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 $810.00.
$790.00. Please notify the
nearest office of the RRB if your earnings exceed $810.00
$790.00 a month.
Month

Day

Year

THE PERIOD COVERED IN THIS REPORT IS

Section 2

TO PRESENT

Identifying Information

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.
Identifying

1 Employee's Name

Information

2 Employee's Social Security Number

3 Employee's Railroad Retirement Claim Number

4 Your Name

5 Your Social Security Number

Section 3
Work for
Employer

Information about Work for an Employer

6 Have you worked for an employer (railroad or
nonrailroad) during the period
to present?

Yes

Go to Item 7

No

Go to Section 4

Form G-254
Form
G-254(XX-XX)
(12-12) 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)

(10a) Date Work
Began

Month

Day

Year

Hourly Rate of Pay
$

(10b) Date Work
Ended

Month

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)

(

)

(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)

(10a) Date Work
Began

Month

Day

Year

(11) If work has ended, explain why.

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Hourly Rate of Pay
$

(10b) Date Work
Ended

Month

Day

Year

Third

7 c (1) Third Employer's Name

Last
Employer

(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)

(7) Days Worked Per Week

Monthly Rate of Pay

$__________________
(8) Hours Worked Per Day

(9) Hourly Rate of Pay

$
(10a) Date Work
Began

Month

Day

Year

Month

(10b) Date Work
Ended

Day

Year

(11) If work has ended, explain why.

(If you need more space to list employers, continue in Section 6)
to present, in which you earned more than $810.00.
$790.00.

Earnings

8 List any months during the period

Special

9 a Have your earnings included any other payment,

Earnings

such as tips, bonuses, child care, sick or vacation
pay, free meals, room or transportation?

Yes

Go to Item 9b

No

Go to Item 10

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
because of your disabling condition?

Continue 11
or Return
to Work
Special
Employment

Did you continue in or return to the same work
duties, hours, and pay as you had before your
disabling conditions began?

12 a Are (were) you employed by a friend or relative
or through a special training or rehabilitation
program?
Page 3

Yes
No
Yes

Go to Item 14

No

Go to Item 12

Yes

Go to Item 12b

No

Go to Item 13
Form G-254
G-254 (XX-XX)
Form
(12-12)

Special

12 b Explain how and why you were hired.

Employment
(Cont.)

Different
Job

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

Duties

Yes

Go to Item 13b

No

Go to Item 14

b Check all that apply them go to Item 13c.
1. Shorter hours

2. Different pay scales

3. Fewer or easier duties

4. Extra help given

5. Lower production

6. Lower quality

7. Other - Explain in Item 13c

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.

Impairment–
Related
Expenses

14 a Do you have any impairment–related 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.)

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

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G-254(XX-XX)
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Page 4

Yes

Go to Item 14b

No

Go to Section 4

Section 4

Information about Self-Employment

Only complete Section 4 if you were self-employed during the period
to present. This would include self-employment
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.
Self

15 a Enter the name and address of your business.

Employment

Yes

b Did you work 40 or more hours a month?

No

c Check the box that describes the nature of the
business.

Farm
Non-Farm

d Enter the primary product or service.

e Check the box that describes the business in terms
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?

Sole Owner

Partnership

Farm Tenant

Corporation

Farm Landlord

LLC

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

(2) Describe what you have received of value in lieu of
a salary or wages.

g Enter, below, the requested information about your monthly self-employment income for each month
during the period
to present, 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

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

Yes

work for any corporation at anytime (including a corporation owned by a family
member or friend) whether for pay or not, since
?

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

to present?

Yes
No

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Form G-254
Form
G-254(XX-XX)
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Self
Employment

15 k 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.

(Cont.)

Assistants

16 a Because of your disabling condition, do you need
additional help to perform your usual duties?

Yes

Go to Item 16b

No

Go to Item 17

b Enter the number of assistants you have.
By the day

c Check the box that describes when you receive assistance.

By the week
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.

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Page 6

Assistants

16 f Does your assistant(s) get paid?

(Cont.)

Yes

Go to Item 16g

No

Go to Item 16h

g Enter the amount your assistant(s) gets paid. (Show if per hour, day, or month.)
h Is your assistant(s) related to you?

