UI-38S (Proposed) School Attendance and Availability Questionnaire

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

PROPOSED

FORM APPROVED
OMB NO. 3220-0164

SCHOOL ATTENDANCE AND AVAILABILITY QUESTIONNAIRE

INSTRUCTIONS
Print all answers in ink as neatly as possible. If you need more space for answers, attach a
separate sheet of paper identified with your name and social security number. If you do not
know the answer to a question, print “UNKNOWN” in the answer space. If you do not
understand this form or need help to complete it, contact the RRB office shown below.
Complete Items 1 through 12 of this form unless the instructions tell you to “Go to” another item.
Do not skip items unless instructed to skip. Stop after completing Item 13.
If this form was mailed to you, return it using the enclosed preaddressed envelope. If you do not
have the envelope, mail the form with sufficient postage to the following office of the U.S.
Railroad Retirement Board:

Paperwork Reduction Act and Privacy Act Notices
This notice is given under the Paperwork Reduction Act of 1995 and the Privacy Act of 1974. Under
section 12( l ) of the Railroad Unemployment Insurance Act, the RRB is authorized to collect the
information requested on this form. The information will be used to determine your availability for work,
and your eligibility for benefits. While you are not required to provide us with this information, your
failure to do so may prevent us from paying you additional benefits.
We estimate this form takes an average of 6 to 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 Associate Chief Information Officer for Policy and Compliance, Railroad Retirement Board, 844
North Rush Street, Chicago, IL 60611-1275.

UI-38s (xx-xx)

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

FORM APPROVED
OMB NO.3220-0164

SOCIAL SECURITY NUMBER

SCHOOL ATTENDANCE AND
AVAILABILITY QUESTIONNAIRE

NAME (First, Middle Initial, Last)

SECTION 1 – SCHOOL INFORMATION
1. a. Are you now attending school or are you planning to attend school within the next 6 months?

J Yes - Complete Item 1b

J No - Go to Item 13

b. NAME OF SCHOOL: ___________________________________________________________
LOCATION: ___________________________________________________________________
COURSE OF STUDY: ___________________________________________________________
DATE SCHOOL BEGINS: ________________________________________________________
DATE SCHOOL ENDS: __________________________________________________________
2. What are your present class hours? Enter the time you attend class each day. If there is no scheduled
time that you are required to attend because your course is online, place an "X" on the line under the
column titled "Flexible/Online."
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

FROM
_______
_______
_______
_______
_______
_______

am/pm
am/pm
am/pm
am/pm
am/pm
am/pm

TO
_______
_______
_______
_______
_______
_______

FLEXIBLE/ONLINE
am/pm
am/pm
am/pm
am/pm
am/pm
am/pm

_______
_______
_______
_______
_______
_______

3. How far do you reside from school? _____________ miles

4. Are you willing to quit school at once to accept full-time work with your last railroad employer,
other railroad employer or nonrailroad employer?
J No - Explain below
J Yes
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________

5. a. Has your school attendance prevented you from accepting any full-time job since you began
claiming benefits?
J No
J Yes

UI-38s (xx-xx)

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5. b.

Has your school attendance caused you to refuse a call to work or to miss a call to work?
J No - Go to Item 6a
J Yes

c.

Enter the date(s) on which the event(s) occurred and explain the circumstances in detail.
___________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
___________________________________________________________________________

6. a.

Enter the amount you paid for tuition and books for the present semester or term. $_______________

b.

Enter the date this amount was paid. ______________________________________________

c.

Enter how much of this amount you could recover if you quit school now. $___________________

7. Do you receive any education allowances such as payments under the GI Bill, etc?

J Yes - Specify below.
J No
_______________________________________________________________________________
SECTION 2 – PROSPECTS FOR EMPLOYMENT
8. a.

Enter when you expect to return to work. If unknown, estimate. __________________________
_____________________________________________________________________________

b.

If you expect to return to work within 30 days, enter the name and address of your expected
employer. ____________________________________________________________________
_____________________________________________________________________________

9. List the names and addresses of employers whom you have contacted for full-time work and the
dates of application. Use the back of this form, if necessary.
DATE APPLIED
________________
________________
________________
________________
________________

NAME AND ADDRESS OF EMPLOYER
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________

10. Would you work a regular full-time job for one of the above employers or any other employer offering
suitable work and continue your school attendance while working?
J No
J Yes - Explain below
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Page 3

UI-38s (xx-xx)

SECTION 3 – PREVIOUS EMPLOYMENT/REMARKS
11. Have you previously worked full-time while attending school?

J Yes - Complete Items 11a-f

J No - Go to Item 12

a. Enter the name and address of the employer. _______________________________________
____________________________________________________________________________
b. How many hours per week did you work? __________________________________________
c. What months and years were you so employed? ____________________________________
____________________________________________________________________________
d. How many credit hours did you carry in school at the time? ____________________________
e. How many credit hours do you carry now? __________________________________________
f. What caused the previous work-school situation to end? _______________________________
_____________________________________________________________________________
12. Remarks (Include any other information you wish to add.)

SECTION 4 – CERTIFICATION
13. I CERTIFY THAT THE INFORMATION I HAVE PROVIDED ON THIS FORM IS TRUE AND
COMPLETE. I KNOW THAT I MUST IMMEDIATELY REPORT TO THE RAILROAD RETIREMENT
BOARD ANY CHANGES WHICH MIGHT AFFECT MY ENTITLEMENT TO BENEFITS. I
UNDERSTAND THAT A SUBSTANTIAL PENALTY MAY BE IMPOSED ON ME FOR FALSE OR
FRAUDULENT STATEMENTS OR CLAIMS.

SIGNATURE _____________________________________________ DATE SIGNED _____________

STOP HERE. Item 13 is the last item for you to complete on this form. Take time now to go back over
this form to make sure you answered each item accurately and completely. If you are about to be
interviewed, give this form to the RRB representative who will interview you. If you received this form
by mail, return it in the enclosed preaddressed envelope.

FOR RRB USE ONLY
Interviewed by: _____________________________________
Remarks:

UI-38s (xx-xx)

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