In the

United States Court of Appeals

For the Seventh Circuit ____________________

No. 14-2122

MELISSA L. VARGA,

Plaintiff-Appellant,

v.

CAROLYN W. COLVIN, Acting Commissioner of Social Security,

Defendant-Appellee.

____________________

Appeal from the United States District Court for the

Eastern District of Wisconsin.

No. 1:12-cv-1102 — William C. Griesbach, Chief Judge.

____________________

ARGUED DECEMBER 12, 2014 — DECIDED JULY 24, 2015

____________________

Before ROVNER, WILLIAMS, and TINDER, Circuit Judges.

WILLIAMS, Circuit Judge. Melissa Varga suffers from a 

combination of physical and mental impairments, including 

post-traumatic stress disorder, endometriosis, major depression, irritable bowel syndrome, and fibromyalgia. As a result, she applied for disability insurance benefits, but an 

Administrative Law Judge (“ALJ”) denied her application.

Varga sought review in the district court, which affirmed the 
2 No. 14-2122

decision of the ALJ. Varga appeals, arguing the ALJ erred by 

failing to include her mental limitations in the areas of concentration, persistence, and pace in the hypothetical question 

that he posed to the vocational expert. She contends the 

flawed hypothetical led the vocational expert and the ALJ to 

erroneously conclude she was not disabled. We agree that 

the hypothetical was fatally flawed. We therefore reverse the 

judgment of the district court and remand to the agency for 

further proceedings.

I. BACKGROUND

Melissa Varga, who is presently forty-two, applied for 

disability insurance benefits in July 2006, alleging she had 

been disabled since December 2005. Prior to this, Varga 

served in the Army. She received a medical discharge from 

the military in 1994 because of her severe endometriosis (a 

condition which causes pelvic pain). She then worked as a 

correctional officer, and later an office worker, at the Federal 

Correctional Institute (FCI) in Oxford, Wisconsin. She left 

the FCI in 2005 because of her continuing physical and mental impairments. Varga has not worked since March 2006, 

when her application for disability retirement under the 

Federal Employees Retirement System was approved. 

Between 2005 and 2011, Varga’s condition was assessed

by an array of medical professionals in connection with her 

attempts to obtain disability benefits. She was diagnosed 

with a combination of debilitating conditions, including 

post-traumatic stress disorder, endometriosis, major depression, irritable bowel syndrome, and fibromyalgia (a chronic

muscle pain disorder). While Varga’s medical history is 

lengthy, we limit our review here to the one medical assessment relevant to her appeal. 
No. 14-2122 3

In August 2006, Dr. Roger Rattan, a state agency psychological consultant, reviewed Varga’s medical records and 

completed two forms regarding her condition: the Psychiatric Review Technique (PRT) form and the Mental Residual 

Functional Capacity Assessment (MRFCA) form. On the PRT 

form, Dr. Rattan noted that Varga had a moderate restriction 

in activities of daily living, mild difficulties in maintaining 

social functioning, and—of particular relevance to this appeal—moderate difficulties in maintaining “concentration, 

persistence, or pace.”

On the MRFCA form, Dr. Rattan attributed similar difficulties to Varga. In Section I of the form,1 Dr. Rattan checked 

boxes indicating that Varga was moderately limited in (1) 

understanding and remembering detailed instructions; (2) 

carrying out detailed instruction; (3) maintaining attention 

and concentration for extended periods; (4) completing a 

normal workweek without interruption from psychologically based symptoms and performing at a consistent pace 

without an unreasonable number and length of rest periods;

(5) accepting instructions and responding appropriately to 

criticism from supervisors; (6) getting along with coworkers

without distracting them or exhibiting behavioral extremes; 

and (7) responding appropriately to changes in the work setting.

 1 Section I is a “worksheet to aid in deciding the presence and degree 

of functional limitations and the adequacy of documentation.” It contains twenty mental functions grouped under four main categories: (1) 

understanding and memory, (2) sustained concentration and persistence, 

(3) social interaction, and (4) adaptation. To the right of each of the items 

is a series of decision check blocks under the headings “not significantly 

limited,” “moderately limited,” “markedly limited,” “no evidence of limitation,” and “not ratable on available evidence.”
4 No. 14-2122

Section III of this MRFCA form (the “Functional Capacity 

Assessment” section) instructed Dr. Rattan to “Explain your 

summary conclusions in a narrative form.” Dr. Rattan, however, instead wrote “See EWS” in the space provided. This 

notation referred to an electronic worksheet, which was lost 

by the agency. As a result, Dr. Rattan’s narrative summary 

of Varga’s mental residual functional capacity, if it ever existed, was not part of the record before the district or this 

court. 

