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United States of America
Railroad Retirement Board
Form Approved
OMB No. 3220-0002
Do Not Write In This Space
Officially Filed
Month
Application
For Determination
Of Employee’s Disability
Day
Year
Office Number
Approved
Application Number
Month
Date Coded
Day
Year
Coded by
Section 1
General Instructions
Before you complete this application, be sure to read Part 1 of booklet RB-1d, Employee Disability Benefits, which explains
information you will need to answer many of the questions in this application.
Please read “Important Notices” on page 13 of this application.
Type or print legibly in ink. If you need more space than is provided to answer a question, use Section 9 for this purpose. If
you do not know the answer to a question, print “Unknown” in the the space provided for the answer.
When entering dates, always use numbers. Also, be sure there is one number in each box. For example, you would enter
June 06, 2007, as:
Month
Day
Year
0 6 0 6 2 0 0 7
Some items in this application will not apply to you so you will not need to answer them. Based on your answer to a
question, you may be told to skip to another item number or even another section. Follow the instructions that tell you to
“Go to” another item. These are designed to save you time and help you move through the application form quickly, filling
in 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 completing this application on behalf of someone else, you must answer each question as it applies to the
applicant.
Section 2
Identifying Information
Check the information entered by the Railroad Retirement Board (RRB) for Items 1 through 5 for accuracy.
If the information is correct, go to Section 3.
If the information is not correct, enter the correct information.
If the information is missing, fill it in.
Employee 1 Employee’s Name
Identification
2 Employee’s Railroad Retirement Claim Number
3 Employee’s Social Security Number
A
4a Employee’s Street Address
b City and State
c ZIP Code
d County
5 Daytime Telephone Number
Form AA-1d (02-14) Destroy Prior Editions
Medical
Condition
6 Describe the medical conditions causing you to file. Enter the exact diagnosis if known and any secondary condition.
Also enter if no medical records are being forwarded for each condition described.
When
Condition
Began
7 Enter the date this condition began to affect
your ability to work.
How
Condition
Affects
Work
8 Enter an “X” in the appropriate box:
Have you worked since the date in Item 7?
Yes
Go to Item 9
No
Go to Item 11
9 Enter an “X” in the appropriate box:
Has your condition caused you to change any aspect of your
work (such as job duties, hours of work, attendance, etc.)?
Yes
Go to Item 10
Information About Your Medical Condition
No
Section 3
Go to Item 11
Month
Day
Year
10 Explain what the changes in your work circumstances were, the dates they occurred, and why your condition made these
changes necessary.
CHANGES
When
Unable
To Work
DATES
11 Enter the date you could no longer work
because of your condition.
CONDITION
Month
Day
Year
12 Describe how your condition prevents you from working.
Current
Work
Status
13 Enter an “X” in the appropriate box:
Does your condition prevent you from working now?
14 Enter the date you again became able to work.
Section 4
Yes
Go to Section 4
No
Go to Item 14
Month
Day
Information About Your Medical Care
Medical
15a Enter an “X” in the appropriate box:
Care or
Have you received medical care or been examined for
Examination
your condition since the date in Item 7?
15b Enter an “X” in the appropriate box:
Are you scheduled for any additional medical care for your
condition (i.e., surgeries, etc.) after you file this application?
Yes
No
Yes
Explain below
No
Go to Item 16
Yes
Go to Item 17
No
Go to Item 18
Explain:
Treatment
or Testing
16 Enter an “X” in the appropriate box:
Have you been treated or tested (inpatient or outpatient)
at a hospital, institution, or clinic, including a
Department of Veterans Affairs or other government facility?
Form AA-1d (02-14) Page 2
Year
Treatment
or Testing
(Cont)
17 Enter information about each hospital, institution, or clinic where you have received treatment or care since the date in
Item 7.
Address of Facility (Street Address, City, State, and ZIP Code)
a Name of Facility
Attending Physician’s Name
Enter an “X” in the appropriate box:
Inpatient
Outpatient
Telephone Number (Include Area Code)
Patient Number
(
Dates Treated or Tested
)
Describe Type of Treatment or Testing
Address of Facility (Street Address, City, State, and ZIP Code)
b Name of Facility
Attending Physician’s Name
Enter an “X” in the appropriate box:
Inpatient
Outpatient
Telephone Number (Include Area Code)
Patient Number
(
Dates Treated or Tested
)
Describe Type of Treatment or Testing
Address of Facility (Street Address, City, State, and ZIP Code)
c Name of Facility
Attending Physician’s Name
Enter an “X” in the appropriate box:
Outpatient
Telephone Number (Include Area Code)
Patient Number
(
Doctor
Treatment
Describe Type of Treatment or Testing
18 Enter an “X” in the appropriate box:
Has your personal physician or other doctor treated
you since the date in Item 7?
