G-3emp (08-15)

United States of America

Form Approved

CURRENT

Railroad Retirement Board

OMB No. 3220-0038

Report of Medical
Condition by Employer
Section 1

Instructions

Print all answers in ink or use a typewriter. When entering dates, always use numbers. Also, be sure there is
one number in each box. For example, you would enter February 13, 2014, as:
MONTH

0

2

DAY

1

YEAR

3

1

4

Based on your answer to a question, you may be told to skip to another item number. Follow the instructions
that tell you to “Go to” another item. These are designed to save you time and help you move through the report
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. Please read “Important Notices” on the second
page of this report.

Section 2

Identifying information

1

Employee’s Social Security Number

2

Employee’s Railroad Retirement Claim Number

3

Name of Employee’s Most Recent Railroad Employer

4

Employee’s Most Recent Railroad Occupation

5
6

Employee’s Name
Employee’s Address

7

Employee’s Daytime Telephone Number

AREA CODE

TELEPHONE NUMBER

Section 3 Ability to Work Information
8 Enter an “X” in the appropriate box;

Yes
No

The employee is presently able to work in his/her last occupation

9
10
11

Provide the beginning date that the employee became able to
work.
Enter an “X” in the appropriate box;
The employee will be able to work in his/her last occupation in the
future.

Yes
No
MONTH

Enter an “X” in the appropriate box;
The employee is presently able to perform some type of work.

13

Provide the beginning date that the employee became able to
work.
Enter an “X” in the appropriate box;
The employee will be able to perform some type of work in the
future.
Provide the date that the employee will be able to perform some
type of work.

15

DAY

DAY

YEAR

Go to Item 11
Go to Item 12
YEAR

Provide the date that the employee will become able to work.

12

14

MONTH

Go to Item 9
Go to Item 10

Yes
No
MONTH

DAY

Yes
No
MONTH

DAY

Go to Item 13
Go to Item 14
YEAR

Go to
Item 16

Go to Item 15
Go to Item 17
YEAR

Go to
Item 16

G-3EMP (08-15)

United States of America
Railroad Retirement

Form Approved
OMB No. 3220-0038

Page 2

,

16

Describe the type of work the employee is able to perform.

Section 4 Restriction/Disqualification Information
17 Enter an “X” in the appropriate box;
The employee has been restricted from work in his/her regular
occupation.

Yes
No

Go to Item 18
Go to Item 19

18

Describe why the employee has been restricted from work in his/her regular occupation.

19

Enter an “X” in the appropriate box;
Yes
Go to Item 20
The employee has been disqualified from his/her regular
No
Go to Item 21
occupation.
Describe in detail the basis for the employee’s disqualification and attach any medical evidence relevant to
the disqualification.

20

Section 5

21
22
23

Certification

With the understanding that section 13 of the Railroad Retirement Act (45 U.S.C. 231I) 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.
Name of Railroad Official
Title
A. Street Address
B. City and State
C. ZIP Code
AREA CODE

24

Daytime Telephone Number

25

Signature

TELEPHONE NUMBER

Date

Important Notices
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 of the named employee’s claim.
We estimate this form takes an average of 10 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 the completion time to: Chief of Information Resources
Management, Railroad Retirement Board, 844 North Rush Street, Chicago, IL 60611-2092.
COMPUTER MATCHING AND PRIVACY PROTECTION ACT NOTICE
The Computer Matching and Privacy Protection Act of 1988 (P.L. 100-503) requires the Railroad Retirement Board (RRB) to advise you
that information you may have provided may be used, without your consent, in automated matching programs. These matching programs
are computer comparisons 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.

G-3EMP (08-15)