Form G-251 (11-03)

United States of America
rd

Vocational Report

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Form Approved
OMB No. 337.0-01 41

General Instructions
Be sure to read the 'Important Notice at the bottom of page 5.
Print all answers in ink or use a typewriter. If you need more space than is provided to answer a question, attach a
separate sheet of paper. If you do not know the answer to a question, print "unknown" in the space provided for the
answer. Additional forms may be obtained from the RRB office shown on page 6 .
If you are completing this form on behalf of someone else, you must answer each question as it applies to the applicant.

Identifying lnformation
Check the information entered by the Railroad Retirement Board (RRB) for Items 1 through 6 for accuracy.
If the information is correct, go to Section 3.
If the information is not correct, cross out the incorrect information and enter the correct information above it.
If the information is missing, fill it in.
Employee
Identification

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1

Name
2 Employee's Social Security Number
3 Employee's Railroad Retirement Claim
Number, if different from ltem 2

Applicant

4 Applicant's Name
5 Applicant's Address (Include Street
Address, City, State, ZIP Code and
County)

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Area Code

Telephone Number

6 Daytime Telephone Number

lnformation About Your Work History
Work History

7 List all railroad and nonrailroad jobs you have had in the last 15 years befo&e you stopped working.
Include jobs both within and outside the railroad industry. (If you have a 6 grade education or less
and Derformed onlv heavv unskilled labor for 35 vears or more. list all of the iobs vou have had since
you began to work:) NOTE: If you list only one jbb in ltem 7, cJo not compleie paqes 3 and 4. If you
have more than 3 jobs to list, continue on another Form G-251.
Dates Worked
Hours
Type of Business
Job Title
To
From
Per
(Railroad or Nonrailroad)
MO I YR
Week
MO I YR

Regular
Occupation

8 Enter an "X" in the appropriate box:
Are you applying for an employee occupational disability annuity?

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Yes - Go to Item 9
No - Go to Item 12

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9 Enter the title of your usual railroad job in the last 5 years.

10 Enter the title of your usual railroad job in the last 15 years.
11 Enter an "X" in the appropriate box:
Which iob did vou claim as vour reaular occu~ation?

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Job in Item 9

nJob in Item 10
Form G-251 (1 1-03)

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Description of
Job in ltem
7a

1 12 a.

In the job described in ltem 7a, did you: (circle all that apply)
2 Use technical 3 Do any writing,
4 Use manipulative
5 Have
supervisory
tools or equipment
knowledge or
complete reports, or
skills, i.e., manual
dexterity?
responsibilities?
of any kind?
skills?
perform similar duties?
b. Describe your basic duties (explain what you did and how you did it) below. Also, explain all circled
answers in ltem 12a by giving a full description of: the type of machines, tools, or equipment you
used and the exact operation you performed; the technical knowledge or skills involved; the type of
writing you did, and the nature of any reports; the manipulative skills used; and the number of
people you supervised and the extent of your supervision. If more space is needed attach a sheet
of paper.
1 Use machines,

13 a. Environmental Hazards (circle the hazards you were exposed to)
1 Walking on
3 Dangerous 4 Extremes of
5 Fumes or
Uneven Terrain
Heights
Machinery
Temperature
Noxious Gases

7 Excessive
Dust

Noise or Vibration

b. If you circled any of the hazards in ltem 13a, briefly explain your exposure.

14 Indicate below the kind and amount of physical activity this job involved durirlg a typical 8-hour
workday. (The total hours shown should equal 8 hours or the exact number of hours worked dail
a. Circle the number of hours a day spent:
(1) Standinglwalking
(2) Sitting
b. Circle how often a day you had to:
(1)
(2)
(3)
(4)
(5)

Bend .................................................
CrouchISquat ....................................
Kneel .................................................
Reach above shoulder level .............
Climb .................................................
Circle what you climbed ...............