Yes
Dates Treated or Tested
)
Go to Item 19
No
Inpatient
Go to Item 20
Form AA-1d (02-14) Page 3
19 Enter information about each personal physician or other doctor who has treated you.
Address of Physician (Street Address, City, State, and ZIP
a Name of Physician
Telephone Number (Include Area Code)
Patient Number
(
)
Describe Type of Treatment or Examination
Dates Treated or Examined
Address of Physician (Street Address, City, State, and ZIP
b Name of Physician
Telephone Number (Include Area Code)
Patient Number
(
)
for examination or treatment since the date in Item 7?
Yes
Railroad
20 Enter an “X” in the appropriate box:
Employer
Has your railroad employer referred you to a medical source
Examination
Go to Item 21
No
Describe Type of Treatment or Examination
Dates Treated or Examined
Doctor
Treatment
(Cont)
Go to Item 22
21 Enter information about this examination or treatment.
Address of Source (Street Address, City, State, and ZIP Code)
Name of Medical Source
Attending Physician’s Name
Enter an “X” in the appropriate box:
Inpatient
Outpatient
Patient Number
Telephone Number (Include Area Code)
(
Dates Treated or Examined
Form AA-1d (02-14) Page 4
)
Describe Type of Treatment or Examination
Yes
Go to Note then Item 23
No
Railroad
22 Enter an “X” in the appropriate box:
Employer
Have you been medically disqualified for work by your employer?
Examination
(cont)
Go to Item 23
25 Enter the date the restriction began.
Yes
24 Enter the name of the medical doctor who imposed
the restriction.
Go to Item 24
No
23 Enter an “X” in the appropriate box:
Has a medical doctor restricted your daily activities since the
date in Item 7?
Activity
Restriction
Note: If answered “Yes,” you must submit a copy of the Disqualification Notice.
Go to Item 28
Month
Year
26 Describe the restriction.
Yes
Go to Item 29
No
28 Enter an “X” in the appropriate box:
Has medication been prescribed for you?
Medication
Address (Street Address, City, State, and ZIP Code)
27 Enter the address of the medical doctor in Item 24 if
it has not previously been entered in Items 17, 19, or 21.
Go to Section 5
29 Enter from the prescription labels the following information for all medications prescribed for you:
Name or type of medication, dosage, and frequency. (For example, Penicillin, 1.5 gram tablet, 3 times a day.)
Name / Type
Yes
Go to Item 32
No
Go to Item 35
Yes
Go to Item 34
No
31 Enter an “X” in the appropriate box:
Have you attended technical school?
30b Enter the last year that you attended school.
30a Enter the highest grade of school you completed.
Go to Item 35
Schooling
Frequency
Information About Your Education And Training
Section 5
Dosage (Grams, Number of Pills, Etc.)
Yes
32 Describe the type of technical school you attended.
33 Enter an “X” in the appropriate box:
Have you received a certification or license from the technical
school you attended?
34 Enter an “X” in the appropriate box:
Is the certification or license you received currently valid?
No
Form AA-1d (02-14) Page 5
Yes
Go to Item 36
No
35 Enter an “X” in the appropriate box:
Did you receive specialized training?
Schooling
(Cont)
Go to Section 6
36 Enter the type of specialized training you received and the period of time you received it.
Type
Yes
37 Enter an “X” in the appropriate box:
Have you used any of this training in your work?
Go to Item 38
No
Dates
Go to Section 6
38 Describe when and how you have used this training in your work.
Information About Your Daily Activities
Section 6
Easy
Hard
Not
At All
Sitting
Standing
Walking
Eating
Bathing
Dressing (Tying Shoes,
Combing Hair, etc.)
Other Bodily Needs
Indoor Chores (Meal
Preparation, Laundry,
Cleaning, etc.)
Outdoor Chores
(Shopping, Yardwork, etc.)
Driving a Motor Vehicle
Using Public Transportation
Conducting Personal Business
(Talking to and Dealing
with Other People)
Reading English (For example,
newspapers and magazines)
39 Check the one box after each activity listed below that best describes your ability to do that activity.
• EASY – I can easily do the activity.
