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DCM Part_11 DPS Forms Instructions Revised September 22, 2023 Page 1 of 63

11.1 Scope of Chapter

This part of the DCM contains instructions for completing forms used by the 

Disability Benefits Division (DBD). The forms in this chapter are arranged in 

alphabetical-numerical order. Some of the disability forms referred to in this 

DCM chapter have hyperlinks to FOM1 where the actual forms are fully 

explained. This is because some forms are handled by work units other than 

DBD such as Field Service (FS). The explanations for these forms are in FOM1. 

The forms used by DBD are explained in detail in this DCM chapter. 

Generally the instructions for a specific form are broken down into the following 

categories:

• Use: A brief statement of the form's purpose and when it is used.

• Completion: Item by item instructions for normal completion of the form.

• Special Situations: Instructions for completing the form in infrequent or 

complex situations.

• Disposition: Instructions for disposing of the form, any copies of the form, 

and the folder for the form. 

11.1A “AA” Forms

AA-1D Application For Determination of Employee Disability

Use

An employee uses Form AA-1D, Application For Determination of Employee’s

Disability as a supplement to Form AA-1, Application for Employee Annuity when 

applying for a disability annuity under the Railroad Retirement Act, or a period of 

disability (disability freeze or DF) under the Social Security Act, or to establish 

disability for Medicare entitlement. 

Completion

See FOM1 1710 AA-1D for more information on how Form AA-1D should be 

completed.

Adjudication 

Disability Benefits Division (DBD) examiners must consider and compare the 

information provided on the AA-1D to all relevant evidence sources in file when 

making a disability decision. If there are material inconsistencies on the AA-1D 

that may impact the outcome of the decision, the disability examiner must resolve 

the inconsistencies. If explanations are vague or incomplete, the disability 

examiner must develop for more information. 
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The disability examiner should pay particular attention to changes in job duties 

and non-work activities, educational achievement, special training, as well as the 

applicant’s description of how the condition has affected his/her daily activities. 

Changes in job duties include, but are not limited to, hours worked and how the 

job was performed. This consideration also applies to forms as part of the 

adjudication process. See DCM 3.4.301 and 3.4.302 for more information. 

NOTE: If any suspicious patterns or inconsistencies are noted, such as use of 

technical/descriptive terms or copied dialogue, that cannot be resolved while 

examining the disability claim, the disability examiner should notify his/her lead 

examiner or supervisor as soon as possible. See DCM 8.8 for more information. 

Section 1, General Instructions, contains the instructions and information that 

the applicant must read prior to completing the form. 

Section 2, Identifying Information, will prefill from RRAILS. 

Section 3, Information About Your Medical Condition, contains information 

about the applicant’s medical condition. These items are not purely medical in 

nature, but can assist in the determination as to whether a physical or mental 

condition exists that prevents the performance of work. The disability examiners 

should consider the factors relevant to assessing the nature, intensity, 

persistence, and the limiting effects of the individual’s symptoms. In addition, the 

disability examiner should:

• Consider if the primary and secondary conditions are consistent with and 

supported by the medical evidence in file: 

For example: Due to alleged knee pain, an individual alleges extreme 

symptoms that limit his or her ability to stand and walk; however, the 

medical evidence does not contain objective medical evidence of a 

medically determinable knee impairment from an acceptable medical 

source that could reasonably be expected to produce the alleged 

symptoms. 

• Consider dates when the condition began to affect the individual’s ability 

to perform work and whether the medical evidence sufficiently show that 

the disability began before the dates when the individual states they could 

no longer perform work. This may include any work attempts. See DCM 

3.4.9, DCM 3.4.200, and DCM 10.5.3 for more information;

• If a mental impairment, neurological impairment, chronic pain, or chronic 

fatigue is alleged or suspected; check if there is a form G-31 worksheet 

(previously known as an Activities of Daily Living Report (ADL)) completed 

in conjunction with the disability application. If a G-31 is not in file, contact 

the field office to develop one.

Section 4, Information About Your Medical Care, contains information about 

the applicant’s medical care, examinations, treatment, and testing. The disability 
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examiner should check to see that medical evidence was requested from all 

hospitals, clinics, and treating physicians listed in this section. In addition, the 

disability examiner should: 

• Consider if the claimant documented recent or future surgeries as this 

may indicate a persistence and intensity of symptoms. Evidence for 3 

months post-operative may be necessary;

• Review all medical sources listed. Determine if medical evidence has 

been received from the source and is sufficient for a determination. If all 

source medical has not been received and the medical evidence in file is 

not sufficient to make a determination, contact the field office to develop 

the additional medical sources; 

• In Occupational cases where the individual claims disqualification by their 

railroad employer, note if there is a Form G-3EMP, Report of Medical 

Condition by Employers, or similar notice in file. If so, it is sufficient to 

make a rating with the medical evidence in file that confirms the 

impairment. If Form G-3EMP is not in file, contact the field office to 

develop for the form. See DCM 13.7 and DCM 4.10.1 for more 

information;

• Identify any claimed restrictions by a medical doctor; 

• Review the type and dosage of all prescribed medications listed and 

consider their effects on the individual; 

• Consider treatment, other than medication, that the individual receives or 

has received for relief of pain or other symptoms; and 

• Consider any indication of non-compliance and the reasons given for noncompliance. 

