the SSA-3441-BK (Disability Report – Appeal) document sources of medical and non-medical evidence we use to assess the claimant's limitations and functioning, such as:

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The claimant;
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Medical sources;
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Third party contact(s) (as defined in DI 23007.001C);
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Schools;
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Past employers;
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Social services agencies;
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Vocational rehabilitation agencies; and
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Support services (e.g., Individualized Education Plan (IEP) for students 18-21).

For information on sources of evidence about functioning in a continuing disability review, see DI 28030.020.

For information on sources of evidence about functioning in a Title XVI childhood disability case, see DI 25205.010.

1. Medical source

The adjudicator must make every reasonable effort to develop a complete medical history for at least the 12 months preceding the month in which the claimant files their application unless there is reason to believe that development of an earlier period is necessary, or unless the claimant says their alleged disability began less than 12 months before they filed the application. We will seek evidence from all relevant sources identified on the SSA-3368 or SSA-3441, or from sources we discover during development, for any alleged, documented, or discovered impairment(s), as explained in DI 22505.001.

If information about the claimant's functioning provided by a medical source introduces an inconsistency or additional information is needed to clarify the claimant’s functional abilities, use existing procedures to recontact the medical source as appropriate, see DI 22505.008.

For information on inconsistent evidence, see DI 24501.016.

For information on symptom evaluation, see DI 24501.021.

2. Consultative examination (CE)

When you have made every reasonable effort to obtain evidence from the claimant’s medical sources, but the case evidence is insufficient to make a determination or to resolve an inconsistency in the evidence, consider whether a CE could provide the needed information or clarification.

For information on when to purchase a CE, see DI 22510.005

For information on when not to purchase a CE, see DI 22510.006

3. Non-medical sources

A non-medical source is any source of evidence that is not a medical source, as explained in DI 22505.001A.5. The adjudicator determines, based on the case facts, when developing evidence from a non-medical source (e.g., educational personnel, public and private social welfare agency personnel, family members, caregivers, friends, neighbors, employers, and clergy) could be useful to assess the claimant's limitations and functioning. When contacting a non-medical source by telephone, verify the source's identity using information documented on the SSA-3368 or SSA-3441 (e.g., address or relationship to the claimant) and do not disclose any unnecessary personal information about the claimant or their disability claim, see DI 22505.014 and GN 03313.001B.

Before making any attempt to contact a non-medical source about the claimant's functioning, confirm there is a valid SSA-827 (Authorization to Disclose Information to the Social Security Administration (SSA)) in the file. If there is no valid SSA-827 in file, pause development until disclosure is authorized by a new SSA-827. While the SSA-827 serves as an authorization for parties to disclose information to us about the claimant, the SSA-827 does not authorize us to disclose claimant information to third parties. We should only disclose the minimal amount of information to third parties where authorized by routine use or the claimant’s consent.

In situations where a non-medical source asks us to send them a valid SSA-827, ensure that the claimant's SSN and other unnecessary personal information is redacted unless needed by the non-medical source to search their records (e.g., a public school system may need date of birth or social security number to locate the claimant's records). Do not automatically send a non-medical source the SSA-827 when we ask them to submit evidence (e.g. SSA-3380-BK (Function Report – Third Party)), unless the source specifically requests it.

IMPORTANT: The intent of requesting functional information from the claimant or other non-medical sources is to obtain a sufficient picture of the claimant's functioning over time. Generally, do not undertake the failure to cooperate procedures explained in DI 23007.015 when the case evidence includes sufficient information to assess the claimant's functioning, but the claimant did not comply with a request to submit the SSA-3373-BK (Function Report – Adult).

For information on obtaining a new SSA-827, see DI 22501.007.

For information on how to follow up on a request for evidence or action by telephone or by letter from the claimant or a third party, see DI 22505.014.

For information on our minimization policy, see GN 03313.001B.

a. Claimant

Generally, we collect information from the claimant about their functioning by sending them the SSA-3373. The SSA-3373 may provide information about the claimant's daily activities, such as the ability to complete personal care, prepare meals, do household chores, travel, shop, manage money, do hobbies, and socialize with others.

When further clarification is needed after reviewing the SSA-3373, consider whether a telephone contact with the claimant or their designated third party (as defined in DI 23007.001C) for additional information might be useful, as explained in DI 22511.011. Document the telephone contact following DI 22511.007D, in this section.

NOTE: When you have made and documented a reasonable but unsuccessful effort to obtain the claimant's cooperation to comply with a request for evidence or action, including involving a third party in claims requiring special handling, you may discontinue developing evidence that requires the claimant's cooperation, as explained in DI 23007.015.

For information on how to follow up on a request for evidence or action, see DI 22505.014.

For information on how to involve a third party when the claimant fails to cooperate in cases requiring special handling, see DI 23007.010C.

b. Third party

Third party information about the claimant's functioning is not required in all cases but can be useful to clarify or supplement other case evidence or the claimant’s statements, even when special handling is not involved. When the Disability Determination Services (DDS) decides that additional evidence is needed to fully evaluate a claimant's functional limitations, and the claimant-designated third party(as defined in DI 23007.001C) is considered to be a good source for that information, send the third party a request to complete the SSA-3380-BK (Function Report – Adult – Third Party). Do not contact a third party from a prior folder or a prior level of adjudication, as noted in DI 23007.001C (NOTE).

For information on the third party contact and where to locate their information on the SSA-3368 or SSA-3441, see DI 23007.001C.

For information on identifying and involving the third party, see DI 23007.010.

c. Employer

Generally, information from the claimant's past employer(s) is not necessary to assess the claimant's functional abilities; however, there may be certain situations in which information from an employer is useful. For example, to obtain information about whether the claimant:

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Received special help or supervision to perform their job duties;
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Responded appropriately to others, including co-workers and supervisors; and
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Maintained regular attendance and punctuality.

When the adjudicative team decides that more information is needed, and the claimant's past employer(s) is considered to be the best source of that information, send the employer a request to complete the SSA-3385-BK (Report of Adult Functioning – Employer). Contact the claimant and ask to whom we should send the SSA-3385 and the address or location where it should be sent.

C. Developing evidence outside the 12-month period

Use existing procedures to develop evidence about the claimant’s functioning during initial case development (see DI 22501.002). To make accurate findings on duration, residual functional capacity, and establishing onset, you may need to develop evidence outside of the 12-month period described in section B.1., above, which we generally consider a complete medical history. When a prior folder exists, copy the relevant evidence (including evidence about functioning) into the current folder (see DI 20505.010A.2).

When the case evidence is insufficient to determine how the claimant performs activities of daily living or basic work activities, or there are inconsistencies or ambiguities in the case evidence, consider whether supplemental development is needed, as explained in DI 22505.008.

For information on when to stop development, see DI 22501.001D.

For information on making every reasonable effort to develop a complete medical history, see DI 22505.001A.

D. Documenting development of evidence by telephone

When developing or obtaining evidence about functioning from a medical or non-medical source by telephone, verify the source's identity prior to discussing the claim (see DI 22511.007B.3. in this section) document the date, the content of your conversation, and with whom you spoke on an SSA-5002 (Report of Contact) or a Case Note in the Disability Case Processing System (DCPS), and "write to" the case development worksheet (CDW) or the Disability Determination Explanation (DDE), as applicable.

For information on documenting evidence from a medical source obtained by telephone contact, see DI 22505.030.

For information on the required elements of the DDE, see DI 26515.001.

Social Security

Program Operations Manual System (POMS)

DI 22511.007 Evidence about Functioning