The Social Security Administration (“SSA”) denied both

Varga’s claim for benefits and her request for reconsideration, so she requested an administrative hearing. In April 

2009, Varga appeared for a video hearing before an ALJ, 

who found Varga not disabled. After the Appeals Council 

denied Varga’s request for review, she filed suit in federal 

court. In February 2011, the district court reversed and remanded the case to the agency for further proceedings because the ALJ did not analyze opinions from Varga’s treating physician and psychologist, and gave inadequate consideration to the disability determination made by the Veterans Administration. The following month, the Appeals 

Council remanded the case to a new ALJ for further proceedings consistent with the district court’s order. 

On June 12, 2012, Varga had her second hearing. As part 

of the hearing, the ALJ formulated a hypothetical question to

a vocational expert (“VE”) to assess what jobs Varga could 

perform. See 20 C.F.R. § 416.960(b)(2) (an ALJ may enlist a 

VE to “offer expert opinion testimony in response to a hypothetical question” about whether “physical and mental limitations imposed by the claimant’s medical impairment(s) can 

meet the demands of the claimant’s previous work”). The 
No. 14-2122 5

ALJ directed the VE to assume an individual with Varga’s 

vocational profile (age, education, and work experience) 

who was able to perform 

simple, routine, or repetitive tasks in a work 

environment ... free of fast paced production 

requirements, involving only simple work related decisions with few if any work place [sic] 

changes and no more than occasional interaction with coworkers or supervisors.

The VE testified that such a person could perform Varga’s 

past work (as an office helper) as she actually performed the 

job, as well as the jobs of inspector, laundry worker, hand 

packager, and cashier.

After considering this and other evidence, the ALJ applied the SSA’s five-step disability evaluation. See 20 C.F.R. 

§§ 404.1520, 416.920.2 At step one, the ALJ determined that 

Varga had not engaged in substantial gainful activity since 

December 2005. At steps two and three, the ALJ found Varga

had “moderate difficulties” with “concentration, persistence, 

or pace.” However, at step three, he concluded that Varga

did not have an impairment or combination of impairments 

that met or medically equaled the criteria of Listing 12.03, 

 2 The regulations require the ALJ to review (1) the claimant’s current 

work activity; (2) the medical severity and duration of the claimant’s impairments; (3) whether the claimant’s impairments meet or medically 

equal the requirements of an impairment listed in the regulations; (4) 

whether the claimant has the residual functional capacity to return to 

past relevant work; and (5) if the claimant cannot return to past relevant 

work, whether he or she can “make an adjustment to other work” in the 

national economy. 20 C.F.R. § 404.1520(a)(4)(i)-(v).
6 No. 14-2122

which pertains to schizophrenic, paranoid and other severe 

psychotic disorders.

Prior to undertaking the fourth and fifth steps, the ALJ 

was required to make an assessment of Varga’s residual 

functional capacity (“RFC”). 20 C.F.R. § 404.1545(a)(1). This 

is an assessment of what work-related activities the claimant 

can perform despite her limitations, which must be assessed 

based on all the relevant evidence in the record. Id. In the

ALJ’s RFC assessment, he determined Varga could perform

light work as defined in 20 CFR 404.1567(b) except that the claimant can climb ladders, ropes 

and scaffolds occasionally. The claimant must 

avoid all exposure to noise and even moderate 

exposure to unprotected heights, hazards and 

the use of moving machinery. The claimant is 

limited to simple, routine, and repetitive tasks 

in a work environment free of fast paced production requirements, involving only simple, 

work-related decisions with few if any work

place [sic] changes.

