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This is the form which is sent to the person filing and to a third party (someone other than you). The questions are the same on both forms. Third Parties should fill out their forms without the help of the person filing for the claim.


If you need help in filling out the form call Social Security: 1-800-772-1213

*Print or type

*DO NOT LEAVE ANSWERS BLANK. If you do not know the answer, or the answer is "none" or "does not apply," please write "don't know" "none" or "does not apply."

* Do not ask a doctor or hospital to complete this form.

* Be sure to explain an answer if the question asks for an explanation, or if you think you need to explain an answer.

* If you need more space to answer any questions, use the "REMARKS" section, and show the number of the question being answered (example:7a)


How the disabled person's illnesses, injuries, or conditions limit his/her activities.


1. NAME OF DISABLED PERSON (first, middle, last)

2. YOUR NAME (the person completing this form)

3. RELATIONSHIP (to disabled person)

4. DATE (month, day, year)

5. YOUR DAYTIME PHONE NUMBER (If there is no telephone number where you can be reached, please give us a daytime number where we can leave a message for you)

(area code) (phone number) (Check one) Your number Message Number None

6. a. How long have you known the disabled person?

b. How much time do you spend with the disabled person and what do you do together?

7. a. Where does the disabled person live? (Check One



Boarding House

Nursing Home


Group Home

Other (What?)

b. With whom does he/she live? (Check One)


With Family

With Friends

Other (Describe relationship)


8 Describe what the disabled person does from the time he/she wakes up until going to bed.

9. Does this person take care of anyone else such as a wife/husband, children, grandchildren, parents, friend, other? YES NO

If "YES", for whom does he/she care, and what does he/she do for them?

10. Does he/she take care of pets or other animals? YES NO

If "YES," what does he/she do for them?

11. Does anyone help this person care for other people or animal? YES NO

If "YES," who helps, and what do they do to help?

12. What was the disabled pers able to do before his/her illnesses, injuries, or conditions he/she can't do now?

13. Do the illnesses, injuries, or conditions affect his/her sleep? YES NO

If "YES," how?

14. PERSONAL CARE (Check here if NO PROBLEM with personal care)

a. Explain how the illnesses, injuries, or conditions affect this person's ability to:



Care for Hair


Feed Self

Use the Toilet


b. Does he/she need any special reminders to take care of personal needs and grooming? YES NO

If "YES," what type of help or reminders are needed?

c. Does he/she need help or reminders taking medicine? YES NO

If "YES," what kind of help does he/she need?


a. *Does the disabled person prepare his/her own meals? YES NO

If "YES," what kind of food is prepared (For example, sandwiches, frozen dinners, or complete meals with several courses)

*How often does he/she prepare food or meals? (For example, daily, weekly, monthly)

*How long does it take him/her?

*Any changes in cooking habits since the illnesses, injuries, or conditions began?

b. If "NO," explain why he/she cannot or does not prepare meals.


a. List household chores, indoors and outdoors, that the disabled person is able to do. (For example, cleaning, laundry, household repairs, ironing, mowing, etc.)

b. How much time do chores take, and how often does he/she do each of these things?

c. Does he/she need help or encouragement doing these things? YES NO

If "YES," what help is needed?

d. If the disabled person doesn't do house or yard work, explain why not.


a. How often does this person go outside?

If he/she doesn't go out at all, explain why not.

b. When going out, how does he/she travel? (Check all that apply.)


Drive a car

Ride in a car

Ride a bicycle

Use public transportation

Other (Explain)

c. When going out, can he/she go alone? YES NO

If "NO," explain why he/she can't go out alone.

d. Does the disabled person drive? YES NO

If the disabled person doesn't drive, explain why not.


a. If the disabled person does any shopping, does he/she shop: (Check all that apply.)

In stores

By phone

By mail

By computer

b. Describe what he/she shops for.

c. How often does he/she shop and how long does it take?


a. Is he/she able to:

Pay bills YES NO

Count change YES NO

Handle a savings account YES NO

Use checkbook/money orders YES NO

Explain all "NO" answers.

b. Has the disabled person's ability to handle money changed since the illnesses, injuries, or conditions began? YES NO

If "YES," explain how the ability to handel money has changed.


a. What are his.her hobbies and interests? (For example, reading, watching tv, sewing, playing sports, etc.)

b. How often and how well does he/she do these things?

c. Describe any changes in these activities since the illnesses, injuries, or conditions began.


a. Does the disabled person spend time with others? In person, on the phone, on the computer, etc.) YES NO

If "YES," describe the kinds of things he/she does with others.

How often does he/she do these things?

b. List the places he/she goes on a regular basis (For examle, church, community center, sports events, social groups, etc.)

Does he/she need to be reminded to go places? YES NO

How often does he/she go and how much does he/she take part?

Does he/she need someone to accompany him/her? YES NO

c. Does this person have any problems getting along with family, friends, neighbors or others? YES NO

If "YES," explain.

d. Describe any changes in social activities since the illnesses, injuries, or conditions began.


22. a. Check and of the following items the disabled person's illnesses, injuries, or conditions affect:











Stair Climbing



Completing Tasks



Following Instructions

Using Hands

Getting Along with Others

Please explain how his/her illnesses, injuries, or conditions affect each of the items you checked. (For example, he/she can olny lif X pounds, or he/she can only walk x miles)

b. Is the disabled person:

Right Handed

Left Handed

c. How far can he/she walk before needing to rest?

If he/she has to rest, how long befor he/she can resume walking?

d. For how long can the disabled person pay attention?

e. Does the disabled person finish what he/she starts? (For example, a conversation, chores, reading, watching a movie) YES NO

f. How well does the disabled person follow written instructions? (For example, a recipe)

g. How well does the disabled person follow spoken instructions?

h. How well does the disabled person get along with authority figures? (For example, police, bosses, landlords, or teachers.)

i. Has he/she ever been fired or laid off from a job because of problems getting along with others? YES NO

If "Yes," please explain.

IF "YES," give name of employer.

j. How well does the disabled person handle stress?

k. How well does he/she handle changes in routine?

l. Have you noticed any unusual behavior or fears in the disabled person? YES NO

If "YES," please explain.

23. Does the disabled person need the use of any of the following? (Check all that apply)



Wheel Chair



Artificial Limb

Hearing Aid

Glasses/Contact Lenses

Artificial Voice Box

Other (Explain)

Which of these was prescribed by a doctor?

When was it prescribed?

When does this person need to use these aids?


Use this section for any added information you did not show in earlier parts of this form. When you are done with this section (Or if you didn't have anything to add), be sure to go to complete the fields at the bottom of this page.

Name of person completing this form. (Please print)

Date (month, day, year)

Address (Number and street)

Email address (Optional)



Zip Code


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