G-250A (09-05) Medical Assessment of Residual Functional Capacity

UNITEDSTATESOF AMERICA

RAILROADRETIREMENTBOARD

Form Approved
OMB NO. 3220-0038

OFFICE OF PROGRAMS/POLICY & SYSTEMS

844 NORTHRUSHSTREET
CHICAGO,
ILL.60611-2092

MEDICAL ASSESSMENT OF
RESIDUAL FUNCTIONAL CAPACITY
RRB CLAIM NUMBER

NAME

INSTRUCTIONS
Complete this form and submit to us along with your narrative report and office records, as requested on the enclosed
cover letter. Describe below any restrictions in the claimant's ability to perform basic work-related functions within a
regular work setting on a day-to-day basis. Relate any assessed reduction to capacity to particular medical
findings. Do not consider non-medical factors such as age, sex, education, or work experience.
Note: You may include this medical assessment in your narrative report, however, we prefer you use this Form G-250A.

When using this form, use the space to the left of a function or condition to enter "NA" if you find that it is NOT
AFFECTED by the claimant's impairment(s). If you are unable to assess the claimant's ability to perform an activity or
tolerate a condition shown, use the space to show "UNK indicating UNKNOWN. Otherwise, complete as appropriate,
being sure to explain limitations and relate them to specific findings in the space provided.
Please read page 4 for the authorization for this report and other important notices.
A. Exertional Restrictions - For all claimants with physical impairments.

I '.

In an 8-hour workday claimant can STAND andlor WALK, with normal breaks, for:
less than 2 hours total

at least 2 hours total

6 hours or more

MEDICAL FINDINGS TO SUPPORT RES'TRIC'TION:

I

In an 8-hour workday claimant can SIT, with normal breaks, for:
2.
less than 6 hours total

6 hours or more

MEDICAL FINDINGS TO SUPPORT RESTRICTION:

1

A.

Exertional Restrictions, Continued
3.

Claimant can LIFT:

Unlimited

~re~uentlyl

0ccasionally2

Never

Less than 10 pounds
10 pounds
20 pounds
50 pounds
I 0 0 pounds or more

MEDICAL FINDINGS TO SUPPORT RESTRICTIONS:

4.. Claimant is able to:
BendIStoop

Never

~requentlyl

El

1

CrouchISquat
Climb
Reach above shoulder level

MEDICAL FINDINGS TO SUPPORT RESTRICTIONS:

I

I

5. Claimant can use BOTH HANDS for repetitive:

YES

NO (Limitation MUST be explained)

I

Simple Grasping
Fine Manipulation
PushinglPullir7g

6. Claimant can use BOTH FEET for repetitive:
Foot Controls

7. Claimant can, without restriction:
See
Hear
Speak

MEDICAL FINDINGS TO SUPPORT RESTRICTIONS:

1
2

FREQUENTLY means occurring one-third to two-thirds of an 8-hour workday; cumulative, not continuous.
OCCASIONALLY means occurring from very little up to one-third of an 8-hour workday; cumulative, not continuous.

G-250A (09-05)

B.

Environmental Restrictions - For all claimants, as applicable.
Claimant is restricted in activities involving:

No

~ i l d l ~ ~

oder rat el^^

Totally

Unprotected Heights
DrivingIOperating Machinery
Being around moving Machinery
Uneven TerrainIStairs
Exposure to Dust, Fumes, Etc.
Exposure to Noise
Exposure to Vibration
Exposure to Temperature
ExtremesIHumidity
Other:

MEDICAL FINDINGS TO SUPPORT RESTRICTIONS:

Mental Restrictions - For all claimants with mental impairments.
Claimant is limited in ability to:

V
Io

Totally

ReasonIUse Judgment
Maintain Appropriate Mood
Maintain Personal Habits
Perform Normal Daily Activities
Make Social Adjustments
Relate to Other People
Make Occupational Adjustments
Maintain Normal Work Pace
Maintain Normal Concentration

RememberIUnderstandlCarry Out
Instructions
Other:

MEDICAL FINDINGS TO SUPPORT RESTRICTIONS:

MILDLY means tolerancelability to function is limited but satisfactory.

y
4

G-250A (09-05)

1

I

In your opinion, is the claimant able to handle benefit
payments in hislher own best interest

Yes

u

No

u
Phone Number with area code

Signature
(

1

Printed Name, Title, and Address

Please return this form along with your narrative report and copies of your office records to:

RAILROAD RETIREMENT BOARD

PRIVACY ACT AND PAPERWORK REDUCTION 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 for the claimant
named and to determine the claimant's entitlement to disability benefits under the Railroad Retirement Act.
We estimate this form takes an average of 20 minutes per response to complete, including time for reviewing the
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing *
the collection of information. 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 N. Rush Street, Chicago, IL 60611-2092.