Section 5, Information About Your Education And Training, asks the 

applicant to enter the highest grade of school completed, and indicate if they are 

currently attending any technical, specialized, vocational schools to include 

online courses, or receiving any educational services, etc. The applicant’s 

education will be considered with the residual functional capacity, age, and work 

experience at step 5 of the sequential evaluation. See DCM 3.6.1 for more 

information. When considering education and recent vocational training, the 

disability examiner should consider education level, illiteracy, as well as the 

ability to communicate in English. See DCM 5.2 and DCM 5.4 for more 

information. The disability examiner should also consider:

• If the education provides for direct entry into skilled or semiskilled work 

(whether skills can transfer to other work);

NOTE: The shorter the period of education and the lesser the skill of the 

occupation it prepared the claimant for, the shorter time lapse we should 

consider that the education could provide for direct entry into that 
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occupation.

The longer the period of education and the higher the skill of the 

occupation it prepared the claimant for, the longer time lapse we should 

consider that the education could provide for direct entry into that

occupation.

Example: An applicant who completed a registered nurse bachelor’s 

degree program two years ago would be more likely to have an education 

that provided for direct entry than a claimant who completed a six-month 

travel agent training course two years ago. 

• The recency of education and the amount time that has passed between 

the completion of the education and the date of the adjudication; and 

• When direct entry into skilled or semiskilled work is material to the 

disability determination or not. 

NOTE: If any recent education is listed and direct entry into skilled or 

semiskilled work is material to the case, the disability examiner must 

develop and resolve any direct entry issues before making a decision. All 

findings must be documented in the rationale. Remember to cite the 

corresponding specific skilled or semiskilled occupation. 

Rationale documentation example: 58-year-old applicant with a high 

school education completed an 18 month program for medical coding one 

year prior to filing and received a medical record coder certification. The 

RFC permits a full range of light work. The applicant retains the ability to 

perform light work and is denied by medical vocational rule 202.05. The 

applicant retains the ability to perform work as a medical record coder. 

Section 6, Information About Your Daily Activities, asks the applicant about 

his/her daily activities, volunteer work, and social or recreational activities. This 

description from the applicant is an account of their current daily activities and 

how they have changed due to the individual’s medical condition. During 

adjudication, the disability examiner should consider: 

• If changes in the activities indicated are due to the applicant’s medical 

condition; 

• If the activities precipitate or aggravate the symptoms. For example, the 

applicant indicates that the activity cause them to be fatigued or suffer 

constant pain; 

• If limitations in the daily activities are consistent with alleged impairment. 

For example, the applicant alleges an injured rotator cuff, but claims ADL 

limitations in walking; or the applicant lists playing racquet ball or golfing 

as a recreational activity, but alleges ADL limitations in standing or 

walking; and
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• If reduced or structured activities minimize the symptoms. 

Section 7, Information About Your Work And Earnings, asks the applicant for 

information on current work and earnings in addition to the previous year and 

next 12 months. The disability examiner should compare the information given 

with the applicant’s date last work. If earnings are reported after the applicant’s 

date last work, reconcile the earnings by contacting the employee and/or 

employer and reviewing the DEQY, SEQY or The Work Number. The disability 

examiner should also closely review the reported earnings and note: 

• Whether there have been large earnings up until the time of the alleged 

onset date of disability, which may indicate a sudden traumatic injury;

• Cases where chronic impairments lasting over extended periods of time 

exist, but there is no indication that the applicant lost time or earnings 

during this chronic disease period; 

• If self-employment is Substantial Gainful Activity. If so, use the three 

earnings test, NOT just gross/net earnings. See DCM 10.4.5 for more 

information; and

• If an AA-4, Self-Employment Questionnaire and/or G-252, SelfEmployment/Corporate Officer Work and Earnings Monitoring forms are in 

file in cases where self-employment is indicated. If forms are not in file, 

develop with field service, if needed. See DCM 8.5.14 for more 

information. 

Section 8, General Information, asks the applicant about Self-Employment, 

Worker’s Compensation, Public Disability Benefits, Social Security Benefits, and 

Criminal Offenses. Examiners should consider statements made in connection 

with claims for other types of disability, such as private insurance benefits and 

develop for medical evidence from these sources, if needed. 

NOTE: If the applicant is filing an AA-1 at the same time as filing the AA-1D, 

questions about “Self-Employment”, “Worker’s Compensation”, “Public Disability 

Benefits”, and “Social Security Benefits” will be skipped on the AA-1D. The 

disability examiner must review the AA-1 to determine if the applicant reported 

self-employment and verify that an AA-4 is in file. If an AA-4 form is not in file, 

ask the field office to develop for the form. The disability examiner should also 

review the AA-4 to determine if the applicant indicated that they were a 

corporate officer or owner/operator. If the applicant indicated corporate officer or 

owner/operator, verify that a form G-252 is in file. If the G-252 form is not in file, 

develop for the form. See DCM 8.5.14 for more information. 

If the applicant indicates on the AA-1 that they have filed or plans to file an 

application for social security benefits, the disability examiner should check the 

Social Security Administration’s (SSA) queries to determine if the applicant is 

receiving any type of SSA benefits, including SSI, and release Form RR-5, 

Request for SSA Medical Evidence. See DCM 11.4, RR-5 for more information. 
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If the applicant has indicated that they have been imprisoned or given a sentence 

of confinement due to a conviction for a criminal offense, and answered ‘Yes’ that 

their disability is related to confinement, then disability examiner must follow the 

felony conviction provisions in DCM 6.4.5 in considering conditions that were 

worsened or newly acquired during the commission of a criminal offense and/or 

confinement. 

Reminder: In an effort to control, prevent, and deter fraud, disability examiners

must become familiar with the best practices to consider when examining 

disability claims that show particular elements outlined in DCM 8.8.2. Examiners 

must note and attempt to resolve any responses that appear vague, generic, not 

specific, or otherwise suspicious or inconsistent when adjudicating claims. The 

presence of any one element may not necessarily be an indication of fraud but

should serve as a flag to the disability examiner that greater care is needed in 

adjudicating the disability claim. 