• HARD – I can do the activity with difficulty or with help.
• NOT AT ALL – I cannot do the activity even with help.
Writing English (For example,
notes and letters)
Form AA-1d (02-14) Page 6
Explanation - Explain each “HARD” answer.
Activity
Activities
40 Enter any additional information that describes your daily activities during a normal day (i.e., a typical day from the time
you get up until you go to bed).
41 Enter an “X” in the appropriate box:
Have you worked for pay for a railroad or nonrailroad employer in
the last 12 months? (Do not include any self-employment.)
Yes
Work for
an
Employer
Last 12
Months
Information About Your Work And Earnings
Go to Item 42
No
Section 7
Activities
(cont)
Go to Item 44
42 Enter your earnings before any deductions for each month you have already worked this year. Then starting with the
current month, enter your expected gross earnings for this month and each remaining month this year.
January
February
March
April
May
June
July
August
September
October
November
December
43 Enter your earnings before any deductions for each month last year.
April
May
June
July
August
September
October
November
December
Yes
Go to Item 45
No
Go to Section 8
46 Enter the date(s) you expect to work.
(For example: “June and July”;
Indefinitely starting 11-89; etc.)
45 Enter the name and address of the person or
company for whom you expect to work.
(If self-employed, enter “Self.”)
44 Enter an “X” in the appropriate box:
Do you expect to work during the next 12 months?
(Include self-employment, if any.)
March
February
47 Enter the gross amount you expect to earn.
(If you are self-employed, enter the
net amount.)
Work
Next 12
Months
January
Form AA-1d (02-14) Page 7
No
Have you been self-employed in the last 12 months?
Go to Item 54
Yes
Self49 Enter an “X” in the appropriate box:
Employment
Go to Note and Item 50
No
48 Enter an “X” in the appropriate box:
Are you filing Form AA-1 at this time?
Filing
AA-1
General Information
Section 8
Go to Item 50
Yes
Go to Item 49
Yes
No
expect to receive, worker’s compensation payments?
Go to Note and Item 51
Worker’s
50 Enter an “X” in the appropriate box:
Compensation
Since the date in Item 7, have you received, or
NOTE: If answered “Yes,” also complete and return to the RRB Form AA-4, Self Employment Questionnaire.
Go to Item 51
Yes
51 Enter an “X” in the appropriate box:
Since the date in Item 7, have you received, or do you expect to
receive, disability benefits under a Federal, state, or local government plan or law based on employment not covered under the
Social Security Act? (Answer “No” if your benefits are railroad
retirement, social security, Veterans Affairs or welfare benefits.)
Go to Note and Item 52
No
Public
Disability
Benefits
NOTE: Proof of the amount(s) and effective date(s) of your worker’s compensation is required.
Go to Item 52
60 Enter an “X” in the appropriate box:
Has the confinement ended?
61 Enter the date confinement ended.
Form AA-1d (02-14) Page 8
Yes
Go to Item 55
No
Go to Section 9
Day
Year
Month
Day
Year
Month
Day
Year
Month
Yes
No
Yes
Yes
59 Enter an “X” in the appropriate box:
Is your disability related to your confinement?
Go to Item 61
No
58 Enter the date that confinement began.
Go to Item 54
57 Enter the date of the sentence of confinement.
No
56 Enter an “X” in the appropriate box:
Is your disability related to the commission of the criminal offense?
Go to Item 53
55 Enter the date of the conviction.
Yes
54 Enter an “X” in the appropriate box:
Within the past 12 months, have you been imprisoned or
given a sentence of confinement due to a conviction for a
criminal offense?
53 Enter the social security claim number under which you
have filed or will file.
Criminal
Offense
52 Enter an “X” in the appropriate box:
Have you filed, or expect to file, for monthly
social security disability benefits or SSI?
Go to Section 11
No
Month
Social
Security
Benefits
NOTE: Proof of the amount(s) and effective date(s) of your public disability is required.
Day
Year
Section 9
Remarks
Remarks
62 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 space to enter any additional information
that you feel may be important to include.
