Psychiatric Impairment

1. Your Name *This question is required.

2. Today's Date *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

1. Ability to comprehend and follow instructions

How has your function been affected in these areas. Document with specific examples.

the ability to maintain attention and concentration for necessary periods
the ability to understand written or oral instructions
the ability to do work requiring set limits, tolerances or standards

2. Ability to perform simple and repetitive tasks

How has your function been affected in these areas. Document with specific examples.

the ability to ask simple questions or request assistance
the ability to perform activities of a routine nature
the ability to remember locations and work procedures

3. Ability to maintain a work pace appropriate to a given work load

How has your function been affected in these areas. Document with specific examples.

the ability to perform activities within a schedule, maintain regular attendance and be punctual
the ability to complete a normal work day and/or work week and perform at a consistent pace

4. Ability to perform complex and varied tasks

How has your function been affected in these areas. Document with specific examples.

the ability to the ability to synthesize, coordinate, and analyze data
the ability to perform jobs requiring precise attainment of set limits, tolerances, or standards
the ability to perform a variety of duties, often changing from one task to another of a different nature without loss of efficiency or composure

5. Ability to relate to other people beyond giving and receiving instructions

How has your function been affected in these areas. Document with specific examples.

the ability to get along with co-workers or peers
the ability to perform work activities requiring negotiating with, explaining, or persuading
the ability to respond appropriately to evaluation or criticism

6. Ability to influence people

How has your function been affected in these areas. Document with specific examples.

the ability to convince or direct others
the ability to understand the meaning of words and to use them appropriately and effectively
the ability to interact appropriately with people

7. Ability to make generalizations, evaluations or decisions without immediate supervision

How has your function been affected in these areas. Document with specific examples.

the ability to recognize potential hazards and follow appropriate precautions
the ability to understand and remember detailed instructions
the ability to make independent decisions or judgements based on appropriate information
the ability to set realistic goals or make plans independent of others

8. Ability to accept and carry out responsibility for direction, control and planning

How has your function been affected in these areas. Document with specific examples.

the ability to set realistic goals or make plans independently of others
the ability to negotiate with, instruct or supervise people
the ability to respond appropriately to changes in the work conditions