Section 9, Remarks, is used for the continuation of answers to other items. 

Disability examiners should review for additional information that may be relevant 

to the disability determination.

Section 10, Relinquishment Of Rights, contains information advising that 

disability applicants are not required to relinquish rights to return to the their 

railroad employer prior to full retirement age.

Section 11, Certification, asks the applicant if an attorney or non-family 

member assisted them in completing the application and whether the applicant 

paid a fee for that assistance. The disability examiner should verify that a 

USTAR work item for Facilitator Physician Tracking (PPT-FPT) has been 

created. If a USTAR work item has not been completed notify the supervisor or 

lead. The disability examiner should consider if additional interview of the 

applicant is needed. See DCM 8.7.2 for more information.

If the applicant indicates that they have or will have a guardian sign the 

application, check to see there is a Form AA-5, Application for Substitution of 

Payee in file. If no form is in file, have the FS develop for the form. See FOM1 

1710 AA-5 for more information. 

NOTE: In cases where the examiner cannot reach or is not getting a response 

from the applicant, please note if the applicant has a guardian/representative 

signing the form for the applicant, before denying a claim for failure to comply.

Section 12, How To Return Your Application, explains how to return the 

application to the RRB field office. 
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Disposition

The disability examiner will use information collected on the AA-1D, along with 

other relevant information in file, to determine how the applicant functions on a 

day-to-day basis and make a disability determination. If the outcome of the 

decision is impacted by material discrepancies found on the AA-1D, an 

explanation as to how the conflicting information was resolved should be 

indicated in D-Brief. See DCM 12.5 for information on D-Brief. The form should 

be imaged. 

Receipt For Your Claim

The Receipt For Your Claim page of the Form AA-1D is detached and given to 

the applicant when the claim is officially filed. The text of the detached portion is 

appropriate only if a completed application has been received. FS will only date 

and release this receipt for an initial disability retirement claim after the 

employee’s Form AA-1 is received.

11.2 "G" Forms

G-3EMP, Report of Medical Condition By Employer

See FOM1 1720, G-EMP. 

G-26F, Disability Coordination Material

Use

Disability examiners use the Form G-26F when transmitting documents to SSA. 

The form should be attached on top of all medical and non-medical documents 

being forwarded to SSA. 

Access

The form can be found on RRAILS.

Completion

Complete as follows:

Item Entry

RR Claim Number Enter the railroad claim number of the applicant

RR Employee's SS No. Enter the RR employee's social security number
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Wage Earner's SS No. Enter the social security number of the person 

whose wage record the applicant is filing under at 

SSA

RR Employee's Name Enter the name of the railroad employee

Wage Earner's Name Enter the name of the person whose wage record 

the applicant is filing under at SSA.

Disabled Person's Name 

and Date of Birth

Enter the name of the disabled applicant and that 

person's date of birth

Remarks Enter any information that is pertinent to this 

transmittal

Disposition

1. Email the G-26F document to SSA. For instructions on scanning and 

sending the form by email to SSA, click here: How to Scan and Email 

Documents. 

2. Send the G-26F document to IMAGING.

G-26t (02-15) - DPS Route Slip

Use

Form G-26t is a white color form and is used by disability examiners to route 

folders in the Disability Post Section (DPS) of DBD. This form is attached to a 

claim folder or folder packet. This is a stocked form and is not in RRAILS. For a 

copy of this form, contact DBD.

Completion

The following will describe when and how the items should be completed:

ITEM ENTRY AND WHEN USED

"Medical Consultant" Enter an "X" in this box if the folder is being 

forwarded to the medical consultant's office. Check 

the "Physical" and/or "Mental" box as appropriate. 

Also, fill in the filing date of the disability application.
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"Single Freeze" Enter an "X" in this box when the folder is being 

referred to the medical consultant and the case 

involves a single freeze disability determination.

"Dual Freeze" Enter an "X" in this box when the folder is being 

referred to the medical consultant and the case 

involves a dual freeze disability determination.

"Widow(er)" Enter an "X" in this box when the folder is being 

referred to the medical consultant and the case 

involves a widow(er) disability determination.

"Child" Enter an "X" in this box when the folder is being 

referred to the medical consultant and the case 

involves a child disability determination.

"Continuance/Cessation" Enter and "X" in this box when the folder is being 

referred to the medical consultant for a continuing 

disability review determination.

"Previously reviewed by 

Dr."

Enter an "X" in this box when the folder is being 

referred to the medical consultant for a 

reconsideration disability determination and the 

case was previously reviewed by a medical 

consultant. Also, enter the name of the doctor who 

previously reviewed the case.

"Additional M/E 

requested by Dr.“

Enter an "X" in this box when the folder is being 

referred to the medical consultant and additional 

medical evidence was obtained per a medical 

consultant. Enter the name of the medical 

consultant who requested the additional medical 

evidence.

"Reconsideration" Enter and "X" in this box when the folder is being 

referred to the medical consultant and the case 

involves a reconsideration disability determination.

“OCC/T&P” Enter an "X" in this box when the folder is being 

referred to the medical consultant and the case 

involves an Occupational or Total and Permanent

(T&P) disability determination.

“Urgent” Enter an "X" in this box when the folder is being 

referred to the medical consultant and the case 
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involves a terminal illness (TERI), compassionate 

allowance (CAL), or other special handling. 

“Reject Dr.” Enter an "X" in this box when the folder is being 

referred back to the medical consultant because the 

examiner disagrees with the medical consultant. 

Enter the name of the medical consultant who 

previously reviewed the case.

"Routing Order" Enter an "X" in this box when the folder is being 

routed to at least one of the destinations shown in 

the column under this heading.

