G-254 (Proposed) Continuing Disability Report

PROPOSED

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0187

Continuing Disability Report
Paperwork Reduction Act and Privacy Act Notices
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 Associate Chief Information Officer of Policy and Compliance, Railroad Retirement Board,
844 North Rush Street, Chicago, Illinois 60611-1275.

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 report 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.
Work and earnings (regardless of amount) can affect the payment of your annuity and must be reported immediately to
the RRB.
Month

Day

Year
TO PRESENT

THE PERIOD COVERED IN THIS REPORT IS

Section 2

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.

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

Work for
Employer

Information about Work for an Employer

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

 Yes
 No

 

Section 3



Identifying
Information

Go to Item 7
Go to Section 4

Form G-254 (XX-XX) 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.)
(7) Days Worked Per Week

(6) Monthly Rate of Pay
$
(8) Hours Worked Per Day
Day

Year

(10b) Date Work
Ended

Month

Day

Year



Month



(10a) Date Work
Began

(9) Hourly Rate of Pay
$

(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 (XX-XX)

(10b) Date Work
Ended


Month



(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

$
Day

Year

(10b) Date Work
Ended

Month

Day

Year



Month



(10a) Date Work
Began

(11) If work has ended, explain why.

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

8 List any months and their corresponding years (in month/year format), during the period XX-XX-XXXX

9 a Have your earnings included any other payment,
such as tips, bonuses, child care, sick or vacation
pay, free meals, room or transportation?



Special
Earnings

 Yes
 No

 

to present, that you worked and earned money.

Go to Item 9b
Go to Item 10

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

11

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

Special
Employment

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

 Yes
 No

 

Continue
or Return
to Work

 Yes
 No
Go to Item 14

 Yes
 No

 

Did you work 3 months or less and then stop work
because of your disabling condition?



10



3 Months
or Less
Work



and employer’s name.

Go to Item 12b

Go to Item 12

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

Different
Job
Duties

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

 Yes
 No

 

12 b Explain how and why you were hired.



Special
Employment
(Continued)

Go to Item 13b
Go to Item 14

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

 2. Different pay scales
 5. Lower production

 3. Fewer or easier duties
 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 one 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, prostheses,
or similar items or services.)

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

Form G-254 (XX-XX)

Page 4

 Yes
 No

 

14 a Do you have any impairment-related expenses


Impairment–
Related
Expenses

Go to Item 14b
Go to Section 4

Section 4



 Yes - Go to Item 15b
 No - Go to Section 5



 Yes
 No



 Farm
 Non-Farm



co-owner during the period XX-XX-XXXX 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.).








15 a Are you or were you self-employed as a partner, owner,

 Yes - Go to Item 15g(2)
 No - Go to Item 15h

b Enter the name and address of the business.

c Did you work 40 or more hours a month?
d Check the box that describes the nature of the
business.

e Enter the primary product or service.

terms of arrangement and/or ownership. If “Other,”
describe.

g (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.

 Corporation
 LLC
 Partnership

Sole Owner
Farm Tenant
Farm Landlord
Other



f Check the box that describes the business in

h Enter, below, the requested information about your monthly self-employment income for each month
during the period XX-XX-XXXX 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

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

Net Income

k Was this business your sole livelihood before the
period XX-XX-XXXX to present?
Page 5



 Yes
work for any corporation at anytime (including a corporation owned by a
 No
family member or friend) whether for pay or not, since XX-XX-XXXX?
j 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?



Self–
Employment

Information about Self-Employment

 Yes
 No
Form G-254 (XX-XX)

Self–
Employment
(Continued)

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

Assistants

16 a Because of your disabling condition, do you need



Go to Item 16b
Go to Item 17

b Enter the number of assistants you have.

c Check the box that describes when you receive assistance.





additional help to perform your usual duties?

 Yes
 No

 

business because of your disabling condition, such as a reduced or restricted number of clients,
customers or business hours, lower volume, fewer acres under cultivation, etc.

 By the day
 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.

Form G-254 (XX-XX)

Page 6

 Yes
 No

 

16 f Does your assistant(s) get paid?



Assistants
(Continued)

Go to Item 16g
Go to Item 16h



 Yes
 No

 

Go to Item 16i

 Yes
 No

 

h Is your assistant(s) related to you?



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

Go to Item 17b

Go to Item 16j

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 or
supervised other employees during the period
XX-XX-XXXX to present?

Go to Item 18

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

Page 7

Form G-254 (XX-XX)

 
 

 Yes
 No

 

additional special services been supplied?

Go to Item 20

Go to Item 21

 Yes
 No

 

20 Do you still receive this special assistance or have

 Yes
 No

Go to Item 23

 

or other source in setting up your business?