( 6 ) PushlPull...........................................
Briefly explain what and how you
pushed and pulled

Never
Never
Never
Never
Never
Stairs

Occasionallyl
Occasionally
Occasionally
Occasionally
Occasionally
Vertical ladder

~re~uen
Frequently
Frequently
Frequently
Frequently
Step ladder

t Constantly
l~~
Constantly
Constantly
Constantly
Constantly

Never

Occasionally

Frequently

Constantly

Never

Occasionally

Frequently

Constantly

c. (1) Name the objects you lift and carry
(2) Circle how often a day you lift and
carry

Heaviest Weight Lifted
10lbs
20Ibs
50Ibs
100Ibs
OverlOOIbs
Weight Frequently LiftedlCarried
Up to 10 Ibs Up to 25 Ibs Up to 50 Ibs Over 50 Ibs
10ccasionally means occurring from very little up to one-third of a typical workday; cumulative, not continuous.
2~requentlymeans occurring one-third to two-thirds of a typical workday; cumulative, not continuous.
(3) Circle the weight of the objects you
lift and carry

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Form G-251 (1 1-03)

Description of
Job in Item

Do not complete this page unless you have entered a job title i n ltem 7b.
15 a. In the job described in ltem 7b did you: (circle all that apply)

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1 Use machines,
tools or equipment
of any kind?

2 Use technical
knowledge or
skills?

3 Do any writing.
complete reports, or
perform similar duties?

4 Use manipulative
skills, i.e., manual
dexterity?

5 Have
supervisory
responsibilities?

b. Describe your basic duties (explain what you did and how you did it) below. Also, explain all circled
answers in ltem 15a by giving a full description of: the type of machines, tools, or equipment you
used and the exact operation you performed; the technical knowledge or skills involved; the type of
writing you did, and the nature of any reports; the manipulative skills used; and the number of
people you supervised and the extent of your supervision. If more space is needed attach a sheet
of paper.

16 a. Environmental Hazards (circle the hazards you were exposed to)
1 Walking on
Uneven Terrain

Heights

3 Dangerous 4 Extremes of
Machinery
Temperature

5 Fumes or
Noxious Gases

Dust

7 Excessive
Noise or Vibration

b. If you circled any of the hazards in ltem 16a, briefly explain your exposure.

17 Indicate below the kind and amount of physical activity this job involved during a typical 8-hour
workday. (The total hours shown should equal 8 hours or the exact number of hours worked daily.)
a. Circle the number of hours a day spent:
0
1
2
3
4
5
6
7
'
8
(1) Standinglwalking
0

(2) Sitting

1

2

3

4

5

6

7

8

b. Circle how often a day you had to:
~

(1)
(2)
(3)
(4)
(5)

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Bend .................................................
CrouchISquat ....................................
Kneel................................................
Reach above shoulder level .............
Climb .................................................
Circle what you climbed ...............

Never
Never
Never
Never
Never
Stairs

Occasionallyl
Occasionally
Occasionally
Occasionally
Occasionally
Vertical ladder

~re~uen
Frequently
Frequently
Frequently
Frequently
Step ladder

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Never

Occasionally

Frequently

(6) PushIPull...........................................
Briefly explain what and how you
pushed and pulled
c. (1) Name the objects you lift and carry
(2) Circle how often a day you lift and
carry

t Constantly
l~~
Constantly
Constantly
Constantly
Constantly

Constantly

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Never

Occasionally

Frequently

Constantly

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Heaviest Weight Lifted
(3) Circle the weight of the objects you
lift and carry

10 lbs

20 Ibs

50 Ibs

100 Ibs

Over 100 Ibs

Weight Frequently LiftedICarried
Up to 10 Ibs

Up to 25 Ibs

Up to 50 Ibs

Over 50 Ibs

1 0 ~ ~ a ~ i means
~ n a occurring
~ ~ y
from very little u p t o one-third of a typical workday; cumulative, not continuous.
2~requentlymeans occurring one-third to two-thirds of a typical workday; cumulative, not continuous.
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Form G-251 (1 1-03)

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Description of
Job in Item
7c

Do not complete this page unless you have entered a job title i n ltem 7c.
18 a. In the job described in ltem 7c, did you: (circle all that apply)
1 Use machines,
2 Use technical 3 Do any writing,
4 Use manipulative
5 Have
tools or equipment
supervisory
knowledge or
complete reports, or
skills, i.e., manual
of any kind?
skills?
dexterity?
responsibilities?
perform similar duties?
b. Describe your basic duties (explain what you did and how you did it) below. Also, explain all circled
answers in ltem 18a by giving a full description of: the type of machines, tools, or equipment you
used and the exact operation you performed; the technical knowledge or skills involved; the type of
writing you did, and the nature of any reports; the manipulative skills used; and the number of
people you supervised and the extent of your supervision. If more space is needed attach a sheet ,

19 a. Environmental Hazards (circle the hazards you were exposed to)
1 Walking on
3 Dangerous 4 Extremes of
5 Fumes or
7 Excessive
Uneven Terrain
Heights
Machinery
Temperature
Noxious Gases
Dust
Noise or Vibration
b. If you circled any of the hazards in ltem 19a, briefly explain your exposure.

