[Federal Register Volume 74, Number 30 (Tuesday, February 17, 2009)]
[Notices]
[Pages 7515-7518]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: E9-3382]


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SOCIAL SECURITY ADMINISTRATION

[Docket No. SSA-2008-0062; Social Security Ruling, SSR 09-5p]


Title XVI: Determining Childhood Disability--The Functional 
Equivalence Domain of ``Interacting and Relating With Others''

AGENCY: Social Security Administration.

ACTION: Notice of Social Security Ruling (SSR).

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SUMMARY: We are giving notice of SSR 09-5p. This SSR consolidates 
information from our regulations, training materials, and question-and-
answer documents about the functional equivalence domain of 
``Interacting and relating with others.'' It also explains our policy 
about that domain.

DATES: Effective Date: March 19, 2009.

FOR FURTHER INFORMATION CONTACT: Janet Truhe, Office of Disability 
Programs, Social Security Administration, 6401 Security Boulevard, 
Baltimore, MD 21235-6401, (410) 965-1020.

SUPPLEMENTARY INFORMATION: Although 5 U.S.C. 552(a)(1) and (a)(2) do 
not require us to publish this SSR, we are doing so under 20 CFR 
402.35(b)(1).
    SSRs make available to the public precedential decisions relating 
to the Federal old-age, survivors, disability, supplemental security 
income, special veterans benefits, and black lung benefits programs. 
SSRs may be based on determinations or decisions made at all levels of 
administrative adjudication, Federal court decisions, Commissioner's 
decisions, opinions of the Office of the General Counsel, or other 
interpretations of the law and regulations.
    Although SSRs do not have the same force and effect as statutes or 
regulations, they are binding on all components of the Social Security 
Administration. 20 CFR 402.35(b)(1).
    This SSR will be in effect until we publish a notice in the Federal 
Register that rescinds it, or publish a new SSR that replaces or 
modifies it.

(Catalog of Federal Domestic Assistance, Program No. 96.006 
Supplemental Security Income.)

    Dated: February 9, 2009.
Michael J. Astrue,
Commissioner of Social Security.

Policy Interpretation Ruling

Title XVI: Determining Childhood Disability--The Functional Equivalence 
Domain of ``Interacting and Relating With Others''

