Form G-3EMP (07-00) G-3EMP (07-00) Report of Medical Condition by Employer

United States of America
Railroad Retirement Board

Form A ~ ~ r o v e d
OMB~NO.
3220-0038
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Report of Medica,l
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
MONTH

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, Cillirlg in only necessary information. If no "Go to" 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

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1

2

I EMPLOYEE'S SOCIAL SECURITY NUlblBER

I EMPLOYEE'S RAILROAD RETIREMENT CLAIM NUMBER

3

NAME OF EMPLOYEE'S MOST RECENT RAILROAD EMPLOYER

4

EMPLOYEE'S MOST RECENT RAILROAD OCCUPATION

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5 , EMPLOYEE'S NAME
6 EMPLOYEE'S FULL ADDRESS

Enter an " X in the appropriate box;
The employee is presently able to perform some type of work.
Provide the beginning date that the err~ployeebecame 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.
15 Provide the date that the employee will be able to perform some
type of work.
13

MONTH

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Yes

Go to ltem 11

Yes
No

Go to ltem 13
Go to Item 14

DAY

Yes
No
MONTH

DAY

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YEAR

G,~,
Itern 16

Go to ltem 15
Go to ltem 17
YEAR

GO to
Itern 16

United States of America
Railroad Retirement Board

Form Approved
OMB NO. 3220-0038
Page 2

16

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

Restriction/Disqualification lnformation
17 Enter an " X in the appropriate box;

Yes

The employee has been restricted from work in hislher regular
occu~ation.

No

Go to ltem 18
Go to ltem 19

18

Describe why the employee has been restricted from work in hislher regular occupation.

19

Enter an "X" in the appropriate box;
Yes
Go to Item 20
The employee has been disqualified from hislher regular
No
Go to ltem 21
occupation.
Describe in detail the basis for the employee's disqualification and attach any medical evidence relevant t o
the disqualification.

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1 NAME OF RAILROAD OFFICIAL

Certification

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23

1 TITLE

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a. STREET ADDRESS
b. CITY AND STATE
c. ZIP CODE
TELEPHONE NUMBER

AREA CODE

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DAYTllVlE TELEPHONE NUMBER

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SIGNATURE

DATE
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PRIVACY ACT AND PAPERWORK REDUC'l7ON 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.
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 60611-2092.
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. lnformation 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.