G-250A (Proposed) Medical Assessment of Residual Functional Capacity

UNITED STATES OF AMERICA

Form Approved
OMB No. 3220-0038

RAILROAD RETIREMENT BOARD
OFFICE/P
NAME
OFFICE OF PROGRAMS
OLICY & SYSTEMS
ADDRESS
RUSH STREET
844 NORTH
CITY, ,STATE,
ZIP
CHICAGO
IL 60611-1275

Proposed

WWW.RRB.GOV

MEDICAL ASSESSMENT OF
RESIDUAL FUNCTIONAL CAPACITY
NAME

RRB CLAIM NUMBER

SOCIAL SECURITY NUMBER

INSTRUCTIONS
Complete this form and submit to us along with your narrative report and office records, as requested on the enclosed
cover letter. Describe below any restrictions in the claimant's ability to perform basic work-related functions within a
regular work setting on a day-to-day basis. Relate any assessed reduction to capacity to particular medical
findings. Do not consider non-medical factors such as age, sex, education, or work experience.
Note: You may include this medical assessment in your narrative report, however, we prefer you use this Form G-250A.
When using this form, use the space to the left of a function or condition to enter "NA" if you find that it is NOT
AFFECTED by the claimant's impairment(s). If you are unable to assess the claimant's ability to perform an activity or
tolerate a condition shown, use the space to show "UNK" indicating UNKNOWN. Otherwise, complete as appropriate,
being sure to explain limitations and relate them to specific findings in the space provided.
Please read page 4 for the authorization for this report and other important notices.
A. Exertional Restrictions - For all claimants with physical impairments.
1. _________ In an 8-hour workday claimant can STAND and/or WALK, with normal breaks, for:
less than 2 hours total

at least 2 hours total

6 hours or more

MEDICAL FINDINGS TO SUPPORT RESTRICTION:

2. _________ In an 8-hour workday claimant can SIT, with normal breaks, for:
less than 6 hours total

6 hours or more

MEDICAL FINDINGS TO SUPPORT RESTRICTION:

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A.

Exertional Restrictions, Continued
3. __________ Claimant can LIFT:

Unlimited

Frequently1

Occasionally2

Never

Less than 10 pounds
10 pounds
20 pounds
50 pounds
100 pounds or more

MEDICAL FINDINGS TO SUPPORT RESTRICTIONS:

4. Claimant is able to:
Unlimited Frequently1
________ Bend/Stoop
________ Crouch/Squat
________ Climb
________ Reach above shoulder level

Occasionally2

Never

MEDICAL FINDINGS TO SUPPORT RESTRICTIONS:

5. Claimant can use BOTH HANDS for repetitive:

YES

NO (Limitation MUST be explained)

________ Simple Grasping
________ Fine Manipulation
________ Pushing/Pulling
6. Claimant can use BOTH FEET for repetitive:
________ Foot Controls
7. Claimant can, without restriction:
________ See
________ Hear
________ Speak

MEDICAL FINDINGS TO SUPPORT RESTRICTIONS:

1
2

FREQUENTLY means occurring one-third to two-thirds of an 8-hour workday; cumulative, not continuous.
OCCASIONALLY means occurring from very little up to one-third of an 8-hour workday; cumulative, not continuous.

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B.

Environmental Restrictions - For all claimants, as applicable.
Claimant is restricted in activities involving:
_______
_______
_______
_______
_______
_______
_______

Mildly3

No

Moderately4

Totally

Unprotected Heights
Driving/Operating Machinery
Being around moving Machinery
Uneven Terrain/Stairs
Exposure to Dust, Fumes, Etc.
Exposure to Noise
Exposure to Vibration

_______ Exposure to Temperature
Extremes/Humidity
Other:

MEDICAL FINDINGS TO SUPPORT RESTRICTIONS:

C.

Mental Restrictions - For all claimants with mental impairments.
Claimant is limited in ability to:
________
________
________
________
________
________
________
________
________

Mildly3

No

Moderately4

Totally

Reason/Use Judgment
Maintain Appropriate Mood
Maintain Personal Habits
Perform Normal Daily Activities
Make Social Adjustments
Relate to Other People
Make Occupational Adjustments
Maintain Normal Work Pace
Maintain Normal Concentration

________ Remember/Understand/Carry Out
Instructions
Other:

MEDICAL FINDINGS TO SUPPORT RESTRICTIONS:

In your opinion, is the claimant able to handle benefit
payments in his/her own best interest
3
4

Yes

No

MILDLY means tolerance/ability to function is limited but satisfactory.
MODERATELY means tolerance/ability to function is seriously limited, but not precluded.

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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.
Signature
Date

Printed Name and Title
National Provider Identifier

Address and Daytime Telephone Number
Area Code

Telephone Number

Please return this form along with copies of your office records to:

RAILROAD RETIREMENT BOARD
OFFICE /P
NAME
OFFICE OF PROGRAMS
OLICY & SYSTEMS
ADDRESS
844 NORTH
RUSH STREET
CHICAGO
IL 60611-1275
CITY,,STATE,
ZIP

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 for the claimant named and to determine the claimant's entitlement to disability benefits
under the Railroad Retirement Act.
We estimate this form takes an average of 30 minutes per response to complete, including time for reviewing
the instructions, searching existing data sources, gathering and maintaining the data needed, and completing
and reviewing the collection of information. 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 N. Rush Street, Chicago, IL 60611-1275.
Associate Chief Information Officer for Policy and Compliance

COMPUTER MATCHING AND PRIVACY PROTECTION ACT NOTICES
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 the 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.

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