    Purpose: This SSR consolidates information from our regulations, 
training materials, and question-and-answer documents about the 
functional equivalence domain of ``Interacting and relating with 
others.'' It also explains our policy about that domain.
    Citations: Sections 1614(a)(3), 1614(a)(4), and 1614(c) of the 
Social Security Act, as amended; Regulations No. 4, subpart P, appendix 
1; and Regulations No. 16, subpart I, sections 416.902, 416.906, 
416.909, 416.923, 416.924, 416.924a, 416.924b, 416.925, 416.926, 
416.926a, and 416.994a.
    Introduction: A child \1\ who applies for Supplemental Security 
Income (SSI) \2\ is ``disabled'' if the child is not engaged in 
substantial gainful activity and has a medically determinable physical 
or mental impairment or combination of impairments \3\ that results in 
``marked and severe functional limitations.'' \4\ 20 CFR 416.906. This 
means that the impairment(s) must meet or medically equal a listing in 
the Listing of Impairments (the listings) \5\ or must functionally 
equal the listings, also referred to as ``functional equivalence.'' 20 
CFR 416.924 and 416.926a.
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    \1\ The definition of disability in section 1614(a)(3)(C) of the 
Social Security Act (the Act) applies to any ``individual'' who has 
not attained age 18. In this SSR, we use the word ``child'' to refer 
to any such person, regardless of whether the person is considered a 
``child'' for purposes of the SSI program under section 1614(c) of 
the Act.
    \2\ For simplicity, we refer in this SSR only to initial claims 
for benefits. However, the policy interpretations in this SSR also 
apply to continuing disability reviews of children under section 
1614(a)(4) of the Act and 20 CFR 416.994a.
    \3\ We use the term ``impairment(s)'' in this SSR to refer to an 
``impairment or a combination of impairments.''
    \4\ The impairment(s) must also satisfy the duration requirement 
in section 1614(a)(3)(A) of the Act; that is, it must be expected to 
result in death, or must have lasted or be expected to last for a 
continuous period of not less than 12 months.
    \5\ For each major body system, the listings describe 
impairments we consider severe enough to cause ``marked and severe 
functional limitations.'' 20 CFR 416.925(a); 20 CFR part 404, 
subpart P, appendix 1.
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    As we explain in greater detail in SSR 09-1p, we always evaluate 
the ``whole child'' when we make a finding regarding functional 
equivalence, unless we can otherwise make a fully favorable 
determination or decision.\6\ We focus first on the child's activities, 
and evaluate how appropriately, effectively, and independently the 
child functions compared to children of the same age who do not have 
impairments. 20 CFR 416.926a(b) and (c). We consider what activities 
the child cannot do, has difficulty doing, needs help doing, or is 
restricted from doing because of the impairment(s). 20 CFR 416.926a(a). 
Activities are everything a child does at home, at school, and in the 
community, 24 hours a day, 7 days a week.\7\
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    \6\ See SSR 09-1p, Title XVI: Determining Childhood Disability 
Under the Functional Equivalence Rule--The ``Whole Child'' Approach.
    \7\ However, some children have chronic physical or mental 
impairments that are characterized by episodes of exacerbation 
(worsening) and remission (improvement); therefore, their level of 
functioning may vary considerably over time. To properly evaluate 
the severity of a child's limitations in functioning, as described 
in the following paragraphs, we must consider any variations in the 
child's level of functioning to determine the impact of the chronic 
illness on the child's ability to function longitudinally; that is, 
over time. For more information about how we evaluate the severity 
of a child's limitations, see SSR 09-1p. For a comprehensive 
discussion of how we document a child's functioning, including 
evidentiary sources, see SSR 09-2p, Title XVI: Determining Childhood 
Disability--Documenting a Child's Impairment-Related Limitations.
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    We next evaluate the effects of a child's impairment(s) by rating 
the degree to which the impairment(s) limits functioning in six 
``domains.'' Domains are broad areas of functioning intended to capture 
all of what a child can or cannot do. We use the following six domains:
    (1) Acquiring and using information,
    (2) Attending and completing tasks,
    (3) Interacting and relating with others,
    (4) Moving about and manipulating objects,
    (5) Caring for yourself, and
    (6) Health and physical well-being.

20 CFR 416.926a(b)(1).\8\

    \8\ For the first five domains, we describe typical development 
and functioning using five age categories: Newborns and young 
infants (birth to attainment of age 1); older infants and toddlers 
(age 1 to attainment of age 3); preschool children (age 3 to 
attainment of age 6); school-age children (age 6 to attainment of 
age 12); and adolescents (age 12 to attainment of age 18). We do not 
use age categories in the sixth domain because that domain does not 
address typical development and functioning, as we explain in SSR 
09-8p, Title XVI: Determining Childhood Disability--The Functional 
Equivalence Domain of ``Health and Physical Well-Being.''
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    To functionally equal the listings, an impairment(s) must be of 
listing-level severity; that is, it must result in ``marked'' 
limitations in two domains of

[[Page 7516]]

functioning or an ``extreme'' limitation in one domain.\9\ 20 CFR 
416.926a(a).
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    \9\ See 20 CFR 416.926a(e) for definitions of the terms 
``marked'' and ``extreme.''
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Policy Interpretation

