G-254; Continuing Disability Report

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0187

Continuing Disability Report
Paperwork Reduction Act/Privacy 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 Information Resources Management, Railroad Retirement Board, 844 North Rush Street, Chicago, Illinois 60611-2092.

Section 1

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 Items 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 $780.00. Please notify the
nearest office of the RRB if your earnings exceed $780.00 a month.
Month

Day

Year
TO PRESENT

THE PERIOD COVERED IN THIS REPORT IS

Section 2

Identifying Information

M M M

Check the information provided for Items 1 through 5 for accuracy.
If the information is correct, go to 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.

1 Employee's Name
2 Employee's Social Security Number

3 Employee's Railroad Retirement Claim Number

4 Your Name

5 Your Social Security Number

6 Have you worked for an employer (railroad or
nonrailroad) during the period shown in Section 1,
above?

K Yes
K No

M

Work for
Employer

Information about Work for an Employer
Go to Item 7

M

Section 3

M

Identifying
Information

Go to Section 4

Form G-254 (01-10) Destroy Prior Editions

Last
Work
for
Employer

7 Enter information about your employer(s) in Items 7a-c below. (Note: If you have had more than 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) Title/Name of your job
(5) Describe your job duties. (Include weights lifted and how frequently lifted; hours spent standing/sitting;
frequency of bending/stooping/climbing, etc.)
(6) Monthly Rate of Pay
$ __________________

(7) Days Worked Per Week

(8) Hours Worked Per Day

(9) Hourly Rate of Pay
$
Day

Year

(10b) Date Work
Ended

Month

Day

Year

M

Month

M

(10a) Date Work
Began

(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)

(

)

(4) Title/Name of your job
(5) Describe your job duties. (Include weights lifted and how frequently lifted; hours spent standing/sitting;
frequency of bending/stooping/climbing, etc.)

(6) Monthly Rate of Pay
$ __________________

(7) Days Worked Per Week

(8) Hours Worked Per Day

(9) Hourly Rate of Pay
$
Day

Year

(11) If work has ended, explain why.

Form G-254 (01-10)

(10b) Date Work
Ended
M

Month

M

(10a) Date Work
Began

Page 2

Month

Day

Year

Third
Last
Employer

7 c (1) Third Employer's Name
(2) Employer's Address

(3) Employer's Telephone Number (Include Area Code)

(

)

(4) Title/Name of your job
(5) Describe your job duties. (Include weights lifted and how frequently lifted; hours spent standing/sitting;
frequency of bending/stooping/climbing, etc.)

(6) Monthly Rate of Pay
$ __________________

(7) Days Worked Per Week

(8) Hours Worked Per Day

(9) Hourly Rate of Pay

$
Year

(10b) Date Work
Ended

Month

Day

Year

M

Day

M

(10a) Date Work
Began

Month

(11) If work has ended, explain why.

(If you need more space to list employers, continue in Section 6)

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?

K Yes
K No

M M

8 List any months during the period shown in Section 1, in which you earned more than $780.00.

M

Earnings

Go to Item 9b
Go to Item 10

b List below type of other payment(s) received, estimated dollar value, frequency of payment,

Special
Employment

12 a Are (were) you employed by a friend or relative

duties, hours, and pay as you had before your
disabling conditions began?
or through a special training or rehabilitation
program?
Page 3

K Yes
K No

M M

11 Did you continue in or return to the same work

K Yes
K No

K Yes
K No

M M

Continue
or Return
to Work

because of your disabling condition?

M

10 Did you work 3 months or less and then stop work

M

3 Months
or Less
Work

M

and employer’s name.

Go to Item 14
Go to Item 12
Go to Item 12b
Go to Item 13
Form G-254 (01-10)

13 a Have your job duties differed from those of other
workers with the same job title?

K Yes
K No

M

Different
Job
Duties

Go to Item 13b

M

12 b Explain how and why you were hired.

M

Special
Employment
(Continued)

Go to Item 14

b Check all that apply them go to Item 13c.
K 1. Shorter hours
K 4. Extra help given
K 7. Other - Explain in Item 13c

K 2. Different pay scales
K 5. Lower production

K 3. Fewer or easier duties
K 6. Lower quality

c Explain in more detail, each selection made in Item 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.

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 List each impairment-related expense and provide a receipt.