"Review" Enter a number in this box when the folder needs to 

be reviewed for a disability rating determination.

The number should indicate the sequence of the 

routing order.

"Senior Examiner" Enter a number in this box when you are routing the 

folder to a senior examiner. The number should 

indicate the sequence of the routing order. Also, 

enter in the Automated Folder Control System 

(AFCS) location of the senior examiner on the line.

"Claims Examiner" Enter a number in this box when you are routing the 

folder to a disability rating examiner. The number 

should indicate the sequence of the routing order.

Also, enter in the AFCS location of the rating 

examiner on the line.

"Supervisor, DBD" Enter a number in this box when the folder is being 

routed to the disability post and CDR unit 

supervisor. The number should indicate the 

sequence of the routing order. Enter in the AFCS 

location of the supervisor on the line. 

"Copying" Enter a number in this box when routing the folder 

for copying. The number should indicate the 

sequence of the routing order. Use a paperclip or 

rubber band for the material to be copied.

“Medicare Section” Enter a number in this box when the folder is being 

routed to the Medicare section. The number should 

indicate the sequence of the routing order.

"Recon Section" Enter a number in this box when the folder is being 

routed to the Reconsideration (RECON) section. 
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The number should indicate the sequence of the 

routing order.

"Claim Files" Enter a number in this box when you are routing the 

folder to claim files. The number should indicate 

the sequence of the routing order.

"Other" Enter a number in this box when you are routing the 

folder to a location not listed on this form. Enter the 

desired destination and the AFCS code of that 

location on the line. The number should indicate 

the sequence of the routing order.

"Dormant" Enter an "X" in this box when the folder is being 

sent to the dormant cabinets. The call-up date and 

charge to entries must be completed.

"Call-up Date" Enter the date that the folder should be called up 

from dormant. If the folder is returning to dormant, 

cross out the date on the top line and enter the new 

call-up date.

"Charge To" Enter the Automated Folder Control System (AFCS) 

code you want the folder charged to after the 

dormant call-up date expires.

"Remarks" Enter any remarks, instructions, comments, etc. you 

may have regarding this folder.

"Examiner Name Date" Enter you name and the current date.

G-26t.1 (02-15) - DIS Route Slip

Use

Form G-26t.1 is a green color form and is used by disability examiners to route 

folders in the Disability Initial Section (DIS) of DBD. This form is attached to a 

claim folder or folder packet. This is a stocked form and is not in RRAILS. For a 

copy of this form, contact DBD. 

Completion

The following will describe when and how the items should be completed:

ITEM ENTRY AND WHEN USED
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"Medical Consultant" Enter an "X" in this box if the folder is being 

forwarded to the medical consultant's office. Check 

the "Physical" and/or "Mental" box as appropriate. 

Also, fill in the filing date of the disability application.

"OCC" Enter an "X" in this box when the folder is being 

referred to the medical consultant and the case 

involves an Occupational disability determination.

"T&P" Enter an "X" in this box when the folder is being 

referred to the medical consultant and the case 

involves a Total and Permanent (T&P) disability 

determination.

"Widow(er)" Enter an "X" in this box when the folder is being 

referred to the medical consultant and the case 

involves a widow(er) disability determination.

"Child" Enter an "X" in this box when the folder is being 

referred to the medical consultant and the case 

involves a Child disability determination.

"Divorced or Remarried 

Widow"

Enter an "X" in this box when the folder is being 

referred to the medical consultant and the case 

involves a Divorced or Remarried Widow disability 

determination.

"Additional M/E 

requested by Dr."

Enter an "X" in this box when the folder is being 

referred to the medical consultant and additional 

medical evidence was obtained per a medical 

consultant. Enter the name of the medical 

consultant who requested the additional medical 

evidence.

“Urgent” Enter an "X" in this box when the folder is being 

referred to the medical consultant and the case 

involves a terminal illness (TERI), compassionate 

allowance (CAL), or other special handling.

“Reject Dr.” Enter an "X" in this box when the folder is being 

referred back to the medical consultant because the 

examiner disagrees with the medical consultant. 

Enter the name of the medical consultant who 

previously reviewed the case.
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"Routing Order" Enter an "X" in this box when the folder is being 

routed to at least one of the destinations shown in 

the column under this heading.

"Review" Enter a number in this box when the folder needs to 

be reviewed for a disability rating determination. 

The number should indicate the sequence of the 

routing order.

“Senior Examiner” Enter a number in this box when you are routing the 

folder to a senior examiner. The number should 

indicate the sequence of the routing order. Also, 

enter the Automated Folder Control System (AFCS) 

location of the senior examiner on the line.

"Claims Examiner" Enter a number in this box when you are routing the 

folder to a disability rating examiner. The number 

should indicate the sequence of the routing order. 

Also, enter the AFCS location of the rating 

examiner on the line.

“Supervisor, DBD” Enter a number in this box when the folder is being 

routed to the disability initial unit supervisor. The 

number should indicate the sequence of the routing 

order. Enter in the AFCS location of the supervisor 

on the line.

“Physicians Tracking” Enter a number in this box when the folder is being 

routed for physicians tracking. The number should 

indicate the sequence of the routing order. 

“Copying” Enter a number in this box when routing the folder 

for copying. The number should indicate the 

sequence of the routing order. Use a paperclip or 

rubber band for the material to be copied. 

“Medicare Section” Enter a number in this box when the folder is being 

routed to the Medicare section. The number should 

indicate the sequence of the routing order.

“Recon Section” Enter a number in this box when the folder is being 

routed to the Reconsideration (RECON) section. 

