G-251A (Proposed) Railroad Job Information

United States of America
Railroad Retirement Board

Form Approved
OMB No. 3220-0193

PROPOSED
Employee Name
Last 4 Digits of Social Security Number

XXX-XX-####

RAILROAD JOB
INFORMATION

Regular Railroad Job Position or Occupation
Location
Date Sent

Section 1

Date Last Worked

Completion Instructions

The above named railroad employee has applied for an occupational disability benefit under Section 2(a)(1)(iv) of the
Railroad Retirement Act (45 U.S.C. § 231a(a)(1)(iv)). In order to receive an occupational disability benefit, an eligible
employee must be found to be disabled from work in his or her regular railroad occupation because of a permanent physical
or mental impairment. Railroad Retirement Board (RRB) regulations provide that the Board shall consider the employer’s
description of the physical requirements and environmental factors relating to the employee’s regular railroad occupation.
See 20 CFR 220.13(b)(2)(iv)(E). To assist the RRB with making an accurate disability determination, it is imperative that you
read the instructions below and timely complete and return this form to the RRB within 30 days of the Date Sent, as shown
above.
 Check the information entered above by the RRB for accuracy. If the information is not correct, cross it out and enter the
correct information above it.
 Complete all of the items below describing the applicant’s job. The regular railroad occupation is: 1) the occupation in
which the employee has been engaged for more calendar months than any other occupation during the last preceding 5
calendar years, whether consecutive or not; or 2) the occupation which the employee has been in service for not less than
one-half of all months in which the employee has been engaged in service during the last 15 consecutive calendar years;
or 3) if an employee last worked as an officer or employee of a railway labor organization and if that employment is no
longer available, the regular occupation shall be the position to which the employee holds seniority rights or the position
left to work for the railway labor organization. If more space is needed for any item, use Section 9, Remarks, or attach a
separate sheet of paper showing the employee’s name and the last four digits of their social security number. Be sure to
indicate the item number at the beginning of the answer you wish to continue.
 Provide any additional information on the duties the employee performed within the last 5 or 15 years if appropriate.

Section 2



Disqualification Information

Check here if the applicant has been medically disqualified for work by your railroad. If medically disqualified, send all
applicable documentation to the Railroad Retirement Board, along with Form G-3EMP, Report of Medical Condition by
Employer. (Do not check the box if a medical disqualification is in progress, but not yet finalized; check only if the
disqualification has been made.)
If the box is checked, do not complete Sections 3-9 below, and go to Section 10.

Section 3

Summary of Duties

Describe the essential duties of the position or occupation named above. In that description include technical
knowledge or skills involved; any handwritten or typed reports to be completed; any manipulative (manual dexterity)
skills used; any driving and/or operating of machinery; and any supervisory responsibilities.

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Section 4

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FORM APPROVED OMB NO. 3220-0193

Machinery, Tools, Equipment

List machinery, tools, and equipment used.

Section 5

Environmental Conditions

Describe the environmental conditions of the position named above (i.e., working outdoors, indoors, or both; uneven
terrain; heights; temperature/humidity extremes; etc.).

Section 6

Job Accommodations

Describe any permanent accommodation(s) given (e.g., Job Duties, Work Schedule, Overtime Schedule, Attendance
Schedule, etc.) and the start and end dates for each accommodation. If there is not an end date for the
accommodation, enter “N/A.” If no permanent accommodations were given check “None” and go to Section 7.
 None
From
To
Yes
No
Month
Year
Month
Year













Job Duties



Work Schedule



Overtime Schedule



Attendance Schedule



Other



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Section 7

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FORM APPROVED OMB NO. 3220-0193

Sensory Requirements

Complete the sensory requirements for the position named above. If no requirements are applicable check “Not
Applicable” and go to Section 8.   Not Applicable
A) Vision – Describe visual requirements, such as visual perception with or without eyeglasses or contact lenses;
near or far acuity; color vision; field of vision; depth perception, etc. If there are no visual requirements check
“None” and go to Item 7B.   None

B)

