Social Security's three-page form for a medical source's opinion of a claimant's mental work-related abilities on a sustained basis, meaning 8 hours a day, 5 days a week. It reaches the clinician per case during a disability appeal, from a hearing office, the disability determination services or the claimant's representative, and its ratings from none to extreme become evidence for the SSDI or SSI hearing.
The treating psychiatrist, psychologist or other medical source answers all six questions, describes the factors behind each rating, and signs with printed name, title and medical specialty. The claimant has no section to complete.
Page 1 defines sustained basis as eight hours a day, five days a week, or an equivalent schedule, and asks for your opinion of what the individual can still do despite the impairments. It defines the five rating terms and states in capitals that it is very important to describe the factors supporting your assessment, because SSA must consider how well it is supported.
Answer whether this ability is affected. If no, go to question 2. If yes, rate six items from none to extreme: understanding and remembering simple instructions, carrying them out, judgments on simple work-related decisions, and the same three for complex instructions and decisions. Then identify the medical signs, laboratory findings or other factors that support the ratings.
Answer whether the impairment affects the ability to interact with supervisors, co-workers and the public and to respond to changes in a routine work setting. If yes, rate interaction with the public, with supervisors and with co-workers, and responding appropriately to usual work situations and routine changes. Identify the supporting factors in the box below.
Answer whether any other capability is affected, such as the ability to concentrate, persist or maintain pace, or to adapt or manage oneself. If yes, name the capability and describe how it is affected, then identify the supporting factors. Unlike questions 1 and 2, it has no rating grid, so the description carries the whole answer.
Your ratings are assumed to describe current limitations only. If you have enough information to form an opinion within a reasonable degree of medical or psychological probability, give the date the limitations you found were first present. If you can't form that opinion, the ratings stand as current limitations only.
If the claimant's impairments include alcohol or substance abuse, say whether these contribute to any of the limitations you rated. If they do, identify and explain the changes you would make to your answers if the claimant were totally abstinent from alcohol and substance use.
Answer yes or no: can the individual manage benefits in his or her own best interest? Then sign and date, and print your name, title and medical specialty legibly, as the form requests. The Privacy Act statement that follows explains that SSA uses the information to process the named patient's claim.
Download the current version from the source each time; forms change without notice.
Medical Source Statement of Ability to Do Work-Related Activities (Mental)
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Sources for this guide
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Each rating describes functioning independently, appropriately, effectively and on a sustained basis. None means able to function that way; mild means slightly limited; moderate means fair; marked means seriously limited; extreme means unable to function in that area. The words carry these defined meanings, so choose them by the form's definitions.
The treating psychiatrist, psychologist or other medical source who knows the claimant's mental impairments, or a consultative examiner SSA has engaged. SSA asks for a professional opinion of what the individual can still do despite the impairments, based on history, findings, diagnosis, treatment response and prognosis.
Question 5 applies when the claimant's impairments include alcohol or substance abuse. It asks whether these contribute to any of the limitations you rated and, if so, what changes you would make to your answers if the claimant were totally abstinent. Explain the reasoning in the space provided.
It is not on SSA's public forms page; the hearing office, disability determination services or the claimant's representative sends it for one claimant. The OMB-approved copy, listed as HA-1152-U3, is posted on reginfo.gov under control number 0960-0662 alongside the physical statement, HA-1151-BK.