20 Indicate below the kind and amount of physical activity this job involved during a typical 8-hour
workday. (The total hours shown should equal 8 hours or the exact number of hours worked daily.)
a. Circle the number of hours a day spent:
0
1
2
3
4
5
6
7
8
(1) Standinglwalking
(2) Sitting
0
1
2
3
4
5
6
7
8

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b. Circle how often a day you had to:
(1)
(2)
(3)
(4)
(5)

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Bend ..................................................
CrouchISquat .....................................
Kneel ...............................................
Reach above shoulder level ..............
Climb ..............................................
Circle what you climbed ................

Never
Never
Never
Never
Never
Stairs

1

(6) PushlPull ........................................... Never
Briefly explain what and how you
pushed and pulled
c. (1) Name the objects you lift and carry
(2) Circle how often a day you lift and
carry

Occasionallyl
Occasionally
Occasionally
Occasionally
Occasionally
Vertical ladder

~ r e ~ u e n t l ~Constantly
*
Frequently
Constantly
Constantly
Frequently
Frequently
Constantly
Frequently
Constantly
Step ladder

Occasionally

Frequently

Constantly

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Never

Occasionally

Frequently

Constantly

Heaviest Weight Lifted
10lbs
20Ibs
50Ibs
100Ibs
Over100Ibs
Weight Frequently LiftedlCarried
Up to 10 Ibs Up to 25 Ibs Up to 50 Ibs Over 50 Ibs
10ccasionally means occurring from very little u p t o one-third of a typical workday; cumulative, not continuous.
* ~ r e q u e n t l ymeans occurring one-third t o two-thirds of a typical workday; cumulative, not continuous.
(3) Circle the weight of the objects you
lift and carry

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Form G-251 (1 1-03)

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Certification

Certification
21 Enter an "Xu in the appropriate box:
I will have a guardian or other representative sign this report on
my behalf.

Yes - Go to Note and ltern 22
No - Go to Item 22

Note: If answered "Yes, " the guardian or other representative of the
applicant must sign this report.
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22 1 know that civil and criminal penalties may be imposed on me for false or fraudulent statements, or for
withholding information to misrepresent a fact material to determining a right to a payment under the
Railroad Retirement Act. I affirm that to the best of my knowledge, the information I have given
represents the complete truth.
Signature
(First Name, Middle Initial,
Last Name)
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Month

Day

Year

Date

23 If this certification is signed by mark ("Xu) in ltern 22, two witnesses who know the person signing must
sign below, giving their full addresses.
- - - - - - - - - ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ . . ~ . .
a. Signature of Witness

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Address (Number and Street)

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City, State, ZIP Code

b. Signature of Witness

Address (Number and Street)

City, State, ZIP Code

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PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICE
The Railroad Retirement Board is authorized to collect the information on this form under 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 processirlg of the claim. If you fail to provide us with the requested information, we may be unable to pay you
any benefits (as explained in Section 2(a) of the Railroad Retirement Act).
We estimate this form takes an average of 30 to 40 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 completion time, to Chief of Information Resources Management, Railroad Retirement Board,
844 North Rush Street, Chicago, IL 6061 1-2092.

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Form G-251 (1 1-03)

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How to Return Your Report

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Before you return your report, check to make sure that:

Every question that applies to you has been answered.

You have entered "unknown" in any answer space for which you were 1.1nableto answer a
question.
You have signed and dated the report.
You have included all the needed proofs listed in the letter you received with this report.
When ou received your report, you should have also received a pre-addressed envelope.
If ou o not have thls envelope, ou can use any envelope as long as it is addressed to the
R&B office shown below. No ma ter which envelope you use, you must put the correct
postage 017 .the envelope. Be careful to rovide enough posta e because your report may
weigh more than a standard letter. The .S. Postal Service WI I not deliver your report
unless it has the correct postage.

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If you need information or assistance, contact:

U.S. RAILROAD
RETIREMENT
BOARD

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TELEPHONE
NUMBER:

If for some reason you cannot contact that office, you should contact:'

U.S. RAILROAD RETlRENlElVT BOARD
844 NORTH RUSH STREET
CHICAGO, ILLINOIS 6061 1-2092

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Form G-251 (1 1-03)