At step four, the ALJ relied on the testimony of the vocational expert that a person with Varga’s age, experience, education, and residual functional capacity could perform her

past work as an office helper as she actually performed the 

job. At step five, the ALJ made an alternative finding that a 

person with Varga’s age, experience, education, and residual 

functional capacity could perform other jobs such as an inspector, laundry worker, or cashier. In light of these findings, the ALJ concluded that Varga had not been disabled 

between December 2, 2005 and December 31, 2010. 
No. 14-2122 7

The ALJ’s decision became the final decision of the 

Commissioner when the Appeals Council denied Varga’s 

request for review. See 20 C.F.R. §§ 404.955, 404.981. In October 2012, Varga filed a civil action for judicial review of the 

Commissioner’s final decision. The district court affirmed 

the Commissioner’s decision and this appeal followed.

II. ANALYSIS

We review the district court’s affirmance de novo and review directly the ALJ’s decision. Yurt v. Colvin, 758 F.3d 850, 

856 (7th Cir. 2014). Specifically, we need to determine if the 

ALJ’s decision was supported by “substantial evidence,” 

which we have described as “such relevant evidence as a 

reasonable mind might accept as adequate to support a conclusion.” Id. An ALJ need not specifically address every 

piece of evidence, but must provide a “logical bridge” between the evidence and his conclusions. O'Connor-Spinner v. 

Astrue, 627 F.3d 614, 618 (7th Cir. 2010).

Varga presents only one challenge on appeal—that the 

ALJ’s hypothetical question to the vocational expert was 

flawed because it failed to account for all of her mental limitations—namely, the “moderate difficulties” in the areas of 

concentration, persistence, and pace that Dr. Rattan (the 

state agency’s psychological consultant) noted in his assessments and which the ALJ attributed to Varga at steps two

and three of its sequential analysis.

In this circuit, “both the hypothetical posed to the VE and 

the ALJ’s RFC assessment must incorporate all of the claimant’s limitations supported by the medical record.” Yurt, 758

F.3d at 857; O'Connor–Spinner, 627 F.3d at 619 (“Our cases, 

taken together, suggest that the most effective way to ensure 

that the VE is apprised fully of the claimant’s limitations is 
8 No. 14-2122

to include all of them directly in the hypothetical.”); Indoranto v. Barnhart, 374 F.3d 470, 473–74 (7th Cir. 2004) (“If the ALJ 

relies on testimony from a vocational expert, the hypothetical question he poses to the VE must incorporate all of the 

claimant’s limitations supported by medical evidence in the 

record.”); see also SSR 96–5p, 1996 WL 374183, at *5 (RFC assessment “is based upon consideration of all relevant evidence in the case record, including medical evidence and 

relevant nonmedical evidence”); 20 C.F.R. § 404.1545.

Among the mental limitations that the VE must consider 

are deficiencies of concentration, persistence, or pace. Yurt, 

758 F.3d at 857; Stewart v. Astrue, 561 F.3d 679, 684 (7th Cir. 

2009) (hypothetical question “must account for documented 

limitations of ‘concentration, persistence, or pace’”) (collecting cases). Although it is not necessary that the ALJ use the

precise terminology of “concentration,” “persistence,” or

“pace,” we will not assume that a VE is apprised of such limitations unless he or she has independently reviewed the 

medical record. Yurt, 758 F.3d at 857. There is no evidence 

that the VE in this case reviewed Varga’s medical history or 

heard testimony about the various medical limitations that 

Varga argues were omitted from the ALJ's hypothetical. 

Thus, we would expect an adequate hypothetical to include 

the limitations identified by Dr. Rattan. See id. (noting hypothetical question to VE should include findings made by 

state agency psychological consultant of “moderate difficulties” on MRFCA form).

Here, there is medical evidence in the record that Varga 

has moderate difficulties maintaining concentration, persistence, and pace. Most notably, Dr. Rattan’s assessment of 

Varga’s mental RFC for the state agency noted moderate dif-
No. 14-2122 9

ficulties in seven areas related to concentration, persistence, 

and pace: (1) understanding and remembering detailed instructions; (2) carrying out detailed instruction; (3) maintaining attention and concentration for extended periods; (4) 

completing a normal workweek without interruption from 

psychologically based symptoms and performing at a consistent pace without an unreasonable number and length of 

rest periods; (5) accepting instructions and responding appropriately to criticism from supervisors; (6) getting along 

with coworkers without distracting them or exhibiting behavioral extremes; and (7) responding appropriately to 

changes in the work setting. In his decision, the ALJ “concur[red]” with the assessment of Varga’s mental state made 

by the state agency, and this assessment is presumably what 

led the ALJ to find that Varga had moderate difficulties with 

regard to “concentration, persistence, or pace” at steps two

and three of his sequential analysis. However, the ALJ did 

not address all of these difficulties in his hypothetical question to the vocational expert. Because a hypothetical posed to 

a VE must incorporate all of the claimant’s limitations supported by the medical record—including moderate limitation in concentration, persistence, and pace—we find that 

the ALJ committed reversible error. See Yurt, 758 F.3d at 857

(failure of ALJ to include in hypothetical moderate difficulties in concentration, persistence, and pace attributed to applicant in Section I the MRFCA form was reversible error).