Form AA-1d (02-14) Page 9
Relinquishment Of Rights By Disability Annuity Applicant Only
Section 10
I authorize the RRB to relinquish any rights I may have to return to work for a railroad employer, which will affect the
payment of my own or my spouse’s annuity. Based on this authorization, my rights will be relinquished when I reach full
retirement age (FRA) or at age 60-FRA if I become entitled to a supplemental annuity or if my spouse becomes entitled
to a spouse’s annuity. I understand this authorization remains in effect unless my disability annuity terminates before FRA
or before a supplemental or spouse’s annuity becomes payable. My rights will also be relinquished if I am eligible for a
reduced age and service annuity and choose to receive this type of annuity if my disability is denied.
Yes
Will you have a guardian or other representative sign this
application on your behalf?
Go to Note and Item 64
No
Certification
Section 11
Certification 63 Enter an “X” in the appropriate box:
Go to Item 64
NOTE: If answered “Yes,” the guardian or other representative of the applicant must sign this application.
That person must also complete and return Form AA-5, Application for Substitution Of Payee.
64 I know that if I make a false or fraudulent statement in order to receive benefits from the RRB or if I fail to disclose
earnings or report employment of any kind to the RRB, I am committing a crime which is punishable under Federal law.
I have received 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 certify that the information I gave to the RRB on this application is true to the best of my knowledge.
I agree to immediately notify the RRB:
• If I work for any employer, railroad or nonrailroad, or perform any self-employment work;
• If my condition improves;
• If I am confined in a jail, prison, penal institution, or correctional facility due to a conviction for a criminal offense;
• If I begin to receive worker’s compensation payments (or any other public benefit based on disability),
or if the amount of my payment changes;
• If my address changes.
Date
Month
Day
Year
Signature
(First Name, Middle Initial,
Last Name)
I know that if I am receiving a disability annuity and fail to report work and earnings promptly, I am committing a crime
punishable by Federal law that may result in criminal prosecution and/or penalty deductions in my annuity payments.
65 If this certification is signed by mark (“X”) in Item 64, 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 (include area code)
(
)
(
)
b. Signature of Witness
Address (Number and Street)
City, State, and ZIP Code
Daytime Telephone Number (include area code)
Form AA-1d (02-14) Page 10
Section 12
How To Return Your Application
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 application.
You have included all the needed proofs listed in the letter you received with this application.
Before you return your application, check to make sure that:
When you received your application, 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 on page
12. No matter which envelope you use, you must put the correct postage on the envelope. Be careful to provide
enough postage, because your application and the accompanying forms may weigh more than a standard letter.
The U.S. Postal Service will not deliver your application unless it has the correct postage.
NEEDED PROOFS
THE APPLICATION FORM ITSELF
Make one final check before you seal the envelope to ensure that the following are enclosed:
ADDITIONAL FORMS YOU WERE ASKED TO COMPLETE
Note: Make no entries on page 12, which is the receipt for your claim. After the RRB receives your
application, they will complete the blanks on the receipt and send it back to you. When it is returned
to you, you will know that the RRB has received your application and has started the work needed to
determine if you are entitled to benefits. If you do not receive the receipt within a month after you filed
this application, please contact us so we can find out what is causing the delay.
Form AA-1d (02-14) Page 11
Receipt For Your Claim
Employee Applicant’s Name
Date Claim Received
Your application for railroad retirement disability benefits has been received and will be processed as quickly
as possible. If you change your address or if there is some other change that may affect your claim, you or
your representative should report the change. The changes to be reported are listed below. Always give us
your claim number when writing or calling about your claim. If you have any questions about your claim, we
will be glad to help you.
If you need to personally visit one of our field offices, please call for an appointment. You will not be refused
service if you do not have an appointment, but our staff can serve you better when an appointment is made.
Most offices are open to the public from 9:00 AM to 3:30 PM, Monday through Friday.
Always Report These Changes to the RRB
• WORK – If you work for any employer, railroad or nonrailroad, or perform any self-employment work.
• CONDITION – If your condition improves.
• WORKER’S COMPENSATION (or any other benefit based on disability) –
If you begin to receive worker’s compensation payments (or any other public benefit based on disability),
or if the amount of your payment changes.
• CRIMINAL OFFENSE – If you are confined in a jail, penal institution, or correctional facility due to a conviction
for a criminal offense.
• ADDRESS – If your address changes.
How To Report Changes
When a change occurs after you are entitled to disability benefits, you should report the change at once. You can make your
reports by telephone, mail, or in person, whichever you prefer.