General

    In the domain of ``Interacting and relating with others,'' we 
consider a child's ability to initiate and respond to exchanges with 
other people, and to form and sustain relationships with family 
members, friends, and others. This domain includes all aspects of 
social interaction with individuals and groups at home, at school, and 
in the community. Important aspects of both interacting and relating 
are the child's response to persons in authority, compliance with 
rules, and regard for the possessions of others. In addition, because 
communication is essential to both interacting and relating, we 
consider in this domain the speech and language skills children need to 
speak intelligibly and to understand and use the language of their 
community.
    The ability to interact and relate with others begins at birth. 
Children begin to use this ability in early infancy when they bond with 
caregivers, and use it in increasingly complicated ways as they develop 
and grow older.
    This ability is involved in a broad range of childhood activities, 
such as playing, learning, and working cooperatively with others, 
either one-on-one or in groups. To interact and relate effectively in 
any activity, a child must be able to recognize, understand, and 
respond appropriately to emotional and behavioral cues from other 
people. A child whose impairment(s) limits the ability to interact and 
relate with others may have various kinds of difficulties. For example, 
the child may not understand:
     How to approach other children,
     How to initiate and sustain social exchanges, and
     How to develop meaningful relationships with others.
    Children with impairment-related limitations in this domain may not 
be disruptive; therefore, their limitations may go unnoticed. Such 
children may be described as socially withdrawn or isolated, without 
friends, or preferring to be left alone. These children may simply not 
understand how to accomplish social acceptance and integration with 
other individuals or groups.\10\ However, because children achieve much 
of their understanding about themselves and the world from their 
interactions, the impairment-related limitations of children who 
withdraw from social interaction may be as significant as those of 
children whose impairments cause them to be disruptive.
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    \10\ The mere fact that a child prefers to be alone or does not 
have many friends, however, does not necessarily mean that there is 
a limitation that should be evaluated in this domain. There must be 
a limitation that results from a medically determinable 
impairment(s).
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    As with limitations in any domain, we do not consider a limitation 
in the domain of ``Interacting and relating with others'' unless it 
results from a medically determinable impairment(s). However, while it 
is common for all children to experience some difficulty interacting 
and relating with others from time to time, a child who has significant 
but unexplained problems in this domain may have an impairment(s) that 
was not alleged or has not yet been diagnosed. In such cases, 
adjudicators should pursue any indications that an impairment(s) may be 
present.

Interacting With Others

    To interact effectively with others, children must understand how 
to approach another person or a group of people, and must know how to 
respond in an age-appropriate manner to others who approach them. They 
must be able to use not only words, but facial expressions, gestures, 
and actions. The child must also be able to use these forms of 
communication with different people and in different contexts 
throughout the day. In addition, when interacting with a parent, 
teacher, or other adult, the child needs to convey respect for the 
adult. When interacting with peers, the child needs to convey 
willingness to play fairly and follow the rules, consistent with 
expectations for the child's age. A child's interactions may be limited 
to a single exchange, as when buying candy at a neighborhood store, or 
more frequent ones, as when answering a younger sibling's questions. 
They may occur one-on-one, as when talking on the telephone, or in 
groups, as when playing with friends or participating in an organized 
sport.
    Both physical and mental impairments can affect a child's ability 
to interact with others. For example, a child with a hearing impairment 
or abnormality of the speech mechanism (such as a repaired cleft 
palate) may have speech that is difficult to understand. Such a child 
may have difficulty describing an event to strangers. A child with 
attention-deficit/hyperactivity disorder may antagonize others by 
impulsively cutting into a line.

Relating With Others

    To relate effectively with others, a child must be able to form 
relationships with family members, friends, and others, and to sustain 
those relationships over time in an age-appropriate manner. Creating 
relationships with others builds upon effective interaction, and 
involves awareness and consideration of others' feelings, helpful and 
cooperative behaviors, and continuing interest in the relationships.
    Both physical and mental impairments can affect a child's ability 
to relate with others. For example, a child with a physical 
abnormality, such as a disfiguring burn, a missing limb, or an abnormal 
gait, or who uses adaptive equipment because of the impairment(s), may 
have difficulty making friends. A child with an anxiety disorder may be 
extremely uncomfortable around other children and may have difficulty 
spending enough time with others to maintain friendships. An autism 
spectrum disorder may limit a child's emotional and social responses to 
others.

