G-3emp (07-00)

United States of America
Railroad Retirement Board

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Form Approved
OMB No. 3220-0038
I

Report of Medical
Condition by Employer
Instructions
Print all answers in ink or use a typewriter. When entering dates, always use numbers. Also, be sure there is
one number in each box. For example, you would enter February 13,2000, as:
MONTH

YEAR

DAY

I

0

1

1
1

0

Based on your answer to a question, you may be told to skip to another item number. Follow the instructions
that tell you to "Go to" another item. 'These are designed to save you time and help you move through the report
form quickly, filling in only necessary information. If no "Go toJ'instructions are given, answer the next item
in order. Do not skip any items unless directed to do so. Please read "Important Notices" on the second
page of this report.

Identifying information
2

I EMPLOYEE'S SOCIAL SECURITY NUMBER
1 EMPLOYEE'S RAILROAD RETIREMENT CLAIM NUMBER

4

EMPLOYEE'S MOST RECENT RAILROAD OCCLIPATION

5

EMPLOYEE'S NAME

6

a. EMPLOYEE'S STREET ADDRESS

1

b. CITY AND STATE
c. ZIP CODE

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1
I

,
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AREA CODE

TELEPHONE NUMBER

EMPLOYEE'S DAYTIME TELEPHONE NUMBER
I

I

I

I

I

I

I

I

I

I

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Ability to Work Information
Enter an 'X" in the appropriate box;
'The employee is presently able to work in hislher last occupation

Yes
No

Go to Item 9
Go to Item 10

Enter an " X in the appropriate box;
The employee is presently able to perform some type of work.

Yes
No

Go to ltem 13

,

Gotoltem14
-

Provide the beginning date that the employee became able to
work.
14 Enter an " X in the appropriate box;
The employee will be able to perform some type of work in the
future.

MONTH

DAY

No

YEAR

Go to
ltem

Go to ltem 17

,

United States of America
Railroad Retirement Board

Form Approved

OMB No. 3220-0038
Page 2
MONTH

15 Provide the date that the employee will be able to perform some

DAY

YEAR

type of work.

16

GO to
Item
16

Describe the type of work the employee is able to perform.

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RestrictionlDisqualificationlnformation
17 Enter an " X in the appropriate box;

Yes

Go to Item 18

The employee has been restricted from work in hislher regular
No
Go to ltem 19
occupation.
Describe why the employee has been restricted from work in hislher regular occupation.

18

19

Enter an "X" in the appropriate box;
Yes
Go to ltem 20
The employee has been disqualified from hislher regular
No
Go to ltem 21
occu~ation.
Describe in detail the basis for the employee's disqualification and attach any medical evidence relevant to
the disqualification.
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20

1

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Certification
21

NAME OF RAILROAD OFFICIAL

22

TITLE
b. CITY AND STATE
c. ZIP CODE

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AREA CODE

24

DAYTIME TELEPHONE NUMBER

25

SIGNATURE

TELEPHONE NUMBER

DATE

PRIVACY ACT AND PAPERWORK REDUCTION ACT NOTICE
The information requested on this form is authorized by Section 7 (b) (6) of the Railroad Retirement Act. While you are not required to
respond, your cooperation is needed to provide information necessary to complete processing of the named employee's claim.

1

We estimate this form takes an average of 10 minutes per response to complete, including the time for reviewing the instructions, getting
the needed data, and reviewing the completed form. Federal agencies may not conduct or sponsor, and respondents are not required to
respond to, a collection of information unless it displays a valid OMB number. If you wish, send comments regarding the accuracy of our
estimate or any other aspect of this form, including suggestions for reducing the completion time to: Chief of lnformation Resources
Management, Railroad Retirement Board, 844 North Rush Street. Chicago. IL 6061 1-2092.
COMPUTER MATCHING AND PRIVACY PROTECTION ACT NOTICE
In addition to the uses of information described in the Privacy Act notice on the form(s) or application(s) you have completed, the
Computer Matching and Privacy Protection Act of 1988 (P.L. 100-503) requires the Railroad Retirement Board (RRB) to advise you that
information you may have provided may be used, without your consent, in automated matching programs. These matching programs are
computer comparisons of RRB records with records kept by other Federal, state, or local governmental agencies. Information from these
matching programs can be used to establish or verify a person's eligibility for federally funded or administered benefit programs and for
repayment of payments or delinquent debts under these programs.