The number should indicate the sequence of the 

routing order.
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“Claim Files” Enter a number in this box when you are routing the 

folder to claim files. The number should indicate 

the sequence of the routing order.

“Other” Enter a number in this box when you are routing the 

folder to a location not listed on this form. Enter the 

desired destination and the AFCS code of that 

location on the line. The number should indicate 

the sequence of the routing order.

"Dormant" Enter an "X" in this box when the folder is being 

sent to the dormant cabinets. The call-up date and 

charge to entries must be completed.

"Call-up Date" Enter the date that the folder should be called up 

from dormant. If the folder is returning to dormant, 

cross out the date on the top line and enter the new 

call-up date.

"Charge To" Enter the AFCS code you want the folder charged 

to after the dormant call-up date expires.

"Remarks" Enter any remarks, instructions, comments, etc. you 

may have regarding this folder.

"Examiner Name Date" Enter your name and the current date.

 

G-31, Activities of Daily Living Worksheet. 

See FOM1 1720, G-31

G-137, Medical Consultant Opinion

Use

This form is currently used by Disability and RECON examiners (PEMS Staff) to 

refer disability cases to the medical consultant for an opinion. 

Access

The form is on RRAILS.
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NOTE: In a case where a combined physical and mental RFC is requested, the 

examiner may either open the Form G-137 on RRAILS to type in Physical and 

Mental (alerting the medical consultant that two types of RFC’s are requested), or 

simply write in the words Physical and Mental. This is done in the top right hand 

margin of the Form G-137. If the form is opened on RRAILS it must be closed 

after any typed entry is made to preserve the form identification.

Completion 

RRAILS pre-fills the claimant’s Name, Examiner name, and Claim Number. The 

examiner enters the current date and after the claim number enters the applicable 

two-digit code. The two-digit code uses a series of alpha characters from A to Z to 

represent the month in which the Opinion is ordered and another series of alpha 

characters from A to H to represent the annuitant type (i.e., DBD commonly refers 

to this as the “suffix codes”). Use the following chart as a guide:

First Digit

If the initial order is within the month of Use Code

January A

February B

March C

April D

May E

June F

July G

August H

September I

October J

November K

December L

If a secondary order is within the month of Use Code

January M
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February N

March O

April P

May Q

June R

July S

August T

September U

October V

November W

December X

If a third order is within a given month Y

If a fourth or more order is within a given 

month

Z 

Second Digit

If the Annuitant Type is Use Code

Employee A

Widow B

Surviving Child C

Retirement Child D

Additional Code

If a fifth order is within a given month, use the original code for the initial order for 

that particular month for the first digit.

Use the following for the second digit:

If the Annuitant Type is Use Code
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Employee E

Widow F

Surviving Child G

Retirement Child H

The DBD Claims Assistant enters the Form G-137, Medical Consultant Opinion,

into the Financial Management Integrated System (FMIS) and will verify that the 

pre-filled entries of NAME, Examiner Name, Claim Number and codes (i.e., suffix 

codes), and Date are correct, making any necessary adjustments. 

Sections A and C are self-explanatory. 

Section B - In section B, if an onset date is requested, usually the examiner will 

check two boxes. The first box checked will be for Severity Assessment & RFC. 

The second box checked will be Onset Date with an entry of the alleged onset 

date. This date will be the earliest date for which a medical evaluation is needed. 

In most instances, this will be the date in item 11 on the AA-1d, Application for 

Determination of Employee’s Disability, or the date in item 12 of the AA-17b, 

Application for Determination of Widow(er)s Disability, or the date in item 12 of AA19a, Application for Determination of Child’s Disability. However, there may be 

situations where a different date would be appropriate, as decided by the 

examiner.

EXAMPLE 1: It may be possible to establish an unsuccessful work attempt prior 

to an actual date last worked. In this instance, a date earlier than claimed in items, 

11 and item(s) 12 may be appropriate.

EXAMPLE 2: A child may allege disability from age 10, but the earliest medical 

evidence in file is from age 14. In this instance, a date later than that claimed may 

be appropriate since the later onset date would have no effect on the rate or 

beginning date of the annuity.

Section B of the G-137 is also used when the examiner must evaluate whether 

there has been significant medical improvement since the date of the last medical 

assessment. The examiner checks the box labeled Re-evaluation for Significant 

Medical Improvement. The medical consultant reviews all the medical submitted 

with the case and makes a determination on the G-137 SUP (citing the supporting 

medical records in Part II of the SUP). The medical consultant must state whether 

there has been ‘significant medical improvement’ (using the specific wording) or 

no medical improvement. The medical consultant may provide a Severity 

Assessment & RFC on the G-137 SUP and cite the supporting medical in Part II 

of the G-137 SUP. In cases where the Listing of Impairments is either met or 

equaled, no RFC will be provided in Part I. The Listing of Impairments will be 
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DCM Part_11 DPS Forms Instructions Revised September 22, 2023 Page 18 of 63

identified in Part II, and the medical consultant provides the onset date of 

‘significant medical improvement’ in Part II of the SUP. 

Section D - In many cases the examiner may opt to leave this section blank, unless 

there is a need to highlight a specific piece of medical for review. The submission 

of the G-137 carries with it the implied request that all medical in the file is to be 

reviewed by the medical consultant. If the examiner opts to fill in this section, then 

the treating doctor’s name and the date signed in Section 13 – Certification of any 

Form G-250, Medical Assessment, in the disability file may be entered. 

Additionally, the examiner may enter any other treating doctor’s RFC’s in file by 

name and date signed. All references to the G-250 or other treating doctors must 

be signed by an acceptable medical source, such as the following:

• licensed physician, 

• osteopath, 

• psychiatrist, 

• licensed optometrist, 

• licensed or certified clinical psychologist,

• and persons authorized to send copies or summaries of medical records 

from a hospital, clinic, sanitarium, mental institution or health care facility. 