The role of communication in interacting and relating with others

    The ability to interact and relate with others requires the ability 
to communicate in an age-appropriate manner.\11\ To communicate with 
others, a child needs both speech and language. Speech is the 
production of sounds for the purpose of oral communication.\12\ 
Language provides the message of communication. It involves 
understanding what is heard and read (receptive language) and 
expressing what one wants to say to others, either orally or in writing 
(expressive language).\13\ Within age-appropriate expectations, a child 
must speak clearly enough to be understood, understand the message that 
another person is communicating, and formulate sentences well enough to 
convey a

[[Page 7517]]

message. An impairment(s) may affect speech, language, or both speech 
and language.
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    \11\ The ability to communicate is first manifested at birth. 
Even before speaking their first words, infants communicate through 
gestures and vocalizations to express feelings and needs.
    \12\ In addition to articulation (which relates to clarity), 
speech also concerns fluency (which relates to the flow of speech) 
and voice (which relates to vocal quality, pitch, and intensity). 
For a comprehensive discussion of speech issues in childhood 
disability cases, including guidelines for evaluating the severity 
of speech impairments, see SSR 98-1p, Title XVI: Determining Medical 
Equivalence in Childhood Disability Claims When a Child Has Marked 
Limitations in Cognition and Speech.
    \13\ When we evaluate the communication ability of children who 
speak a language other than English, we consider their use of their 
primary language (first language learned) and English. Otherwise, we 
might erroneously find limitations in ``Interacting and relating 
with others'' (or any other domain) when children are, for example, 
simply learning a second language or demonstrating dialectal 
differences.
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    Communication involves using and understanding both verbal and 
nonverbal skills in conversation. This is the social aspect of 
communication, also referred to as pragmatics. It involves verbal 
skills related to vocabulary choice and sentence formulation, and non-
verbal skills, such as maintaining eye contact and using gestures, 
facial expressions, and physical postures.\14\ It also involves other 
``rules'' or conversational skills, such as turn-taking, introducing 
and maintaining a topic, asking for clarification or giving feedback 
when appropriate, and using effective techniques for opening, 
maintaining, and closing a conversation.
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    \14\ A child's cultural background may also influence pragmatic 
behaviors. For example, teachers in many Northern American cultures 
expect children to maintain eye contact during conversations. 
Children from Asian backgrounds, however, are often trained to show 
respect for authority figures by avoiding eye contact.
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    When speaking in a conversation, a child must decide what to say 
and how to say it, using appropriate vocabulary and following the rules 
of grammar to communicate the intended message. In addition, the child 
must consider factors that can influence the expression of the message, 
including the identity of the listener (for example, parent, teacher, 
sibling, or friend) and the child's relationship to the listener (for 
example, how the child states a request to an authority figure or to a 
peer). The child must also pay attention to verbal and nonverbal 
indications of whether the listener understands the message and, if 
not, must be able to rephrase the message so as to be understood.
    When listening in a conversation, a child must follow what is being 
communicated well enough to understand the message and, if a response 
is appropriate, to respond in a meaningful way. A child who has 
difficulty understanding either the verbal or the nonverbal message may 
not be able to participate appropriately in a conversation. For 
example, classmates may become impatient or irritated when a child is 
unable to understand a joke (verbal) or to interpret facial expressions 
(nonverbal).

The Difference Between the Domains of ``Interacting and Relating With 
Others'' and ``Caring for Yourself''