Hearing – Describe auditory requirements, such as hearing with or without a hearing aid; hearing verbal
communication from others; hearing alarms, signals; etc. If there are no auditory requirements, check “None” and
go to Item 7C.   None

C)

Speech – Describe verbal requirements, such as speaking verbal commands loudly, accurately, and quickly;
using phone or two-way radio; speaking public announcements, etc. If there are no verbal requirements, check
“None” and go to Section 8.   None

Section 8

Physical Actions

A) Check the number of hours a day spent:
1. Standing/walking
2. Sitting

0 1 2 3  4  5  6 7  8
0 1 2 3  4  5  6 7  8

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FORM APPROVED OMB NO. 3220-0193

Constantly

Frequently
(1/3 to 2/3)

2

Occasionally
(Up to 1/3)

Descriptive Comments

1

Action

Never

B) Indicate in the chart below, the amount of time and a description of the physical action or activity involved during a
typical 8-hour workday. Use the “Descriptive Comments” column to notate “N/A” if an action listed below
does not apply, or if you want to provide specific details on the amount of time an action is performed. If
more space is needed for any item, use Section 9, Remarks.
Amount of Time

1. Balancing (With or without
equipment in all weather conditions
and on any surface, including
uneven terrain)

   

2. Bending

   

3. Twisting/Turning

   

4. Crouching/Squatting/Stooping

   

5. Kneeling

   

6. Reaching above shoulder level

   

7. Climbing (Indicate what is climbed
such as stairs, ladder, etc.)

   

8. Pushing/Pulling (Indicate what and
how the employee pushed or pulled)

   

9. Crawling under equipment to view,
inspect, or repair

   

10. Gripping/Holding

   

11. Foot Control (Shifting of feet when
using pedals, brakes, clutch, etc.)

   

12. Fine manipulation (Fingering;
keypunch; keyboard; pressing
buttons; picking/pinching/turning
knobs; etc.)

   

13. a. Lifting/Lowering/Carrying
(Indicate the objects the
employee lifted/lowered/carried)

   

b. Check the weight of the objects
the employee lifted/lowered/
carried.
1

2

Heaviest Weight Lifted
10 lbs 20 lbs 50 lbs 100 lbs
Weight Most Often Lifted/Carried
Up to 10 lbs Up to 25 lbs Up to 50 lbs

Over 100 lbs
Over 50 lbs

Occasionally means occurring from very little up to one-third (approx. 2-1/2 hours) of an 8-hour workday; cumulative, not
continuous.
Frequently means occurring one-third (approx. 2-1/2 hours) to two-thirds (approx. 5 hours) of an 8-hour workday; cumulative, not
continuous.

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Section 9

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FORM APPROVED OMB NO. 3220-0193

Remarks

This section is to be used for the continuation of answers to other items. Be sure to include the section and item number at
the beginning of the answer you wish to continue. You may also use this section to enter any additional information that you
feel may be important to include.

Section 10

Employer Certification

I know that it is a federal crime to make a false or fraudulent statement to the Railroad Retirement Board (RRB). I
certify that the information I gave the RRB on this form is true to the best of my knowledge.
NAME:

SIGNATURE:
(Please Print or Type)

TITLE:

DATE:
(Please Print or Type)

TELEPHONE NO (

)_______________________

Call our toll-free number at 1-877-772-5772 with any questions on filling out this form.
Return this completed form to:
U.S. RAILROAD RETIREMENT BOARD
844 NORTH RUSH STREET
CHICAGO, ILLINOIS 60611-1275
ATTENTION: DISABILITY BENEFITS DIVISION
or a facsimile may be sent to (312) 751-7167.

Paperwork Reduction Act Notice
The Railroad Retirement Board is authorized to collect the information on this form under Section 7(b)(6) of the Railroad Retirement
Act. The railroad job information is required to help determine if the employee identified above is eligible for a disability. While you
are not required to respond, the information you provide will be used by the RRB in determining an applicant's eligibility for an
occupational disability under the RRA.
We estimate this form takes an average of 60 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.

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