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pdfUnited States of America
Railroad Retirement Board
Form Approved
OMB No. 3220-0187
Continuing Disability Report
Paperwork Reduction ActlPrivacy Act Notice
The Railroad Retirement Board's (RRB) authority for requesting this information is Section 7(b)(6) of the Railroad
Retirement Act (RRA). The information requested on this report is needed to determine your continuing entitlement to
disability benefits under the RRA and the correct amount of such benefits. If you fail or refuse to furnish information
which is necessary to determine your continuing entitlement to benefits, non-payment of benefits may result (as
explained in Section 2(a) of the RRA).
The information on this form may be disclosed by the RRB to another person or governmental agency only with respect
to railroad retirement benefits and only to comply with Federal law requiring the exchange of information between the
RRB and another agency.
We estimate this form takes an average of 35 minutes 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 60611-2092.
General Instructions
Type or print all answers legibly in ink., If you need more space than is provided to answer a question, use Section 6 for
this purpose. If you do not know the answer to a question, print "Unknown" in the space provided for the answer.
Due to the complexity of ltems 14a and 25a, regarding "Expenses," contact the Railroad Retirement Board if you need
assistance.
If you are completing this form on behalf of someone else, you must answer each question as it applies to the applicant.
Some items in this application will not apply to you so you will not need to answer them. Based on your answers
to a question, you may be told to skip to another item number or section. Follow the instructions that tell you to
"Go to" another item. They are designed to help you move through the report quickly and provide 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.
If you are an employee, your annuity cannot be paid for any month in which you earn over $730.00. Please notify the
nearest office of the RRB if your earnings exceed $730.00 a month.
TO PRESENT
THE PERIOD COVERED IN THIS REPORT IS
Identifying lnformation
Check the information provided for ltems 1 through 5 for accuracy.
b If the information is correct, g o t o Section 3.
b If the information is not correct, cross out the incorrect information and enter the correct information above it.
b If the information is missing, fill it in.
identifying
11
Employee's Name
2 Employee's Social Security Number
3 Employee's Railroad Retirement Claim Number
4 Your Name
5 Your Social Security Number
I
1
lnformation about Work for an Employer
Work for
1
6 Have you worked for an employer (railroad or
nonrailroad) during the period shown in Section 1,
above?
b
0
Yes b Go to Item 7
a NO
b Go to Section 4
Form 6-254 (01-08) Destroy Prior Editions
L
Work
for
Employer
17
~ n t e information
r
about your employer(s) in Items 7a-c below. &ta: If you havehad morethan one
employer during the period covered in this report, enter information about your last employer first.)
~
-
a (1) First Employer's Name
(2) Employer's Address
=
(3) Employer's Telephone Number (Include Area Code)
)
(4) TitlelName of your job
(5) Describe your job duties. (Include weights lifted and how frequently lifted; hours spent standinglsitting;
frequency of bendinglstoopinglclimbing,etc.)
1
( 6 ) Monthly Rate of Pay
/ (7) Days Worked Per Week
I
(8) Hours Worked Per Day
1 (9)
(10a) Date Work
Began b
.
Month
Day
Year
Hourly Rate of Pay
v
A
(lob) Date Work
Ended b
fdonth
Day
Year
(11) If work has ended, explain why.
Second
Last
Employer
b (1) Second Employer's Name
(2) Employer's Address
(3) Employer's Telephone Number (Include Area Code)
%r
(
)
(4) TitlellVame of your job
(5) Describe your job duties. (Include weights lifted and how frequently lifted; hours spent standinglsitting;
frequency of bendinglstoopinglclimbing, etc.)
( 6 ) Monthly Rate of Pay
I (7) Days Worked Per Week
(8) Hours Worked Per Day
1
(10a) Date Work
Began )
Month
Day
Year
(11) If work has ended, explain why.
Form G-254 (0 1-08)
Page 2
(9) Yourly Rate of Pay
(lob) Date Work
Ended )
Month
Day
Year
-
-
-
7 c (1) Third Employer's Name
Third
Last
Employer
(2) Employer's Address
=
(3) Employer's Telephone Number (Include Area Code)
1
(
)
(4) TitleIlVame of your job
(5) Describe your job duties. (Include weights lifted and how frequently lifted; hours spent standinglsitting;
frequency of bending/stooping/climbing, etc.)
(7) Days Worked Per Week
(6) Monthly Rate of Pay
$
(8) Hours Worked Per Day
(9) Hourly Rate of Pay
$
(10a) Date Work
Began )
Month
Day
Year
Month
(lob) Date Work
Ended b
Year
Day
(11) If work has ended, explain why.