19 Did you receive any special assistance from an agency

Go to Item 19



condition began?

 Yes
 No



18 Did you start your business after your disabling



Business
Began

Go to Item 25b

Go to Section 5

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.

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,
prostheses, or similar items or services.)



Impairment
Related–
Expenses

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

Form G-254 (XX-XX)

Page 8

 Yes
 No

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 XX-XX-XXXX to

condition during the period XX-XX-XXXX to present?

 

d Have you received any treatment or care for your

 Yes
 No

Go to Item 26d

 Yes
 No

 

working now?



c Does your condition prevent you from



present. If none, enter “None.”

Go to Item 27

Go to Item 26e

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 (XX-XX)

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.

28 a Are you taking medication or receiving



Medication

treatment now?

 Yes
 No

 

(6) Describe the treatment.

Go to Item 28b
Go to Item 29

b Enter the medication or treatment below. Note: If you are taking prescription medication, furnish

 Yes
 No

 

Go to Item 29b

 Yes
 No

 

29 a Has your doctor restricted your activities?



Restriction
of
Activities



the name or type of medication and dosage from the label. (For example, Penicillin, 1.5 gram
tablet, 3 times a day.)

Go to Item 29d

Go to Item 30

b Describe the restriction(s).

c Is the name of the doctor who restricted your activities
different from the name of the doctor(s) shown in Item
27a or Item 27b?

Go to Item 30

d Enter the name, address, and telephone number of the doctor who restricted your activities.


Form G-254 (XX-XX)

(

)
Page 10

to return to work?

 Yes
 No

 

30 a Has your doctor told you that you are able



Return
to Work

Go to Item 30b
Go to Item 31

Month

b Enter the date your doctor said you could

Day

Year

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

 

return to work.


31 a

)

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.
• DIFFICULT - I can do the activity with difficulty.
• HARD - I can only do the activity with assistance.
• NOT AT ALL - I cannot do the activity even with assistance.
• N.A. - Not applicable.
Easy Difficult Hard

Not
At All

N.A.

Explain each “DIFFICULT,” “HARD,”
and “NOT AT ALL” answer











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 (For example,
newspapers and magazines)











Writing (For example,
notes and letters)











Page 11

























Sitting



Activity



Activities

(



 Yes
Go to Item 30d
able to return to work different from the name of the
 No
Go to Item 31
doctor(s) shown in Item 27a, Item 27b, or Item 29d?
d Enter the name, address, and telephone number of the doctor who told you that you are able to return to work.

Form G-254 (XX-XX)

31 b Enter any additional information that describes your daily activities during a normal day, including any



c Do you use any assistive equipment or device,
for example, cane, oxygen, wheelchair, etc.?

 Yes
 No

 

hobbies you may have (i.e., a typical day from the time you get up until you go to bed).

Go to Item 31d

 

Activities
(Continued)

Go to Item 32b

Go to Item 32

d List the equipment or device(s) and when used.

32 a During the period XX-XX-XXXX to present, have you
received services, such as training, counseling, placement,
medical examination, treatment, etc., from other agencies,
such as VA, Worker’s Compensation, Welfare, etc.?



Rehabilitation
Agency

 Yes
 No

Go to Item 33

b Enter the Name, Address, and Telephone Number of your vocational rehabilitation counselor/agency
(include area code).



(

)

c Enter the date(s) you received services.

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

 Yes
 No

 

Education



d Describe the services you received.

Go to Item 33b
Go to Section 7

b Enter the Name, Address, and Telephone Number of the school (include area code).


Form G-254 (XX-XX)

(

)
Page 12

Education
(Continued)

33 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

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)
Page 13

Form G-254 (XX-XX)

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

 Yes
 No



Authorization 35
and
Certification

Authorization and Certification
 

Section 7

Read Note then go to Item 36
Go to Item 36

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

36 By signing this certification, I confirm that the above is true to the best of my knowledge. I understand
that civil and criminal penalties may be imposed on me for: (1) Providing false or fraudulent statements;
(2) withholding information or misrepresenting a fact or facts material to determining a right to benefits
under the Railroad Retirement Act; and/or (3) failing to promptly report work earnings to the Railroad
Retirement Board.

Date

Month



Signature



I have received and reviewed the booklet, RB-1D.1, How Work and Earnings Can Affect Employees
Initially Awarded Disability. I understand that I am responsible for reporting any events that would
affect my annuity as explained in this booklet.

Day

Year

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/Province, and ZIP Code
Telephone Number

Area Code

Telephone Number



Area Code

Daytime Telephone Number
b. Signature of Witness
Address (Number and Street)



City, State/Province, and ZIP Code

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

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” 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 60611-1275



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:

Page 15

Form G-254 (XX-XX)