The Commissioner makes several arguments in defense 

of the hypothetical posed by the ALJ, but none are persuasive. First, she argues that the hypothetical and the RFC did 

in fact account for all of Varga’s mental limitations. But a

careful dissection of the hypothetical question suggests otherwise. The hypothetical question begins by positing a per-
10 No. 14-2122

son capable of performing “simple, routine, and repetitive 

tasks.” These terms refer to “unskilled work,” which the 

regulations define as work that can be learned by demonstration in less than 30 days. See 20 C.F.R. §§ 404.1568, 

404.1520. As Varga notes, whether work can be learned in 

this manner is unrelated to the question of whether an individual with mental impairments—e.g., with difficulties 

maintaining concentration, persistence, or pace—can perform such work. For this reason, we have repeatedly rejected 

the notion that a hypothetical like the one here “confining 

the claimant to simple, routine tasks and limited interactions 

with others adequately captures temperamental deficiencies 

and limitations in concentration, persistence, and pace.”

Yurt, 758 F.3d at 858-59 (citing Stewart v. Astrue, 561 F.3d 679, 

685 (7th Cir. 2009) (collecting cases)); see also Craft v. Astrue,

539 F.3d 668, 677-78 (7th Cir. 2008) (restricting claimant to 

unskilled, simple work does not account for his difficulty 

with memory, concentration, and mood swings); Young v. 

Barnhart, 362 F.3d 995, 1004 (7th Cir. 2004). The question

goes on to clarify that the individual would only be required 

to perform work 

free of fast paced production requirements, involving only simple work related decisions 

with few if any work place [sic] changes and 

no more than occasional interaction with 

coworkers or supervisors.

But these limitations, too, fail to account for all of Varga’s 

difficulties maintaining concentration, persistence, and pace,

which, as the record shows, were related to her diagnosed 

anxiety and depression, as well as her physical problems 

and pain. “Few if any work place changes” with limited “in-
No. 14-2122 11

teraction with coworkers or supervisors” deals largely with

workplace adaptation, rather than concentration, pace, or 

persistence. It is also problematic that the ALJ failed to define “fast paced production.” Without such a definition, it 

would have been impossible for the VE to assess whether a 

person with Varga’s limitations could maintain the pace 

proposed. 

Our recent decision in Yurt—issued after the district 

court rendered its decision here—is squarely on point. 

There, the applicant’s moderate limitations noted in Section I 

of the MRFCA form were substantially similar to Varga’s (he 

had six of the seven difficulties in concentration, persistence 

and pace attributed to Varga). See 758 F.3d at 855. However, 

we rejected a hypothetical almost identical to the one posed 

here because it did not adequately encompass all of the limitations. Id. (rejecting hypothetical that described an individual that can “remember and carry out unskilled task[s] 

without special considerations ... relate on at least a superficial basis with coworkers and supervisors ... attend to tasks 

for sufficient periods of time to complete” and who “should 

not work around large numbers of people”).

Next, we address the Commissioner’s argument that at 

steps two and three, the ALJ did not find Varga suffered 

from moderate difficulties in all three of the categories of 

concentration, persistence, and pace. The Commissioner 

rests this contention on the fact that the ALJ referred to difficulties in “concentration, persistence, or pace”—rather than 

concentration, persistence, and pace. The Commissioner 

suggests that the ALJ was referring only to concentration, 

although this is nowhere expressed in the decision and is not 

supported by the record, and that this impairment was cov-
12 No. 14-2122

ered by the hypothetical question posed. We disagree with 

the Commissioner’s interpretation. The word “or” has an inclusive sense (A or B, or both) as well as an exclusive one (A 

or B, not both). See GARNER DICTIONARY OF LEGAL USAGE, 3d 

ed. at 639 (citing Scott J. Burnham, THE CONTRACT DRAFTING 

GUIDEBOOK 163 (1992)) (noting that “or” is generally used in 

the inclusive sense). For example, a hospital patient may be 

asked whether he has nausea, vomiting, or cramps. If the patient responds “yes,” he may mean one, two, or all three of 

the symptoms are present. Likewise, a person deemed to 

have problems in “concentration, persistence, or pace” may 

have problems with one, two, or all three of those categories. 