(If you need more space to list employers, continue in Section 6)
Earnings
8 List any months during the period shown in Section 1, in which you earned more than $730.00.
Special
Earnings
9 a Have your earnings included any other payment,
such as tips, bonuses, child care, sick or vacation
pay, free meals, room or transportation?
b
a Yes
a No
b Go to ltem 9b
b GotoltemlO
b List below type of other payment(s) received, estimated dollar value, frequency of payment,
and employer's name.
3 Months
or Less
Work
10 Did you work 3 months or less and then stop work
Continue
or Return
to Work
11 Did you continue in or return to the same work
Special
Employment
12 a Are (were) you employed by a friend or relative
because of your disabling condition?
duties, hours, and pay as you had before your
disabling conditions began?
or through a special training or rehabilitation
program?
b
'
a Yes
a NO
a Yes
b Go to ltem I 4
0
b Go to ltem I 2
No
a Yes
a No
b Goto Item 12b
bGotolteml3
-
Page 3
- -
Form G-254 (01-08)
Special
Employment
(Continued)
Different
Job
Duties
12 b Explain how and why you were hired.
a Yes
a No
1 3 a Have your job duties differed from those of other
workers with the same job title?
b Go to Item 13b
b Go to ltem I 4
,
I
b Check all that apply them go to ltem 13c.
0
0
0
1. Shorter hours
4. Extra help given
0
2. Different pay scales
a 5. Lower production
0
3. Fewer or easier duties
6. Lower quality
7. Other - Explain in ltem 13c
c Explain in more detail, each selection made in ltem 13b. Note: For each explanation, include the item
number at the beginning of the answer. Also, if you have had more than 1 employer, identify the
employer after each explanation.
14 a Do you have any impairment-related expenses
ImpairmentRelated
Expenses
that are necessary for you to work? (For example,
prescription medications, medical services, attendant care, medical devices, equipment, prosthesis,
or similar items or services.)
1
b
b List each impairment-related expense and provide a receipt.
Form G-254 (01-08)
Page 4
0
Yes b Go to ltem 14b
a No
b Go to Section 4
Information about Self-Employment
Only complete Section 4 if you were self-employed during the period shown in Section 1. Otherwise, go to Section 5.
the name and address of your business.
Ernpioyment
b Did you work 40 or more hours a month?
a Yes
a No
c Check the box that describes the nature of the
Q Farm
0
business.
r
1
Non-Farm
d ~ n t e z h eprimary product or service.
e Check the box that describes the business in terms
of arrangement andlor ownership.
b
a Sole
owner
a Partnership
Farm
a Tenant
a Farm
Landlord
f Enter, below, the requested information about your monthly self-employment income for each month
during the period shown in Section 1, starting with the latest month. If you need more space, continue
in Section 6 or attach a separate piece of paper.
Month
Year
Hours Worked
in Month
Gross Income
Net Income
g Prior to the period shown in Section I , what did you do in the business in terms of management
I
decisions, responsibilities, hours, production and services?
a Yes
h Was this business your sole livelihood
before the period shown in Section I ?
Q No
Page 5
Form G-254 (01-08)
SelfEmployment
(Continued)
15 i Describe the duties you perform on an average work day. Include any changes in your business
because of your disabling condition, such as reduced business hours, lower volume, fewer
acres under cultivation, etc.
-
Assistants
-
-
-
-
-
-
1 6 a Because of your disabling condition, do you need
additional help to perform your usual duties?
-
b
-
Yes b Go to Item l 6 b
0
No
b Gotolteml7
b Enter the number of assistants you have.
c Check the box that describes when you receive assistance.
Q Bytheday
Q By the week
By the month
1
d Enter how many hours your assistant(s) spends helping you? (Show if per day, week, or month.)
e Describe what your assistant(s) does to help you.
Form G-254 (01-08)
Page 6
Assistant
(Continua
16 f Does your assistant(s) get paid?
b
Yes b Go to ltem 16g
IVo
b Go to ltem l 6 h
g Enter the amount your assistant(s) gets paid. (Show if per hour, day, or month.)
h Is your assistant(s) related to you?
b
a Yes
b Go to ltem l 6 i
IVo
b Gotolteml6j
i Enter the relationship of your assistant(s) to you.
j Explain why you need additional help.
- - -
Decisions
17 a Have you made management decisions during
the period shown in Section I ?
b
a Yes
Q No
-
b Go to ltem 17b
b Gotolteml8
b Describe the type of management decisions you made, how much time you spent making
them, and any changes that have taken place.