Form G-254 (01-10)

Page 4

K Yes
K No

M M

14 a Do you have any impairment–related expenses
M

Impairment–
Related
Expenses

Go to Item 14b
Go to Section 4

Section 4

Information about Self-Employment

Only complete Section 4 if you were self-employed during the period shown in Section 1. This would include selfemployment for a family owned, controlled or managed business, including a business, operated, managed, or owned by
you, a family member, friend or close associate, whether for pay or not, and without regard to how the business is organized (e.g., sole proprietorship, partnership, corporation, LLC, etc.). Otherwise, go to Section 5.

M

business.

M

c Check the box that describes the nature of the

K Yes
K No
K Farm
K Non-Farm

M

b Did you work 40 or more hours a month?

K Sole Owner
K Farm Tenant
K Farm Landlord

M

a Enter the name and address of your business.

K Yes - Go to Item 15f(2)
K No - Go to Item 15g

d Enter the primary product or service.

of arrangement and/or ownership.

f (1) Have you received anything of value in lieu of salary
or wages for any work that you performed?
(2) Describe what you have received of value in lieu of
a salary or wages.

K Partnership
K Corporation
K LLC

M

e Check the box that describes the business in terms

g 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

work for any corporation at anytime (including a corporation owned by a family
member or friend) whether for pay or not, since the date listed in Section 1?

M

h Did you become a corporate officer, own or operate a corporation, or perform

K Yes
K No

i Prior to the period shown in Section 1, what did you do in the business in terms of management
decisions, responsibilities, hours, production and services?

j Was this business your sole livelihood before the
period shown in Section 1?
Page 5

M

15
Self–
Employment

K Yes
K No
Form G-254 (01-10)

Self–
Employment
(Continued)

15 k Describe the duties you perform on an average work day. Include any changes in your business

Assistants

16 a Because of your disabling condition, do you need

M

K Yes
K No

M

additional help to perform your usual duties?

Go to Item 16b

M

because of your disabling condition, such as reduced business hours, lower volume, fewer
acres under cultivation, etc.

Go to Item 17

c Check the box that describes when you receive assistance.

M

b Enter the number of assistants you have.
K By the day
K By the week
K By the month

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 (01-10)

Page 6

M

K Yes
K No

Go to Item 16g

M

16 f Does your assistant(s) get paid?

M

Assistants
(Continued)

Go to Item 16h

M
M

K Yes
K No

Go to Item 16i
Go to Item 16j

M

K Yes
K No

Go to Item 17b

M

M

h Is your assistant(s) related to you?

M

g Enter the amount your assistant(s) gets paid. (Show if per hour, day, or month.)

Go to Item 18

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 1?

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 (01-10)

M
M
M M

additional special services been supplied?

K Yes
K No

Go to Item 20

K Yes
K No

M M

20 Do you still receive this special assistance or have

Go to Section 5

Go to Item 21

K Yes
K No

M M

agency or other source in setting up your business?

M

19 Did you receive any special assistance from an

Go to Item 19

M

condition began?

K Yes
K No

M

18 Did you start your business after your disabling

M

Business
Began

Go to Item 23

Go to Item 22

Go to Item 22

21 Describe the continued assistance or special services.

Business
Expenses

22 Are there any normal business expenses paid for or
furnished by another person or organization (for
example, free space or utilities)?

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.

that are necessary for you to work? (For example,
prescription medications, medical services, attendant care, medical devices, equipment, prosthesis,
or similar items or services.)

26 b List each impairment-related expense and provide a receipt.

Form G-254 (01-10)

Page 8

K Yes
K No

M M

25 a Do you have any impairment–related expenses
M

Impairment
Related–
Expenses

Go to Item 25b
Go to Section 5

Section 5
Condition
Before
Full Retirement Age

Information about Your Condition before Full Retirement Age

26 a Describe your present medical condition.

b Describe any change (better or worse) in your condition, if any, during the period shown in Section 1.

condition during the period shown in Section 1?

M

d Have you received any treatment or care for your

K Yes

Go to Item 26d

K No

M

working now?

M

M

c Does your condition prevent you from

Go to Item 26e

K Yes

M M

If none, enter “None.”

Go to Item 27

K No

Go to Item 28

e Explain why your condition does not prevent you from working now.

Treatment
or Care

27 a (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).
(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.

Page 9

Form G-254 (01-10)

Treatment
or Care
(Continued)

27 b (1) Enter the name and address of the second most recent source of treatment or care (doctor, hospital, or clinic).

(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.

treatment now?

