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

Last Update: 9/28/05 (Transmittal I-2-67)

Critical Request Evaluation Sheet

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 completed/attached.]
Other: _________________________________________________________

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

___ Terminal Illness [TERI]—FLAG with Form SSA-2200
- Military service disability claim—FLAG with MSDC flag found in I-2-1-96
- AIDS
- Hospice care [may verify through servicing Field Office.]
- Medical condition that cannot be reversed and is expected to end in death.
___ 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: __________________________________________________________________________________________________________________________________
___ Suicidal or ___ Homicidal [SUICIDAL/HOMICIDAL]. See I-2-1-37. If violent, inform FO or other case handlers.

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

DATE: _________________