Examples of unacceptable medical sources may be those individuals not licensed 

to practice medicine or surgery (i.e., nurse practitioners, physician assistants, 

naturopaths, chiropractors, audiologists, and certain therapists). Their reports will 

be made part of the file and used to support the acceptable medical records.

Section E – In this section, list the doctor’s name and the date of each consultative 

examination or Specialist Consultative Examination (SCE) for which a separate 

RFC has been provided by the doctor. If there is no separate RFC and the doctor 

has included the RFC in the written narrative, the examiner may direct the medical 

consultant to ‘see the narrative for the RFC’.

Adjudication

As stated in IB 17-20, Reminder Concerning Adjudicating Medical Opinions, once 

the G-137SUP, Medical Consultant Determination Worksheet, has been received

back from the doctor providing the medical opinion, review it in its entirety to 

determine if it is acceptable. It is acceptable if the following conditions are met:

• all statements have been completed and descriptions are provided;
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• all cited medical evidence is current (most current twelve months), 

supports the onset date and claimed impairment, and does not conflict 

with non-medical evidence;

Example – EE alleges lumbar degenerative disc disease. A lumbar spine 

magnetic resonance imaging study (MRI) shows a lumbar fusion. Form 

AA-1D, Application for Determination of Employee’s Disability, states 

difficulty walking with ongoing pain. A treating source exam from 

December 2015 shows decreased range of motion, straight leg raise 

positive, difficulty getting on/off exam table, and slow antalgic gait. A 

specialized orthopedic consultative exam shows the same findings as the 

treating source exam of December 2015. 

If the consultative medical opinion states that the EE is restricted to at 

least 2 hours of standing/walking, based on the MRI and treating source 

evidence, be sure the specialized consultative exam findings are also

discussed and the objective findings from that report are listed. 

 

• the referenced explanation is supported by the evidence, and is clear, 

legible and refers to the findings; and

• the medical opinion has been signed and dated on the appropriate form(s) 

by the consulting doctor. 

When review has been completed, the DBD examiner must:

• indicate if the medical opinion is accepted or rejected in the “RRB Use 

Only” box; and

• sign and date the form.

Disposition

 

Step Action

1 The examiner files Form G-137 on the right side of the folder on top of 

all other documents in file. 

2 The examiner attaches a completed Route Slip to the front of the folder 

(G-26t white route slip for Post disability and RECON cases and G-26t.1 

green route slip for Initial disability cases). If the medical opinion is being 

requested on an urgent basis, the examiner writes the word “URGENT” 
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in the top margin of the G-137 and in the top margin of the route slip. The 

AFCS folder location charge is not changed at this time.

3 The disability and RECON examiners place the file in the designated 

pick up area in DBD for the DBD clerk. RECON examiners change the 

AFCS charge to DBD.

4 The DBD clerk picks up the case and charges the case to AFCS charge 

T0CE – Title DBD – Med Opin Contrtr (CEL) Offsite Vendor. 

5 The DBD clerk will enter the form G-137 information into the Federal 

Management Integrated System (FMIS), verifying that the month and 

type suffix codes are correct. The DBD clerk will also enter the case 

information into an in-unit tracking system to verify release and return of 

the folder. 

6 All files for the Med Opin Offsite Vendor are boxed and picked up by a 

courier. 

The same courier returns the completed disability cases usually within 3-

4 business days with the G-137 and G-137 SUP (for physical evaluation 

cases only) filed inside each case. NOTE: In cases where the disability 

examiner has requested a combined psychological (mental) and physical 

evaluation or a singular psychological evaluation, additional forms may 

be included with the G-137 and G-137 SUP. The additional enclosed 

forms are the SSA-2506-BK, Psychiatric Review Technique, and the 

SSA-4734-F4-SUP, Mental Residual Functional Capacity Assessment. 

The psychological SSA forms are completed only by the consultative 

doctors. (See DCM 11.5 SSA Forms) 

7 The DBD clerk verifies the return of the folder using the DBD in-unit 

tracking system and then passes the case on to the DBD examiner. 

RECON cases are either directly delivered to the RECON examiner or 

placed in the RECON bin in DBD for pick up by a RECON clerk.

8 The examiner reviews the form G-137 SUP received with the case and 

if acceptable pays for the medical opinion on the FMIS system. On page 

4 of the G-137 SUP, box labeled FOR RRB USE ONLY, the examiner 

selects either box for M/O Accepted or M/O Rejected, and signs and 

dates in this box. The signature of the examiner and the date signed

verify that the opinion was paid on FMIS. The FMIS screen showing set 

up of payment of the medical opinion is not filed in the folder. NOTE: 

There may be occasions when the examiner finds exception with the G137 SUP and may need to return the case as a REJECT for additional 

review by the medical consultant. 
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DCM Part_11 DPS Forms Instructions Revised September 22, 2023 Page 21 of 63

G-137a, Medical Consultant Opinion – Continuation Sheet. 

Use

This form is used by the medical consultant when completing the Form G-137 

SUP. G-137a accompanies the G-137 SUP and functions as an extra page to the 

G-137 SUP if the medical consultant’s comments extend beyond Part II on the 

SUP. On page 4 of the G-137 SUP the consultant will check the box labeled 

“Check if additional pages are included” and attach the G-137a with all additional 

comments. (As such, this is an optional use form and only used when needed). 

Access

The form will be available on RRAILS. The medical consultant does not have 

access to RRAILS to obtain the G-137 SUP and G-137a. However, the consultant 

is provided with the current WORD versions of the G-137 SUP and G-137a for 

their use. 

