G-251 (proposed) Vocational Report

United States of America
Railroad Retirement Board

Form Approved
OMB 6 . 3 2 2 0 - 0 141

,

Vocational Report

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General Instructions

I Be sure to read the Important Notice at the bottom of page 5.
Tvpe or print leaiblv in ink. 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.
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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 t o 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

1

E m ~ l o ~ e eName
's
2 Employee's Social Security Number

Applicant
Identification

1

3 Employee's Railroad Retirement Claim
Number, if different from ltem 2
4 Applicant's Name
5 Applicant's Address (Include Street
Address, City, State, ZIP Code and
County)

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16
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Daytime Telephone Number

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lnformation About Your Work History
Work History

7 List all railroad and nonrailroad jobs you have had in the last 15 years before you stop ed working and
entar an " X in the appro riate box to indicate whether the work was railroad or nonrai road. If you have
a 6' rade education or ess and performed only heav unskilled labor for 35 years or more, list all of
you have had since you began to work. NOT& If you list only one job in ltem 7 , do not
the
complete paqes 3 and 4. If you have more than 3 jobs to list, continue on another Form G-251.
Dates Worked
Hours
Type and Name of Business
Job Title
From
To
Per
(Railroad or Nonrailroad)
Week
MO
YR
MO
YR
Railroad
Nonrailroad
a.

P

P

I

bi----l
Railroad

Nonrailroad

Railroad

Nonrailroad

C.

Regular
Occupation

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

Yes - Go t o Item 9
No - Go t o Item 12

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 job did you claim as your regular occupation?

Job in Item 9
Job in Item 10

Form G-251 (99-99)

Only complete this page to provide a description of a job listed in ltern 7a.
Description of 1 12 a. In the job described in ltem 7a, did you: (circle all that apply)
. . . .

Job in ltern

1 Use machines,
tools or equipment
of any kind?

7a

2 Use technical
knowledge or
skills?

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

4 Use manipulative

5 Have
supervisory
responsibilities?

skills, i.e., manual
dexterity?

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.

13 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 13a, briefly explain your exposure.

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14 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
1
0
1
2
3
4
5
6
7
8
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) PushIPull...........................................
Briefly explain what and how you
pushed and pulled

Never
Never
Never
Never
Never
Stairs

0ccasionally1
Occasionally
Occasionally
Occasionally
Occasionally
Vertical ladder

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

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
20 Ibs
50 Ibs
100 Ibs
Over 100 Ibs
10 lbs
Weight Most Often LiftedlCarried
u p t o 10 lbs Up to 25 Ibs
Up to 50 Ibs Over 50 Ibs
10ccasionally means occurring from very little up to one-third (approx. 2-112 hours) of an 8-hour workday; cumulative, not
continuous.
2~requentlymeans occurring one-third (approx. 2-112 hours) to two-thirds (approx. 5 hours) of an 8-hour workday; cumulative, not
continuous.

(3) Circle the weight of the objects you
lift and carrv

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Form G-251 (99-99)

Only complete this page t o provide a description o f a job listed i n ltem 7b. Otherwise g o to page 5.
Description of 15 a. In the job described in ltem 7 b did you: (circle all that apply)
Job in Item

7b

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

3 Dangerous 4 Extremes of

Heights

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) Standiflglwalking
(2) Sitting
0
1
2
3
4
5
6
7
8
b. Circle how often a day you had to:
(1) Bend..................................................
(2) CrouchISquat....................................
(3) Kneel.................................................
(4) Reach above shoulder level .............
(5) Climb .................................................
Circle what you climbed ...............
(6) PUS~IPUII .........................................
Briefly explain what and how you
pushed and pulled

Never
Never
Never
Never
Never
Stairs

Occasionallyl
Occasionally
Occasionally
Occasionally
Occasionally
Vertical ladder

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

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
10 lbs
20 Ibs
50 Ibs
100 Ibs
Over 100 Ibs
Weight Most Often 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 (approx. 2-112 hours) of an 8-hour workday; cumulative, not
continuous.
2~requentlymeans occurring one-third (approx. 2-112 hours) to two-thirds (approx. 5 hours) of an 8-hour workday; cumulative, not
continuous.

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

Form G-251 (99-99)

Only complete this page t o provide a description of a job listed in ltem 7c. Otherwise go to page 5.
Description of 18 a. In the job described in ltem 7c, did you: (circle all that apply)
Job in Item

7~

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 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
of paper.

1 Walking on
Uneven Terrain

3 Dangerous 4 Extremes of

Heights

Machinery

Temperature

5 Fumes or
Noxious Gases

7 Excessive

Dust

Noise or Vibration

b. If you circled any of the hazards in ltem 19a, briefly explain your exposure.

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
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) PUS~IPUII ........................................
Briefly explain what and how you
pushed and pulled

Never
Never
Never
Never
Never
Stairs

Occasionallyl
Occasionally
Occasionally
Occasionally
Occasionally
Vertical ladder

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

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
10 lbs
20 Ibs
50 Ibs
100 Ibs
Over 100 Ibs
Weight Most Often LiftedlCarried
Up to 10 Ibs Up to 25 Ibs
Up to 50 Ibs Over 50 Ibs
means
occurring
from
very
little
up
to
one-third
(approx.
2-112
hours)
of
an
8-hour
workday;
cumulative, not
l~ccasionally
continuous.
2~requentlymeans occurring one-third (approx. 2-112 hours) to two-thirds (approx. 5 hours) of an 8-hour workday; cumulative, not
continuous.

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

Form G-251 (99-99)

Certification

- e A
Certification

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

Yes - Go to Note and ltem 22
No - Go to ltem 22
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Note: I f answered "Yes, " the guardian or other representative o f 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)
Month

Day

Year

Date

1

23 If this certification is signed by mark ("X) in ltem 22, two witnesses who know the person signing must
sign below, giving their full addresses.
a. Signature o f Witness

Address (Number and Street)

City, State, ZIP Code

b. Signature of Witness

Address (Number and Street)

City, State, ZIP Code

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 processing 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 reducirlg completion time, to Chief of Information Resources Management, Railroad Retirement Board,
844 North Rush Street, Chicago, IL 6061 1-2092.

Form G-251 (99-99)

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How to Return Your Report

Before you return your report, check to make sure that:
a Every question that applies to you has been answered.
a You have entered "unknown" in any answer space for which you were unable to answer a

question.
a

You have signed and dated the report.

a You have included all the needed proofs listed in the letter you received with tl- is report.

When you received your report, you should have also received a pre-addressed envelope.
If ou do not have this 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 on 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.

R

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If you need information or assistance, contact:

U.S. RAILROAD
RETIREMENT
BOARD

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

Form G-251 (99-99)