Quality Review Checklist for SSI/SSDI Applications and Disability Determinations
I. Establishing Protective Filing Date |
|
A. Was SSA contacted to establish protective filing date? What method was used? Phone (local SSA) On-line 1-800-772-1213 (SSA toll-free) |
Yes No |
B. Was filing date noted in individual’s chart? |
Yes No |
C. Does the worker have proof of establishment of protective filing? |
Yes No |
D. Protective Filing Date: mm/dd/yyyy ðð / ðð / ðððð |
|
II. SSI/SSDI Applications: Non-Medical Aspect |
|
A. SSI Application (SSA-8000) |
|
1. Was SSA-8000 initiated: By phone? In person? |
Yes No Yes No |
2. Date completed: mm/dd/yyyy ðð / ðð / ðððð |
|
3. Critical parts of SSI Application |
|
(a) Was documentation of marital status needed? If yes, was it gathered and submitted? |
Yes No Yes No |
(b) Did immigration status need to be addressed? If yes, was documentation submitted? |
Yes No Yes No |
(c) Was living arrangement documentation provided? |
Yes No |
(d) Was documentation of assets/resources provided? |
Yes No |
(e) Was documentation of income provided? |
Yes No |
B. SSDI Application (SSA-16) |
|
1. Was application for SSDI (SSA-16) completed? (a) Submitted on-line? (b) Submitted in-person? (c) Submitted by phone? |
Yes No Yes No Yes No |
2. Date completed: mm/dd/yyyy ðð / ðð / ðððð |
|
C. Was Appointment of Representative (SSA-1696) signed and submitted? |
Yes No |
D. Was Statement of Claimant (SSA-795) regarding current legal status completed and submitted? |
Yes No |
1. If legal complications existed, were these taken care of? |
Yes No |
III. SSI/SSDI Applications: Disability Report SSA-3368 |
|
A. Was SSA 3368 Disability Report completed? 1. Submitted on-line? 2. Submitted in-person? 3. Submitted by phone? |
Yes No Yes No Yes No Yes No |
B. If SSDI application was also completed, was information about date of onset of disability and date last worked consistent with SSA 16? |
Yes No |
C. On the Disability Report (SSA-3368), was the following information provided: |
|
1. Additional contact person besides appointed representative on page 1? |
Yes No |
2. All physical and mental health problems listed in the individual’s words? |
Yes No |
3. Clear explanation of how health problems keep individual from being able to work? |
Yes No |
4. Complete listing of employment history from past 15 years with best estimates of tasks, duration, pay, and dates worked? |
Yes No |
5. Comprehensive listing of medical clinics, hospitals, health care providers (addresses, phone numbers, and dates of treatment, where possible) for ALL past and current physical and mental health treatment, including: (a) Reasons for treatment/treatment provided? (b) Medications currently taking, what they’re for, and ALL side effects? (c) All recent medical tests with approximate dates and location? |
Yes No Yes No Yes No |
6. Are ALL questions answered with complete information and any clarifications included in remarks? |
Yes No |
7. Are all questions answered in individual’s words? |
Yes No |
8. Are additional sheets of information included as needed? |
Yes No |
D. Were enough releases of information (SSA-827) completed for all treatment sources, signed and NOT dated? |
Yes No |
IV. Medical Summary Report |
|
A. Introduction |
|
1. Does the first section of the Medical Summary Report accurately provide the physical description of the individual, the person’s interacting pattern, pattern of speech, ability to answer questions, etc.? |
Yes No |
2. Does the description give the reader an understanding of what it is like to be with this person? |
Yes No |
B. Personal History- Does this section cover: |
|
1. Any trauma issues, including physical and/or sexual abuse (Brain damage is covered under physical health)? |
Yes No |
2. Educational history, including information on learning difficulties, grades repeated, special education, relationships with other students/teachers? |
Yes No |
3. Employment history for 15 years, including all jobs, reasons for leaving, job skills, problems on-the-job in terms of task completion and relationships with supervisors/co-workers? |
Yes No |
4. Legal history, i.e., arrests, convictions, incarcerations (including treatment in jail/prison), probation, parole? |
Yes No |
5. Problems in personal/intimate relationships, including problems with children and current relationships? |
Yes No |
C. Treatment History |
|
1. Does treatment history include substance use history and treatment, including detox? |
Yes No |
2. Does substance use history address reason for use, impact of use (what person feels is positive/negative), treatment history, current drug of choice (reasons, positives/negatives)? |
Yes No |
3. Physical health history: Hospitalizations? Surgeries? Falls/accidents/fights involving head injuries? Current health problems? Medications? Primary care provider? If no treatment now, why? |
Yes No |
4. Mental health history: First symptoms? Age and impact of first symptoms? Hospitalizations? Day treatment/partial hospitaliz.? Outpatient treatment? Psychiatric rehab. services? Emergency room visits? Medications? If no current treatment, why? |
Yes No |
D. Functional Information |
|
1. Description of all functional levels of impairment separated by: activities of daily living, social functioning (incl. ability to be with and relate to other people), impairment of persistence and pace in completion of tasks, efforts at working 3 or more times in last year? |
Yes No |
E. Summary Ending |
|
1. Does the report contain a summary of diagnosis, impairment, evidence of significant functional impairment? |
Yes No |
2. Is report co-signed by a physician/psychiatrist or psychologist? |
Yes No |
3. Are contact names and phone numbers included for the primary writer of report and the co-signing physician/psychiatrist/psychologist? |
Yes No |