To report any of the above changes, contact:
Telephone Number:
(9:00 AM – 3:30 PM)
If for some reason you cannot contact that office, you should contact:
US RAILROAD RETIREMENT BOARD
844 N RUSH STREET
CHICAGO IL 60611-2092
Form AA-1d (02-14) Page 12
Important Notices
PAPERWORK REDUCTION ACT AND PRIVACY ACT NOTICES
This notice is given under the Paperwork Reduction Act of 1995 and the Privacy Act of 1974. The Privacy Act requires that the
Railroad Retirement Board (RRB) tell you the following whenever we ask you for information.
1)
2)
3)
4)
The law which allows us to ask for the information;
whether that law requires you to give us that information and what, if anything, might happen to you if you do not give it to us;
the reason why the information is requested; and
the persons, organizations, and agencies to which we may release the information without your permission.
The RRB’s authority for requesting this information is Section 7(b) of the Railroad Retirement Act (RRA) of 1974. Providing us
with this information is voluntary on your part. However, if you fail to provide us with the requested information we may be unable
to pay you any benefits. The RRB needs this information to determine whether or not you are eligible to receive such benefits
and, if so, the amount you are entitled to receive. If your annuity application is approved and we begin to pay you benefits,
information that we may request from you in the future will be used to determine whether you are entitled to continue to receive
such benefits.
Although the information we request is almost never used for any purpose other than the payment of benefits under the RRA,
the RRB does have the authority to release the following information to the indicated individuals, organizations, and/or agencies
without your approval:
1)
2)
3)
4)
5)
6)
7)
8)
9)
10)
11)
12)
13)
14)
15)
Information may be released to an attorney, the Office of the President, a Congressional office, a labor union or the
Department of State’s embassy or consular offices if they allege to be representing you at your request.
Information may be released to other people who are receiving benefits based on the same railroad retirement account
as you are, if the information affects their payments from the RRB.
Information may be released to a person who will receive benefits on your behalf if the RRB decided that some medical
condition keeps you from receiving your own benefits; such information may also be released in determining whether
such a medical condition exists and who is suitable to receive such benefits for you.
Information (including medical records) may be released to people or organizations who are working for the RRB.
Information may be released to the U.S. Treasury Department or Postal Service to issue payments and to investigate
lost, forged, or stolen payments.
Information may be released to your last employer to make sure that you are eligible to receive railroad retirement benefits
and you continue to receive any available medical benefits, and to any railroad employer (or to its insurance company) to make
sure that you can receive any private retirement or insurance benefits which may be offered by the employer.
Information may be released to the Social Security Administration, Centers for Medicare & Medicaid Services, Pension
Benefit Guarantee Corporation, Office of Personnel Management, Department of Veterans Affairs, or Federal, State, or local
welfare or public aid agencies to determine if you can receive benefits from their organizations and if any previous benefits
were paid incorrectly.
Information may be released to the Internal Revenue Service or to State and local taxing authorities for figuring your
taxes and for use in audits.
Your last address and the name of your last employer may be released to the Department of Health and Human Services to
be used in the Parent Locator Service.
Information may be released to the Government Accountability Office for audits and for collecting overpayments owed to the
RRB or Social Security Administration.
Information may be released to the U.S. Department of Labor as required by the Federal Coal Mine and Safety Act.
Information may be released in certain cases for law enforcement purposes and for court proceedings.
Information about the determination and recovery of an overpayment made to you may be released to any other person
from whom any portion of the overpayment is being recovered.
Your name and address may be released to a Member of Congress to inform you about current or proposed legislation
which could affect the railroad retirement system.
Information may be released to Professional Standard Review Organizations and State Licensing Boards when services
provided by physicians or practitioners suggest unethical or unprofessional conduct.
We estimate this form takes an average of 35 to 60 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 reducing
completion time, to Chief of Information Resources Management, Railroad Retirement Board, 844 North Rush Street, Chicago,
Illinois 60611-2092.
Computer Matching And Privacy Protection Act Notice
The Computer Matching and Privacy Protection Act of 1988 requires the RRB to advise you that information you have provided
may be used, without your consent, in automated matching programs. These matching programs are a computer comparison
of RRB records with records kept by other Federal, State, or local governmental agencies. Information from these matching
programs can be used to establish or verify a person’s eligibility for federally funded or administered benefit programs and for
repayment of payments or delinquent debts under these programs.
Form AA-1d (02-14) Page 13
| File Type | application/pdf |
| File Title | AA-1d 2-14.indd |
| Author | kingsla |
| File Modified | 2016-02-12 |
| File Created | 2014-04-01 |