Here, we find it exceedingly unlikely that the ALJ meant to 

use “or” in the exclusive sense. First, the record shows Varga 

suffers from difficulties in all three of these areas. Moreover,

the agency forms from which these terms emanate often 

lump concentration, persistence, and pace together as an 

umbrella category. The PRT form, for example, treats “concentration, persistence, or pace” as one broad category of 

functioning. And the MRFCA form lists “sustained concentration and persistence” as one category (with the other 

three being “understanding and memory,” “social interaction,” and “adaptation”). See also Yurt, 758 F.3d at 858 (treating “concentration, persistence, or pace” as a broad category 

of mental functioning).3

 3 In any event, even if the Commissioner were correct that the ALJ 

found Varga only suffered from moderate difficulties in concentration

(the Commissioner does not argue that the ALJ only found difficulties in 

either pace or persistence), we fail to see how Varga’s problems “maintaining concentration for extended periods” were encapsulated by the 

hypothetical question, which posited an individual able to do unskilled 
No. 14-2122 13

Finally, the Commissioner argues the boxes checked by 

Dr. Rattan in Section I of the MRFCA form pertaining to 

concentration, persistence, and pace do not constitute medical evidence that the ALJ was required to include in his RFC 

and hypothetical question to the VE. For this proposition, 

the Commissioner cites Smith v. Commissioner of Social Security, 631 F.3d 632, 637 (3d Cir. 2010), which held that an ALJ 

was not required to include findings noted in Section I of the 

MRFCA form that the claimant was moderately limited in 

various areas of mental functioning because Section I is 

merely a worksheet to aid doctors in deciding the presence 

and degree of functional limitations. According to the Commissioner, the ALJ is only required to include findings made 

at Section III of the MRFCA form, in which the doctor is to 

“translate” his or her worksheet observation into a mental 

RFC. See Johansen v. Barnhart, 314 F.3d 283, 286 (7th Cir. 

2002). Conveniently for the Commissioner, there is no narrative assessment here to which the ALJ was required to refer 

because, as noted above, Dr. Rattan failed to fill out Section 

III and the agency lost the electronic worksheet where he allegedly made Varga’s RFC assessment.

This circuit has declined to adopt a blanket rule that 

checked boxes in Section I of the MRFCA form indicating 

moderate difficulties in mental functioning need not be incorporated into a hypothetical to the VE. In fact, in Yurt, we 

explicitly rejected the argument that “we should be unconcerned ... with the failure of the ALJ to mention the six areas 

where [the state psychologist] found moderate limitations 

because the narrative portion of the form adequately ‘trans-

 

work free of “fast paced production requirements” with limited social 

interactions. 
14 No. 14-2122

lated’ these limitations into a mental RFC that the ALJ could 

reasonably adopt.” 758 F.3d at 858. And as noted above, the 

moderate limitations attributed to the claimant in Yurt at 

Section I of the MRFCA form—the exclusion of which from 

the hypothetical question constituted reversible error—were 

virtually identical to those attributed to Varga. See id. at 854-

55.

Worksheet observations, while perhaps less useful to an 

ALJ than a doctor’s narrative RFC assessment, are nonetheless medical evidence which cannot just be ignored. True, in 

some cases, an ALJ may rely on a doctor’s narrative RFC, rather than the checkboxes, where that narrative adequately

encapsulates and translates those worksheet observations. 

See Johansen, 314 F.3d at 286. But where, as here, no narrative 

translation exists—because of error on the part of the doctor 

or the agency—an ALJ’s hypothetical question to the VE 

must take into account any moderate difficulties in mental 

functioning found in Section I of the MRFCA form, including those related to concentration, persistence, or pace.

III. CONCLUSION

For these reasons, the judgment of the district court is 

REVERSED, and this case is REMANDED with instructions that 

it be returned to the SSA for further proceedings consistent 

with this opinion.