G-260 (07-00) Report of Seizure Disorder

Form Approved
OM6 No. 3220-0038

United States of America
Railroad Retirement Board

Report of Seizure Disorder
lnformation for the Medical Examiner
An application for Railroad Retirement Act benefits based on disability for work has been filed. Information about the
applicant's medical condition is essential to evaluate benefit eligibility. If you need more space than is provided to
answer a question, use Item 21 for this purpose.
Since applicants are responsible for presenting medical evidence on their own behalf from their personal physicians,
any fee that may result from completion of this report is a personal matter between the applicant and you (unless we
specifically contract for an examination).

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Please complete and return this report promptly to the address shown in Item 26. Your report may be made on this form
or by a narrative on your own stationery. It is important that your narrative furnish all of the information, relevant to the
applicant's condition, requested on this form.

Instructions
Print all answers in ink or use a typewriter. When entering dates, always use numbers. Also, be sure there is onenumber
in each box. For example, you would enter February 13, 2000, as:

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 to" instructions are given, answer the next item in order. Do not skip any
items unless directed to do so. Please read "Important ~ o t i c e s on
" the last page of this report.

Identifying lnformation
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I 1 / RAILROAD RETIREMENT CLAIM NUMBER

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*

2

SOCIAL SECURITY NUMBER

1 3 1 APPLICANTS NAME

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b

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CITY AND STATE

I I d 1 COUNTY

*

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DAYTIME TELEPHONE NUNIBER

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*

Introduction
Enter a detailed description of the seizures (include character, generalized or focal; auro, if any; loss of consciousness;
bowel or bladder incontinence).

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Form G-260 (07-00) Destroy Prior Editions

Types of Seizure
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a

Check the appropriate description. P

b

Check the appropriate description.

!J Grand Mal
!J Petit Mal
!J Jacksonian
!J Psychomotor

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!J Nocturnal
!J Diurnal

History of Seizures

1 Enter the date of the first seizure.
Enter the date of the last seizure.

c Enter an " X in the appropriate box:
Does verification of seizures exist from
persons other than applicant?

MONTH

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DAY

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YEAR

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*

MONTH

DAY

0

YES b Go to Item d
NO

*

YEAR

b Gotoltemll

d Describe the verification and identify the source.

Precipitating Factors
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11 a

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Enter an "X" in the appropriate box:
Are there any precipitating factors?

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Form G-260 (07-00)

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Q YES b Go to ltem b
Q NO b Go to ltem I 2

Duration of Seizures
12 Describe the duration of the seizures.

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a YES

Enter an "X" in the appropriate box:
Has any treatment been given for
this condition?

13 a

e

b

Describe the type of treatment given.

c

Describe the applicant's compliance to such treatment.

d

Describe the applicant's response to such treatment.

e

Describe the applicant's blood drug level.

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NO

b Go to ltem b
b Go to ltem 14

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Mental Functions
Enter an "X" in the appropriate box:
Has there been any mental deterioration?

14 a

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NO

b Go to ltem 15

Describe the deterioration.

b

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YES b Go to ltem b

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Form G-260 (07-00)

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15 a

b

Enter an "X" in the appropriate box:
Is there evidence of any psychosis?

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YES b Go to ltem b

NO

b Go to ltem 16

Describe the psychosis.

16 Describe behavior manifestations (postictal) and duration.

Neurological Findings
17 Describe the neurological findings.

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Electroencephalographic Findings
18 Describe the EEG findings, and attach a copy of the EEG (or identify the source from which it may be obtained).

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Form G-260 (07-00)

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Miscellaneous
Enter an " X in the appropriate box:
This report is:
a. Compiled entirely from records
b. Based on a new examination

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YES

tl

e
MONTH

20 Enter the date of the most recent examination.

e

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DAY

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YEAR

II

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Remarks

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121 Use this space for further details of history or additional description of condition.

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Certification

Medical Examiner's Name
a

Street Address

b

City and State

c

ZIP Code

*

.AREA CODE

Daytime Telephone Number

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Medical Examiner's Signature

TELEPHONE NUMBER

+

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Date

Please return this form, your narrative report, copies of your office records, and the claimant's RRB claim number to:

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IMPORTANT NOTICES

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 of the named employee's claim.
We estimate ,this form takes an average of 25 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
lnformation Resources Management, Railroad Retirement Board, 844 North Rush
Street, Chicago, Illinois 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 to advise you that
information you have provided may be used, without your consent, in automated
matching programs. These matching programs are a computer comparison of RRB
records with records kept by other Federal, state, or local governmental agencies.
lnformation from these 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.

Form G-260 (07-00)

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