Completion

Completion of the form is self-explanatory for the medical consultant. The 

consultant must sign and date the G-137a. 

Disposition

The form is filed on the right side of the disability folder below the G-137 SUP. 

G-137 SUP - Medical Consultant Determination Worksheet - 

Use

In response to the G-137, Medical Consultant Opinion, the medical consultant 

places a completed Form G-137 SUP (for evaluation of physical impairments only) 

in the file and returns it to DBD. The G-137 SUP must be signed and dated by the 

consultant, and the examiner must confirm that the signature is provided and the 

date signed is correct. NOTE: Additionally, examiners must verify that the 

evaluation provided by the medical consultant covers the entire time period from 

the alleged onset date of disability entered on G-137 to the present date. 

Access

The form is on RRAILS. The medical consultant does not have access to RRAILS 

to obtain the G-137 SUP and G-137a. However, the consultant is provided with 

the current WORD versions of the G-137 SUP and G-137a for their use. 
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DCM Part_11 DPS Forms Instructions Revised September 22, 2023 Page 22 of 63

Completion 

The medical consultant completes the form in accordance with standard medical 

procedure for providing residual functional capacity assessments and medical 

narratives. The examiner should also confirm that any question asked on the 

initiating G-137 was answered on the corresponding G-137 SUP or answered on 

other enclosed Form SSA-2506-BK, Psychiatric Review Technique, and the Form 

SSA-4734-F4-SUP, Mental Residual Functional Capacity Assessment. 

Disposition

The form is filed on the right side of the folder above the G-137.

NOTE: Note to File - During the onsite meeting between the disability or RECON 

examiner and the medical consultant, the medical consultant may write their 

opinion on a Note to File. The Note to File is filed on the right side of the 

disability folder. 

G-197, Authorization To Disclose Information to the Railroad Retirement 

Board

See FOM1 1720, G-197. 

G-219, Simultaneous Processing Disability Decision and Disability Freeze

Use

Effective April 23, 2015 and later, Form G-219, Simultaneous Processing 

Disability Decision and Disability Freeze, is a mandatory form that must be 

completed by the disability examiners in the Disability Benefits Division (DBD) 

when processing Occupational or Total & Permanent disability cases. The 

purpose of this form is to confirm that concurrent adjudication (i.e., simultaneous 

rating of both the disability decision AND period of disability [disability freeze or 

DF]) has been considered within 90 days of the application filing date. The form 

is part of the disability determination process. The G-219 is on RRAILS. 

Completion

ITEM ENTRY AND WHEN USED

RRB Claim Number RRAILS will pre-fill.

Applicant Name RRAILS will pre-fill.
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Application Filing Date RRAILS will pre-fill the applicant’s 

application filing date. This date can be 

found on the paper application (found 

either in the claim folder or in Imaging) 

or in APPLE. NOTE: This date is the 

date from which the 90 day time frame 

begins.

SECTION 1 This section is divided into three parts: 

Occupational Decision; Total & 

Permanent Decision; and Other.

Check the appropriate box: The disability examiner must select 

(check) only one of the following eight 

reasons to describe the status of the 

disability case as shown below and 

then print the G-219 for signature. 

Examiners need to decide if the case is 

either Occupational, Total & Permanent 

or Other before selecting a reason.

Occupational decision – Evidence 

is not sufficient to complete the 

concurrent decision

Self-explanatory.

Occupational decision – Evidence 

is sufficient for concurrent decision, 

Single Freeze completed

Self-explanatory.

Occupational decision – Evidence

is sufficient for concurrent decision, 

Joint Freeze completed

Self-explanatory.

Occupational decision – Evidence

is sufficient for concurrent decision, 

Joint Freeze deferred

Self-explanatory.
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Total & Permanent decision –

Concurrent decision, Single 

Freeze completed

Self-explanatory. 

Total & Permanent decision –

Concurrent decision, Joint Freeze 

completed

Self-explanatory. 

Total & Permanent decision – Joint 

Freeze deferred

Self-explanatory.

Other – Select this box item for those disability 

cases that will be deferred for any other 

reason(s) not stated above such as a 

disability freeze earnings denial; and/or 

1974 Act Medicare; and/or Financial 

Interchange (FI). Be very specific as to 

the reason why you are checking this 

box item. Type or write the reason in 

the space provided.

SECTION 2 This section only contains the 

Comments box item.

Comments The examiner and/or authorizer must 

enter any comments or information that 

they may have to document specific 

notes or actions concerning the case for 

future case adjudicative action(s) and/or 

reference (documentation). Examiner 

and/or authorizer must enter claim file 

(case) status and any next steps to take 

in order to complete case adjudication. 

Type or write the information in the 

space provided.

Examiner Name and Date Self-explanatory.
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Authorizer Name and Date Self-explanatory.

Disposition

The disability examiner prints out a copy of the G-219, then signs and dates, and 

sends an electronic copy of the form to the review folder. Upon receipt of the G219, the disability authorizer confirms that the examiner checked the appropriate 

box during the authorization process. After the review is completed, the 

authorizer signs and dates, and sends the electronic copy of the G-219 to 

Imaging for electronic documentation. The paper G-219 is filed down on the right 

side of the folder. 

G-226, Disability Customer Service Time Lapse Exclusion Case

Use

Form G-226, Disability Customer Service Time Lapse Exclusion Case, is used by 

the Disability Benefits Division examiner when extenuating circumstances exist 

that cause a delay in the disability decision. It is essential to exclude these types 

of cases from the timeliness statistics in order to accurately reflect the agency’s 

performance in rating disability cases. Form G-226 must be completed by the 

initial examiner prior to sending the case to authorization. The form should only 

be approved by the Disability Director, supervisors, lead examiners, or an 

individual(s) designated by a management official. See DCM 4.3.9 for guidance 

on when the exclusion applies. 