Page 7
Form G-254 (01-08)
Business
Began
1
18 Did you start your business after your disabling
condition began?
19 Did you receive any special assistance from an
agency or other source in setting up your business?
20 Do you still receive this special assistance or have
additional special services been supplied?
'
'
'
a Yes
'
a Yes
t Go to Item I 9
0 No t Go to Section 5
a Yes
t Go to ltem 20
0 No t Go to Item 22
a Yes
a No
t Goto Item21
t Go to Item 22
21 Describe the continued assistance or special services.
22 Are there any normal business expenses paid for or
Business
Expenses
furnished by another person or organization (for
example, free space or utilities)?
t Go to ltem 23
0 No t Go to Section 5
23 List the business expenses paid for or furnished, and provide the dollar value.
24 Explain why and by whom these expenses were furnished.
Impairment
RelatedExpenses
2 5 a Do you have any impairment-related expenses
1
that are necessary for you to work? (For example,
prescription medications, medical services, attendant care, medical devices, equipment, prosthesis,
or similar items or services.)
b
b List each impairment-relatedexpense and provide a receipt.
I
Form G-254 (01-08)
Page 8
0
Yes t Go to ltem 25b
No
t Go to Section 5
Information about Your Condition before Full Retirement Age
26 a Describe your present medical condition
Condition
Before
b Describe any change (better or worse) in your condition, if any, during the period shown in Section 1.
If none, enter "None."
c Does your condition prevent you from
b
working now?
d Have you received any treatment or care for your
condition during the period shown in Section I ?
Q Yes b Go to Item 26d
Q No b Go to Item 26e
a Yes
a No
b Go to Item 27
Goto Item 28
e Explain why your condition does not prevent you from working now.
I
~ r e a t r n e n t l 2 7a
or Care I
(1) Enter the name and address of the most recent source of treatment or care (doctor, hospital, or clinic).
(2) Enter the Patient Number (if applicable).
1
(3) Enter the telephone number of the treatment source (include area code).
1
(4) Enter the date(s) you were treated.
(5) Describe the condition(s) for which you received treatment.
(6) Describe the treatment.
1
Page 9
Form G-254 (01-08)
Treatment
27 b (1) Enter the name and address of the second most recent source of treatment or care (doctor, hospital, or clinic).
1
Or Care
(Continued)
I
(2) Enter the Patient Number (if applicable).
(3) Enter the telephone number of the treatment source (include area code).
=
(
)
(4) Enter the date(s) you were treated.
(5) Describe the condition(s) for which you received treatment.
/
(6) Describe the treatment.
(If you need more space to list sources of care, continue in Section 6)
Medication 28
a Are you taking medication or receiving
Q Yes b Go to ltem 28b
Q No b Goto ltem 29
treatment now?
b Enter the medication or treatment below. Note: If you are taking prescription medication, furnish
the name or type of medication and dosage from the label. (For example, Penicillin, 1.5 gram
Form G-254 (01-08)
Page 10
29 a Has your doctor restricted your activities?
Restriction
of
Activities
b
Q Yes b Go to ltem 29b
Q No b Go to Item 30
b Describe the restriction(s).
c Is the name of the doctor who restricted your activities
different from the name of the doctor(s) shown in ltem
27a or Item 27b?
Doctor's Name: -
b
-
Q No b Go to ltem 30
Q Yes b Go to Item 30b
30 a Has your doctor told you that you are able
Return
0
to return to work?
to Work
Q Yes b Enter doctor's name then
go to ltem 30
No
b Go to Item 31
Month
b Enter the date your doctor said you could
Day
Year
return to work.
c Is the name of the doctor who told you that you are
able to return to work different from the name of the
doctor(s) shown in ltem 27a or ltem 27b?
Doctor's Name:
-
i
-
b
Q Yes b Enter doctor's name then
go to Item 31
Q No b Go to ltem 31
-
31 Check the one box after each activity listed below that best describes your ability to do that activity.
Activities
"Yes"
"No"
"Hard"
-
Means you can do the activity without help.
Means you cannot do the activity even with help.
Means the activity is hard for you to do, or that you need help. Explain each "Hard" answer.
Activity
Walking
Yes
No Hard
Explanation
m o m
Eating
1
Dressing, tying shoes,
combing hair, etc.
0 0 0
Other bodily needs
0 0 0
Indoor chores
(cooking, cleaning, etc.)