K Yes

M

a Are you taking medication or receiving

M

Medication 28

Go to Item 28b

K No

M

(If you need more space to list sources of care, continue in Section 6)

Go to Item 29

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
tablet, 3 times a day.)

Form G-254 (01-10)

Page 10

K No

M M

K Yes

M

Enter doctor’s name then
go to Item 30

K No

M

Go to Item 30

K Yes

Go to Item 30b

Go to Item 29b
Go to Item 30

b Describe the restriction(s).

different from the name of the doctor(s) shown in Item
27a or Item 27b?

M

c Is the name of the doctor who restricted your activities

30 a Has your doctor told you that you are able
to return to work?

M

Doctor’s Name: _____________________________
Return
to Work

K Yes

M M

29 a Has your doctor restricted your activities?

M

Restriction
of
Activities

K No

Month

b Enter the date your doctor said you could

Go to Item 31
Day

Year

Doctor’s Name: _____________________________
Activities

K Yes

M

able to return to work different from the name of the
doctor(s) shown in Item 27a or Item 27b?

Enter doctor’s name then
go to Item 31

K No

Go to Item 31

M

c Is the name of the doctor who told you that you are

M

return to work.

31 Check the one box after each activity listed below that best describes your ability to do that activity.
G
G
G

“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

Yes

No Hard

Walking

K K

K

Eating

K K

K

Bathing

K K

K

Dressing, tying shoes,
combing hair, etc.

K K

K

Other bodily needs

K K

K

Indoor chores
(cooking, cleaning, etc.)

K K

K

Outdoor chores
(shopping, yardwork, etc.)

K K

K

Driving a motor vehicle

K K

K

Using public
transportation

K K

K

Talking to and dealing
with other people

K K

K

Explanation

Page 11

Form G-254 (01-10)

K Yes

M

received services, such as training, counseling, placement, medical examination, treatment, etc., from or
through a state vocational rehabilitation agency?

Go to Item 32b

K No

M

32 a During the period shown in Section 1, have you
M

Rehabilitation
Agency

Go to Item 33

b Enter the Name, Address, and Telephone Number of your vocational rehabilitation counselor.



(

)

c Enter the date(s) you received services.

received services such as training, counseling, placement, medical examination, treatment, etc., from
other agencies, such as VA, Worker’s Compensation,
Welfare, etc.?

b Enter the Name, Address, and Telephone Number of the agency.



(

)

c Enter your claim number at that agency.

d Enter the date(s) you received services.

Form G-254 (01-10)

Page 12

K Yes

M

33 a During the period shown in Section 1, have you
M

Other
Agencies

Go to Item 33b

K No

M

d Describe the services you received.

Go to Item 34

academic) during the period shown in Section 1?

K Yes

M

34 a Have you attended school (trade, vocational, or
M

Education

e Describe the services you received.

Go to Item 34b

K No

M

33
Other
Agencies
(Continued)

Go to Section 7

b Enter the Name, Address, and Telephone Number of the school.



(

)

c Briefly describe the type of training you received.

d Enter the dates you attended the school.

Section 6
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 (01-10)

Continuation and
Remarks
(Continued)

35

(If you need more space, attach a separate sheet of paper)
Form G-254 (01-10)

Page 14

K Yes

M

Will this report be signed by a guardian or any
other person representing the beneficiary?

M

Authorization 36
and
Certification

Authorization and Certification
Read Note then go to Item 37

K No

M

Section 7

Go to Item 37

Note: If answered “Yes,” your guardian or representative must sign this report in Item 37.

37 I 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-1d, Employee Disability Benefits, and RB-9,
Employee and Spouse Events That Must Be Reported. I understand that I am responsible for reporting
any events that would affect my annuity as explained in these booklets.

Signature

M

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.

Year

Day

M

Month

Date

Daytime Telephone Number (Include Area Code)



)

If this certification is signed by mark (“X”) in Item 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
Area Code

Telephone Number

Area Code

Telephone Number

M

Daytime Telephone Number
b. Signature of Witness
Address (Number and Street)
City, State, and ZIP Code

Daytime Telephone Number

M

38

(

Page 15

Form G-254 (01-10)

Section 8

How to Return Your Report

M

M M

Before you return your report, check to make sure that:
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 60611-2092

M

If you do not want to use the mail, you can send a facsimile of the entire report to:
Facsimile Number
(312) 751-7167

M

If you need information or assistance, contact:



Telephone Number:

Form G-254 (01-10)

Page 16