    The domains of ``Interacting and relating with others'' and 
``Caring for yourself'' are related, but different from each other. The 
domain of ``Interacting and relating with others'' involves a child's 
feelings and behavior in relation to other people (as when the child is 
playing with other children, helping a grandparent, or listening 
carefully to a teacher). The domain of ``Caring for yourself'' involves 
a child's feelings and behavior in relation to self (as when 
controlling stress in an age-appropriate manner).
    A decision about which domain is appropriate for the evaluation of 
a specific limitation depends on the impact of the particular behavior. 
For example:
     If a girl with hyperactivity interrupts conversations 
inappropriately, we evaluate this problem in social functioning in the 
domain of ``Interacting and relating with others.'' However, if she 
impulsively runs into the street, endangering herself, we evaluate this 
problem in self-care in the domain of ``Caring for yourself.''
     If a boy with a language disorder avoids other children 
during playtime, we evaluate this problem in social functioning in the 
domain of ``Interacting and relating with others.'' But the child may 
also use language for ``self-talk'' to calm himself down in a stressful 
situation, so the language disorder may cause a limitation in self-
regulation, which we evaluate in the domain of ``Caring for yourself.''
    Some impairments may cause limitations in both domains. For 
example, a boy with Oppositional Defiant Disorder who refuses to obey a 
parent's instruction not to run on a slippery surface, disrespects the 
parent's authority and endangers himself by running instead of walking. 
In this case, the child's mental disorder is causing limitations in the 
domains of ``Interacting and relating with others'' and ``Caring for 
yourself.'' Similarly, a teenage girl with depression who avoids 
friends and wants to be left alone may also develop poor eating habits 
as a way of coping with social isolation. We evaluate the limitations 
resulting from her depression in both the domains of ``Interacting and 
relating with others'' and ``Caring for yourself.'' Rating the 
limitations caused by a child's impairment(s) in each and every domain 
that is affected is not ``double-weighting'' of either the 
impairment(s) or its effects. Rather, it recognizes the particular 
effects of the child's impairment(s) in all domains involved in the 
child's limited activities.\15\
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    \15\ For more information about how we rate limitations, 
including their interactive and cumulative effects, see SSR 09-1p.
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Effects in Other Domains

    Children with limitations in the ability to interact and relate 
with others may also have limitations in other domains. For example, 
learning and thinking also require the ability to communicate, so an 
impairment(s) affecting communication may cause a limitation that we 
evaluate in the domain of ``Acquiring and using information'' in 
addition to the domain of ``Interacting and relating with others.'' 
Therefore, as in any case, we evaluate the effects of the child's 
impairment(s), including the effects of medication or other treatment 
and therapies, in all relevant domains.

Examples of Typical Functioning in the Domain of ``Interacting and 
Relating With Others''

    While there is a wide range of normal development, most children 
follow a typical course as they grow and mature. To assist adjudicators 
in evaluating impairment-related limitations in the domain of 
``Interacting and relating with others,'' we provide the following 
examples of typical functioning drawn from our regulations, training, 
and case reviews. These examples are not all-inclusive, and 
adjudicators are not required to develop evidence about each of them. 
They are simply a frame of reference for determining whether children 
are functioning typically for their age with respect to the ability to 
interact and relate with others.
1. Newborns and Young Infants (Birth to Attainment of Age 1)
     Begins to form intimate relationships (for example, by 
gradually responding visually and vocally to a caregiver, and by 
molding body to caregiver's when held).
     Initiates early interactive games (for example, playing 
peek-a-boo or pat-a-cake).
     Responds to a variety of emotions (for example, returning 
a caregiver's smile or crying when others are showing distress).
     Begins to develop speech (beginning with vowels and 
consonants, first alone and then combined in babbling sounds).
2. Older Infants and Toddlers (Age 1 to Attainment of Age 3)
     Begins to separate from caregivers, although is still 
dependent on them.
     Expresses emotions and responds to the feelings of others.
     Initiates and maintains interactions with adults.
     Begins to understand concept of ``mine'' and ``his'' or 
``hers.''
     Shows interest in, plays alongside, and eventually 
interacts with other children.

