G-250A Medical Assessment of Residual Functional Capacity

UNITED STATES OF AMERICA

RAILROAD RETIREMENT BOARD
OFFICE NAME
OFFICE ADDRESS

OFFICE CITY, STATE, ZIP CODE
WWW.RRB.GOV

Form Approved
OMB No. 3220-0038

PROPOSED

MEDICAL ASSESSMENT OF
RESIDUAL FUNCTIONAL CAPACITY
NAME

RRB CLAIM NUMBER

INSTRUCTIONS
Complete this form and submit to us along with your narrative report and office records, as requested on the enclosed
cover letter. Describe below any restrictions in the claimant's ability to perform basic work-related functions within a
regular work setting on a day-to-day basis. Relate any assessed reduction to capacity to particular medical
findings. Do not consider non-medical factors such as age, sex, education, or work experience.
Note: You may include this medical assessment in your narrative report, however, we prefer you use this Form G-250A.
When using this form, use the space to the left of a function or condition to enter "NA" if you find that it is NOT
AFFECTED by the claimant's impairment(s). If you are unable to assess the claimant's ability to perform an activity or
tolerate a condition shown, use the space to show "UNK" indicating UNKNOWN. Otherwise, complete as appropriate,
being sure to explain limitations and relate them to specific findings in the space provided.
Please read page 4 for the authorization for this report and other important notices.
A. Exertional Restrictions - For all claimants with physical impairments.
1. _________ In an 8-hour workday claimant can STAND and/or WALK, with normal breaks, for:
less than 2 hours total

at least 2 hours total

6 hours or more

MEDICAL FINDINGS TO SUPPORT RESTRICTION:

2. _________ In an 8-hour workday claimant can SIT, with normal breaks, for:
less than 6 hours total

6 hours or more

MEDICAL FINDINGS TO SUPPORT RESTRICTION:

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A.

Exertional Restrictions, Continued
3. __________ Claimant can LIFT:

Unlimited

1

Frequently

2

Occasionally

Never

Less than 10 pounds
10 pounds
20 pounds
50 pounds
100 pounds or more

MEDICAL FINDINGS TO SUPPORT RESTRICTIONS:

4. Claimant is able to:
________ Bend/Stoop

1

Frequently

2

Occasionally

Never

________ Crouch/Squat
________ Climb
________ Reach above shoulder level

MEDICAL FINDINGS TO SUPPORT RESTRICTIONS:

5. Claimant can use BOTH HANDS for repetitive:

YES

NO (Limitation MUST be explained)

________ Simple Grasping
________ Fine Manipulation
________ Pushing/Pulling
6. Claimant can use BOTH FEET for repetitive:
________ Foot Controls
7. Claimant can, without restriction:
________ See
________ Hear
________ Speak

MEDICAL FINDINGS TO SUPPORT RESTRICTIONS:

1
2

FREQUENTLY means occurring one-third to two-thirds of an 8-hour workday; cumulative, not continuous.
OCCASIONALLY means occurring from very little up to one-third of an 8-hour workday; cumulative, not continuous.

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B.

Environmental Restrictions - For all claimants, as applicable.
Claimant is restricted in activities involving:

No

3

Mildly

4

Totally

4

Totally

Moderately

_______ Unprotected Heights
_______ Driving/Operating Machinery
_______ Being around moving Machinery
_______ Uneven Terrain/Stairs
_______ Exposure to Dust, Fumes, Etc.
_______ Exposure to Noise
_______ Exposure to Vibration
_______ Exposure to Temperature
Extremes/Humidity
Other:

MEDICAL FINDINGS TO SUPPORT RESTRICTIONS:

C.

Mental Restrictions - For all claimants with mental impairments.
Claimant is limited in ability to:

No

3

Mildly

Moderately

________ Reason/Use Judgment
________ Maintain Appropriate Mood
________ Maintain Personal Habits
________ Perform Normal Daily Activities
________ Make Social Adjustments
________ Relate to Other People
________ Make Occupational Adjustments
________ Maintain Normal Work Pace
________ Maintain Normal Concentration
________ Remember/Understand/Carry Out
Instructions
Other:

MEDICAL FINDINGS TO SUPPORT RESTRICTIONS:

3
4

MILDLY means tolerance/ability to function is limited but satisfactory.
MODERATELY means tolerance/ability to function is seriously limited, but not precluded.

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In your opinion, is the claimant able to handle benefit
payments in his/her own best interest

Yes

No

CERTIFICATION
With the understanding that section 13 of the Railroad Retirement Act (45 U.S.C. 231l) provides that anyone who makes
false or fraudulent statements or claims for the purpose of causing an award or payment under the Railroad Retirement
Act is subject to a fine of up to $10,000, or imprisonment of up to one year, or both, I certify that the information I have
furnished is correct to the best of my knowledge.
Signature
Date

Printed Name, Title, and National Provider Number
National Provider Number

Address and Daytime Telephone Number

Area Code

Telephone Number

Please return this form along with your narrative report and copies of your office records to:

RAILROAD RETIREMENT BOARD
OFFICE NAME
OFFICE ADDRESS
OFFICE CITY, STATE, ZIP CODE

PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICES
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 for the claimant
named and to determine the claimant's entitlement to disability benefits under the Railroad Retirement Act.
We estimate this form takes an average of 20 minutes per response to complete, including time for reviewing the
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. 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 N. Rush Street, Chicago, IL 60611-2092.

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