0 0 0
Outdoor chores
(shopping, yardwork, etc.)
Driving a motor vehicle
1 1 1
(
10I~l0I
I
Using public
transportation
I
Talking to and dealing
with other people
0 0 O~
010
- -
0
Page 11
Form G-254 (01-08)
-
-
a During the period shown in Section I,have you
-
--
Q Yes b Go to Item 32b
Q NO b GO to ltem 33
received services, such as training, counseling, placement, medical examination, treatment, etc., from or
through a state vocational rehabilitation agency?
Agency
-
b Enter the Name, Address, and Telephone Number of your vocational rehabilitation counselor
I
c Enter the date(s) you received services.
d Describe the services you received.
33 a During the period shown in Section 1, have you
Other
Agencies
received services such as training, counseling, placement, medical examination, treatment, etc., from
other agencies, such as VA, Worker's Compensation,
Welfare. etc.?
Tr
(
)
c Enter your claim number at that agency.
d Enter the date(s) you received services.
I
Form G-254 (01-08)
Page 12
b
0
Yes b Go to ltem 33b
Q No b Go to Item 34
Other
Agencies
33 e Describe the services you received.
Education
34 a Have you attended school (trade, vocational, or
academic) during the period shown in Section I ?
'
a Yes
a No
b Go to Item 34b
,
Go to Section 7
b Enter the Name, Address, and Telephone Number of the school.
c Briefly describe the type of training you received.
1
d Enter the dates you attended the school.
I
Continuation and Remarks
Continuation and
Remarks
35 This section is to be used for the continuation of answers to other items. Be sure to include the
item number at the beginning of the answer you wish to continue. You may also use this section
to enter additional information that you feel may be important to include.
(Continue on next page)
Page 13
Form G-254 (01-08)
1 35
continuation and
Remarks
(Continued)
(If you need more space, attach a separate sheet of paper)
I
Form G-254 (01-08)
Page 14
Authorization and Certification
Auhizabn 36 Will this report be signed by a guardian or any
and
other person representing the beneficiary?
Certification
b
a Yes
a No
b Read Note then go to ltem 37
b Go to Item 37
/
( Note: If answered "Yes,"your guardian or representative must sign this report in ltem 37.
\
37 1 understand that civil and criminal penalties may be imposed upon me for false or fraudulent statements,
or for withholding information to misrepresent a fact or facts material to determining a right to benefits
under the Railroad Retirement Act. I affirm that to the best of my knowledge, the information I have
provided on this form is true, complete, and correct.
I have received the appropriate application booklets, RB-ld, Employee Disability Benefits, and RB-9,
Employee and Spouse EventsThat Must Be Reported. I understand that I am responsible for reporting
any events that would affect my annuity as explained in these booklets.
I authorize the Railroad Retirement Board to secure any information from the Social Security Administration
which is required to determine my continuing entitlement to benefits under the Railroad Retirement Act.
Signature b
Date
1
138
I
b
Daytime Telephone Number (Include Area Code)
If this certification is signed by mark ("X) in ltem 37, two witnesses who know the person signing must
sign below, giving their full addresses and daytime telephone numbers.
a. Signature of Witness
Address (Number and Street)
City, State, and ZIP Code
Daytime Telephone Number
b
Telephone Number
Area Code
b. Signature of Witness
Address (Number and Street)
City, State, and ZIP Code
Daytime Telephone Number
b
v
Page 15
Area Code
I
I
Telephone Number
I
1
I
.
1
1
Form G-254 (01-08)
Before you return your report, check to make sure that:
b
b
b
Every question that applies to you has been answered.
You have entered "Unknown" in any answer space for which you were unable to answer a
question.
You have signed and dated the report.
When you received your report, you should also have received a pre-addressed return envelope. If
you do not have this envelope, you can use any envelope as long as it is addressed to the RRB office
shown below. No matter which envelope you use, you must put the correct postage on the envelope.
Be careful to provide enough postage because your report may weigh more than a standard letter.
The U.S. Postal Service will not deliver your report unless it has the correct postage.
Address envelope to:
U S Railroad Retirement Board
Disability Benefits Division
844 N Rush Street
Chicago IL 6061 1-2092
t
If you do not want to use the mail, you can send a facsimile of the entire r e ~ o rto:
b
Facsimile Number
(312) 751-7167
If you need information or assistance, contact:
b
Telephone Number:
Form G-254 (01-08)
Page 76
| File Type | application/pdf |
| File Modified | 2008-12-17 |
| File Created | 2008-12-17 |