Yes

Go to Item 16i

No

Go to Item 16j

Yes

Go to Item 17b

No

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

to present?

b Describe the type of management decisions you made, how much time you spent making
them, and any changes that have taken place.

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Form G-254
Form
G-254(XX-XX)
(12-12)

Busines
Began

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?

Yes

Go to Item19

No

Go to Section 5

Yes

Go to Item 20

No

Go to Item 22

Yes

Go to Item 21

No

Go to Item 22

Yes

Go to Item 23

No

Go to Section 5

21 Describe the continued assistance or special services.

Busines
Expenses

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

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
Related
Expenses

25 a Do you have any impairment–related 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.)

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

Form
FormG-254
G-254(XX-XX)
(12-12)

Page 8

Yes

Go to Item 25b

No

Go to Section 5

Section 5
Condition

Information about Your Condition before Full Retirement Age

26 a Describe your present medical condition.

Before
Full Retirement Age

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

to present.

If none, enter “None.”

c Does your condition prevent you from
working now?

d Have you received any treatment or care for your
condition during the period

to present?

Yes

Go to Item 26d

No

Go to Item 26e

Yes

Go to Item 27

No

Go to Item 28

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

Treatment

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

or Care

(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.

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Form G-254
G-254(XX-XX)
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Treatment

27 b (1)

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

or Care
(Cont.)

(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
treatment now?

Yes

Go to Item 28b

No

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
Form G-254
G-254(XX-XX)
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Page 10

Restriction

Yes

Go to Item 29b

No

Go to Item 30

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

Yes

Enter doctor’s name then
go to Item 30

Doctor’s Name: _____________________________

No

Go to Item 30

Yes

Go to Item 30b

No

Go to Item 31

29 a Has your doctor restricted your activities?

of
Activities

b Describe the restriction(s).

c Is the name of the doctor who restricted your activities

Return

30 a Has your doctor told you that you are able

to Work

to return to work?

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 Item 27a or Item 27b?
Doctor’s Name: _____________________________
Activities

Yes

Enter doctor’s name then
go to Item 31

No

Go to Item 31

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

Explanation

Walking

Eating

Bathing
Dressing, tying shoes,
combing hair, etc.

Other bodily needs
Indoor chores
(cooking, cleaning, etc.)

Outdoor chores
(shopping, yardwork, etc.)

Driving a motor vehicle
Using public
transportation
Talking to and dealing
with other people
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Form G-254
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G-254(XX-XX)
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Rehabilitation
Agency

32 a During the period

to present, have you received
services, such as training, counseling, placement,
medical examination, treatment, etc., from or through a
state vocational rehabilitation agency or other agencies,
such as VA, Worker's Compensation, Welfare, etc...?

Yes

Go to Item 32b

No

Go to Item 33

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

(

)

c Enter the date(s) you received services.

d Describe the services you received.

Education

33 a Have you attended school (trade, vocational, or
academic) during the period
present?

to

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.
Form
Form G-254
G-254(XX-XX)
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Page 12

Yes

Go to Item 33b

No

Go to Section 7

Section 6
Continuation and
Remarks

Continuation and Remarks

34 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.

(If you need more space, attach a separate sheet of paper)
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Form G-254
Form
G-254(XX-XX)
(12-12)

Section 7
Authorization 35
and

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

Yes

Read Note then go to Item 36

No

Go to Item 36

Certification

Note: If answered “Yes,” your guardian or representative must sign this report in Item 36.

36 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.
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

Month

Day

Year

Date
Daytime Telephone Number (Include Area Code)
(
37

)

If this certification is signed by mark (“X”) in Item 36, 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

Daytime Telephone Number
b. Signature of Witness

Address (Number and Street)
City, State, and ZIP Code

Daytime Telephone Number
Form
FormG-254
G-254(XX-XX)
(12-12)

Page 14

Section 8

How to Return Your Report

Before you return your report, check to make sure that:
Every question that applies to you has been answered.
You have entered “Unknown” to 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
If you do not want to use the mail, you can send a facsimile of the entire report to:
Facsimile Number
(312) 751-7167

If you need information or assistance, contact:

Telephone Number:

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Form G-254
Form
G-254(XX-XX)
(12-12)