G-260 Report of Seizure Disorder

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0038

CURRENT

Report of Seizure Disorder
Section 1

Information for the Medical Examiner

An application for Railroad Retirement Act benefits based on disability for work has been filed. Information about the
applicant’s medical condition is essential to evaluate benefit eligibility. If you need more space than is provided to
answer a question, use Item 21 for this purpose.
Since applicants are responsible for presenting medical evidence on their own behalf from their personal physicians,
any fee that may result from completion of this report is a personal matter between the applicant and you (unless we
specifically contract for an examination).
Please complete and return this report promptly to the address shown in Item 26. Your report may be made on this form
or by a narrative on your own stationery. It is important that your narrative furnish all of the information, relevant to the
applicant’s condition, requested on this form.

Section 2

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

DAY

YEAR

0 2 1 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 no skip any
items unless directed to do so. Please read “Important Notices” on the last page of this report.

Section 3

Identifying Information

1

Railroad Retirement Claim Number

2

Social Security Number

3

Applicant’s Name

4

a

Street Address

b

City and State

c

Zip Code

d

County

5

Daytime Telephone Number

Section 4
6

Introduction

Enter a detailed description of the seizures (include character, generalized or focal; aura, if any; loss of consciousness;
bowel or bladder incontinence).

Form G-260 (08-15) DESTROY PRIOR EDITIONS

Section 5
7

Types of Seizure

a

Check the appropriate description.

 Grand Mal
 Petit Mal
 Jacksonian
 Psychomotor

b

Check the appropriate description.

 Nocturnal
 Diurnal

Section 6

History of Seizures

8

Enter the date of the first seizure.

MONTH

DAY

YEAR

9

Enter the date of the last seizure.

MONTH

DAY

YEAR

10 a Enter the approximate dates of seizures
in the past year.

b Explain how this is known.

 YES
 NO



Go to Item d
Go to Item 11

 YES
 NO



c Enter an “X” in the appropriate box:
Does verification of seizures exist from
persons other than applicant?

Go to Item b
Go to Item 12

d Describe the verification and identify the source.

Section 7

Precipitating Factors

11 a Enter an “X” in the appropriate box:
Are there any precipitating factors?
b Describe the precipitating factors.

Form G-260 (08-15)

Page 2

Section 8

Duration of Seizures

12 Describe the duration of the seizures.

Section 9

Enter an “X” in the appropriate box:
Has any treatment been given for
this condition?

 YES
 NO

b

Describe the type of treatment given.

c

Describe the applicant’s compliance to such treatment.

d

Describe the applicant’s response to such treatment.

e

Describe the applicant’s blood drug level.

Section 10

b

Go to Item b
Go to Item 14

Mental Functions

Enter an “X” in the appropriate box:
Has there been any mental deterioration?

 YES
 NO



14 a



13 a

Treatment

Go to Item b
Go to Item 15

Describe the deterioration.

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Form G-260 (08-15)

Enter an “X” in the appropriate box:
Is there evidence of any psychosis?

 YES
 NO



15 a

Go to Item b
Go to Item 16

b Describe the psychosis.

16 Describe behavior manifestations (postictal) and duration.

Section 11

Neurological Findings

17 Describe the neurological findings.

Section 12

Electroencephalographic Findings

18 Describe the EEG findings, and attach a copy of the EEG (or identify the source from which it may be obtained).

Form G-260 (08-15)

Page 4

Section 13

Miscellaneous

19 Enter an “X” in the appropriate box:
This report is:
a. Compiled entirely from records
b. Based on a new examination

YES


MONTH

20 Enter the date of the most recent examination.

Section 14

DAY

YEAR

Remarks

21 Use this space for further details of history or additional description of condition.

Section 15

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 or 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.
Date

22 Medical Examiner’s Signature

23 Medical Examiner’s Printed Name and Title
National Provider Identifier

24 Medical Examiner’s Address and Daytime Telephone Number

Area Code

Telephone Number

Please return this form, your narrative report, copies of your office records and the claimant’s RRB claim
number to:

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Form G-260 (08-15)

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 25 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 aspects of
this form, including suggestions for reducing completion time, to Chief of
Information 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 (P.L. 100-503)
requires the Railroad Retirement Board 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 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 G-260 (08-15)

Page 6