I-2-5-89.Sample – Prehearing Questionnaire To Representative

Last Update: 9/28/05 (Transmittal I-2-68)

UNITED STATES OF AMERICA

SOCIAL SECURITY ADMINISTRATION
Office of Hearings and Appeals

In the Case of:

Claim For:

(Claimant)

Disability Insurance Benefits

Supplemental Security Income Benefits

(Wage-Earner)

(Social Security Number)

PRE-HEARING QUESTIONNAIRE

This Pre-Hearing Questionnaire has the following stated goals and objectives:

  1. With timely and complete filings being submitted before a hearing, “post-hearing” development (which delays a decision on the merits) is reduced.

  2. Compliance with this Questionnaire will also permit the undersigned to schedule the proper time for presentation of the evidence and permit the proper scheduling of medical and vocational experts to avoid having the case placed in post-hearing status or the need for a supplemental hearing.

____________________________
U. S. Administrative Law Judge

  1. Please submit all evidence to be considered at the hearing at least 10 days before the scheduled hearing. This includes, but is not limited to, claimant's current medications; claimant's work history; reports, records, or office notes from any treating or examining medical source, functional capacity evaluations or independent medical examinations, medical source statements and other documentary evidence relevant to the claim.

  2. Please respond to the following regarding your client's application:

    1. What medically determinable impairment(s) do(es) your client have and what Exhibits in the Administrative Record do you rely on to establish the existence of these impairment(s)?

    2. Does your client claim to have an impairment that meet or medically equals the criteria of any listed impairment(s) at 20 C.F.R. 404, Subpart P, Appendix 1? If so, what treating source evidence do you rely on and on what date do you propose the medical listing was met or medically equaled? (Identify by date and source and Exhibit Number).

    3. Does your client claim to be disabled under the Medical-Vocational Guidelines (“Grid Rules”) at 20 C.F.R. 404, Subpart P, Appendix 2? If so, identify the Grid Rules you will be relying on.

    4. What exertional limitations (sitting, standing, walking, lifting, carrying, pushing, and pulling) do you allege that your client has as of the result of the impairment(s)? Support such allegations by reference to date, source and Exhibit Number).

    5. What non-exertional limitations does your client allege as a result of the impairment(s)? Remember that pain is not a limitation, but a symptom. Specify the limitations attributed to any alleged pain. Examples of non-exertional limitations would include limitations in vision, hearing, speaking, understanding, carrying out and remembering simple instructions, use of judgment, responding appropriately to supervision, co-workers and usual work situations, environmental limitations, manipulative or postural functions such as reaching, handling, stooping, climbing, crawling, or crouching. Support such allegations by reference to date, source and Exhibit Number.

    6. Please list the names of all witnesses you will present at the hearing, other than your client, and specify what relationship, if any, to the claimant, and whether any of these individuals will testify as a medical or vocational expert. (If the individual(s) will testify as medical or vocational expert, provide a resume).

    7. Identify any proposed stipulations for consideration.

Date:__________________

________________________________
Attorney/Representative for Claimant