I-2-1-95.Exhibit – Critical Request Evaluation Sheet

Last Update: 2/12/09 (Transmittal I-2-73)

CLAIMANT'S NAME (Last, First)

SSN

REQUESTOR/SOURCE

REQUESTOR'S ADDRESS

REQUESTOR'S TELEPHONE NO.

RELATION TO CLAIMANT

DATE OF REQUEST

HOW WAS CRITICAL REQUEST RECEIVED?

Written statement submitted. [Letter or statement attached.]

Telephone contact received by _______________________ (employee). [RC attached.]

Other: _________________________________________________________

ALLEGED CRITICAL SITUATION (Check any and all that apply):

  1. ___ Terminal Illness [TERI]—FLAG with Form SSA-2200.

  2. ___ Military Service Casualty Case [MSCC]—FLAG with MSCC flag found in I-2-1-96

  3. ___ Compassionate Allowance [CAL]—FLAG with Critical Case flag found in I-2-1-94, with clear designation that case involves CAL.

  4. ___ Without and unable to obtain food, medicine, or shelter [DIRE NEED]

    • Lack of food/shelter

    • Lack of necessary medical care/medications

    • Foreclosure or eviction

    • Other: _____________________________________________________________

    • ___ Verified with servicing Field Office (FO) or other source:

      • Income of any kind/source? Yes/No __________________________________

      • Receiving any aid from the state or federal government? (Workers' comp, TANF, food stamps, WIC, Medicare, Medicaid, veterans' benefits, etc.)? Yes/No ______________________________________________

      • Dependents: __________

      • Obligations/Expenses/Debts: __________________________________________________________________________________________________________________________________

  5. ___ Suicidal or ___ Homicidal [SUICIDAL/HOMICIDAL]. See I-2-1-37. .

DESIGNATOR: _________________________ [HOCALJ, HOD, GS, ALJ] (Circle one)

DATE: _________________

  • ENTERED INTO HO DATA SYSTEM (date of designation, type of critical case)

  • CLAIM FILE FLAGGED AS CRITICAL CASE