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     Communicates wishes or needs, first with gestures and 
later with words that can be understood most of the time by people who 
know the child best.
3. Preschool Children (Age 3 to Attainment of Age 6)
     Socializes with children and adults.
     Begins to prefer and develops friendships with playmates 
the same age.
     Relates to caregivers with increasing independence.
     Uses words instead of actions to express self.
     Is better able to share, show affection, and offer help.
     Understands and obeys simple rules most of the time, and 
sometimes asks permission.
     Chooses own friends and plays cooperatively without 
continual adult supervision.
     Initiates and participates in conversations with familiar 
and unfamiliar listeners, using increasingly complex vocabulary and 
grammar.
     Speaks clearly enough to be understood by familiar and 
unfamiliar listeners most of the time.
4. School-Age Children (Age 6 to Attainment of Age 12)
     Develops more lasting friendships with same-age children.
     Increasingly understands how to work in groups to create 
projects and solve problems.
     Increasingly understands another's point of view and 
tolerates differences (for example, playing with children from diverse 
backgrounds).
     Attaches to adults other than parents (for example, 
teachers or club leaders), and may want to please them to gain 
attention.
     Shares ideas, tells stories, and speaks in a manner that 
can be readily understood by familiar and unfamiliar listeners.
5. Adolescents (Age 12 to Attainment of Age 18)
     Initiates and develops friendships with children of the 
same age.
     Relates appropriately to children of all ages and adults, 
both individually and in groups.
     Increasingly able to resolve conflicts between self and 
family members, peers, and others outside of family.
     Recognizes that there are different social rules for 
dealing with other children than with adults (for example, behaving 
casually with friends, but more formally with people in authority).
     Describes feelings, seeks information, relates events, and 
tells stories in all kinds of environments (for example, at home or in 
school) and with all kinds of people (for example, parents, siblings, 
friends, or classmates).
     Develops increasing desire for privacy.
     Focuses less attention on parents and more on 
relationships with peers.

Examples of Limitations in the Domain of ``Interacting and Relating 
With Others''

    To further assist adjudicators in evaluating a child's impairment-
related limitations in the domain of ``Interacting and relating with 
others,'' we also provide the following examples of some of the 
limitations we consider in this domain. These examples are drawn from 
our regulations and training. They are not the only examples of 
limitations in this domain, nor do they necessarily describe a 
``marked'' or an ``extreme'' limitation.
    In addition, the examples below may or may not describe limitations 
depending on the expected level of functioning for a given child's age. 
For example, a toddler may be appropriately fearful of meeting new 
people, but a teenager would be expected to interact with strangers 
more readily. \16\
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    \16\ See 20 CFR 416.924b.
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     Does not reach out to be picked up, touched, and held by a 
caregiver.
     Has no close friends, or has friends who are older or 
younger.
     Avoids or withdraws from people he or she knows.
     Is overly anxious or fearful of meeting new people or 
trying new experiences.
     Has difficulty cooperating with others.
     Has difficulty playing games or sports with rules.
     Has difficulty communicating with others (for example, 
does not speak intelligibly or use appropriate nonverbal cues when 
carrying on a conversation).

DATES: Effective date: This SSR is effective on March 19, 2009.
    Cross-References: SSR 09-1p, Title XVI: Determining Childhood 
Disability Under the Functional Equivalence Rule--The ``Whole Child'' 
Approach; SSR 09-2p, Title: Determining Childhood Disability--
Documenting a Child's Impairment-Related Limitations; SSR 09-3p, Title 
XVI: Determining Childhood Disability--The Functional Equivalence 
Domain of ``Acquiring and Using Information''; SSR 09-4p, Title XVI: 
Determining Childhood Disability--The Functional Equivalence Domain of 
``Attending and Completing Tasks''; SSR 09-6p, Title XVI: Determining 
Childhood Disability--The Functional Equivalence Domain of ``Moving 
About and Manipulating Objects''; SSR 09-7p, Title XVI: Determining 
Childhood Disability--The Functional Equivalence Domain of ``Caring for 
Yourself''; 09-8p, Title XVI: Determining Childhood Disability--The 
Functional Equivalence Domain of ``Health and Physical Well-Being''; 
SSR 98-1p, Title XVI: Determining Medical Equivalence in Childhood 
Disability Claims When a Child Has Marked Limitations in Cognition and 
Speech; and Program Operations Manual System (POMS) DI 25225.030, DI 
25225.035, DI 25225.040, DI 25225.045, DI 25225.050, and DI 25225.055.

[FR Doc. E9-3382 Filed 2-13-09; 8:45 am]
BILLING CODE 4191-02-P