Get Ha-1151-bk 2009-2026

The HA-1151-BK form, known as the Medical Source Statement of Ability to Do Work-Related Activities (Physical), is essential for assessing an individual’s physical capabilities in relation to work. This guide will provide you with clear, step-by-step instructions on how to fill out this form accurately and efficiently online.

Follow the steps to successfully complete the HA-1151-BK form.

1. Click the ‘Get Form’ button to access the HA-1151-BK form and open it in the online editor.
2. Begin by entering the individual’s name in the designated field at the top of the form. Ensure that the spelling is accurate.
3. Input the individual’s Social Security number in the section provided, confirming that the number is correct and complete.
4. Move to Section I, where you will assess the individual's ability to lift and carry various weights. Check the appropriate boxes to indicate how often they can lift or carry specified amounts.
5. In Section II, record how many hours the individual can sit, stand, and walk without interruption. If certain activities cannot be performed for a full hour, indicate how many minutes can be managed.
6. Continue to Section III, which entails assessing the use of hands. Indicate how frequently the individual can perform various hand activities by checking the relevant boxes.
7. For Section IV, evaluate the use of feet for operating controls. Indicate the frequency of foot control activities for both the right and left foot.
8. In Section V, check how often the individual can perform various postural activities such as climbing, balancing, and stooping.
9. Complete Section VI by indicating whether any impairments affect the individual's hearing or vision and providing relevant details.
10. Proceed to Section VII to assess the individual’s tolerance to environmental conditions. Mark the frequency level for each listed condition.
11. In Section VIII, check the appropriate boxes regarding the individual’s ability to perform daily activities affected by their physical impairments.
12. In Section IX, specify any other work-related activities that are impacted by the individual’s impairments and identify supporting medical findings.
13. For Section X, state the date when impairments were first present, if applicable.
14. Finally, ensure the signature field in Section XI is completed with the required signature, date, and printed name, title, and medical specialty.
15. Once all sections are filled, review the form for accuracy. Users can then save changes, download the form for printing, or share it as necessary.

Complete the HA-1151-BK form online to ensure an accurate assessment of work-related physical abilities.