Completion 

Field ENTRY AND/OR WHEN USED

RRB Claim Number RRAILS will pre-fill.

Applicant Name RRAILS will pre-fill.

Official Filing Date Enter the actual or protected filing date.

This date can be found on the application or 

on APPLE PF24 screen. 
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DCM Part_11 DPS Forms Instructions Revised September 22, 2023 Page 26 of 63

Reason for Exclusion This section is divided into six parts with 

check boxes to designate a selection.

Claimant Delay Check this box if a timely ordered 

consultative examination was excluded 

from the Consultative Medical Examination 

timeliness requirements due to one of the 

following reasons:

• Claimant was a “no-show” for a 

scheduled examination appointment.

• Claimant requested that the location or 

date of a scheduled appointment be 

changed.

• The RRB requested that the location or 

date of a scheduled appointment be 

changed.

• The contractor was unable, through no 

fault of its own, to contact the claimant in 

a timely manner.

See DCM 4.3.9.1A for examples of when to 

use this reason code.

Recovery Delay Check this box if a medical assessment 

was delayed due to the recovery period 

status post (s/p) treatment or surgery. 

Be sure to enter the type of 

treatment/surgery and the date of the s/p 

treatment/surgery that caused the delay.

See DCM 4.3.9.1B for examples of when to 

use this reason code.

Evidence Delay Check this box if required evidence was not 

submitted timely and list the required 

evidence in the Remarks section of this 

form.
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DCM Part_11 DPS Forms Instructions Revised September 22, 2023 Page 27 of 63

Note: This can be medical or non-medical 

evidence that caused the delay. 

See DCM 4.3.9.1C for examples of when to 

use this reason code.

Filing Delay Check this box if the case has a protected 

or deterred filing date. Fill in the actual 

physical date the form was completed in the 

first date field and the date the form was 

either received or scanned into imaging in 

the second date field.

See DCM 4.3.9.1D for examples of when to 

use this reason code.

Confinement Delay Check this box if the applicant was confined 

to a correctional institution during the case 

development which caused a delay.

Other Delay Check this box, if the examiner feels that 

the case should be excluded for a reason 

not covered by the guidelines listed above. 

Be sure to give a detailed explanation on 

why you feel the case should be excluded 

in the Remarks section of this form.

See DCM 4.3.9.1F for examples of when to 

use this reason code.

Remarks Use the remarks section for additional 

comments or as a continuation of 

explanations for the reasons for exclusions 

listed above.

Note: Selecting “Evidence Delay” or “Other 

Delay” as a reason code requires entries to 

be made in the Remarks section.
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DCM Part_11 DPS Forms Instructions Revised September 22, 2023 Page 28 of 63

Examiner Name This field is prefilled from RRAILS with the 

name of the examiner initially opening the 

form.

Date This field is prefilled from RRAILS with the 

date the examiner initially opens the form.

Approved The Disability Director, supervisors, lead 

examiners, and individual(s) designated by 

a management official are authorized to 

check this box if they agree with the time 

lapse exclusion reason.

Denied The Disability Director, supervisors, lead 

examiners, or individual(s) directed by a 

management official are authorized to 

check this box if they disagree with the time 

lapse exclusion reason.

Authorized Official Name The Disability Director, supervisor, lead 

examiner, or individual directed by a 

management official who is approving or 

denying the exclusion will type or print their 

name after checking either the “Approved” 

or “Denied” box. 

Authorized Official User ID This field is prefilled from RRAILS with the 

user ID of the individual who is signed on to 

RRAILS at the time either the Approved or 

Denied box is checked. 

Note: Make sure to review this under your 

own sign in name as it is not possible to 

change this field once either the “Approved” 

or “Denied” box is checked. This field 

should also match with the name that is 

typed or printed in the above mentioned 

Authorized Official Name field. 
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DCM Part_11 DPS Forms Instructions Revised September 22, 2023 Page 29 of 63

If this form is completed manually, then this 

field should contain the signature of the 

Disability Director, supervisor, lead 

examiner, or individual directed by a 

management official who reviews the form. 

Date This field is prefilled from RRAILS when the 

either the “Approved” or “Denied” box is 

checked. 

Note: If this form is completed manually, 

then the Disability Director, supervisor, lead 

examiner, or an individual designated by a 

management official should enter in the 

date after signing his/her signature in the 

“User ID” box. 

Disposition

Examiner: 

After completing Form G-226, the examiner must send the form to the Disability 

Initial Authorization folder. Then the examiner must also send an email to the 

Disability Initial supervisor with a cc to the Disability Post supervisor, Disability 

Director, Initial and Post lead examiners, and individuals designated by a 

management official to review the form. In this email, indicate that there is a G226 in the Disability Initial Authorization folder for claim number xxx-xx-xxxx 

(enter the RRB claim number in place of the x’s) which needs to be reviewed and 

approved.

Approved: 

If the exclusion is approved, the examiner will receive email notification from the 

authorized individual stating that the form was approved and is on Imaging. 

Denied: 

If the exclusion is denied, the examiner will receive email notification from the 

authorized individual that the exclusion was denied. The examiner is then to 

update DBrief and/or OLDDS to reflect that the case was not excluded from 

timeliness. 

See DCM 4.3.9.2A for further details.

Supervisor: 
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DCM Part_11 DPS Forms Instructions Revised September 22, 2023 Page 30 of 63

Only the Disability Director and Supervisors are authorized to approve Form G226. After receiving an email from an examiner that a G-226 is in the Disability 

Initial Authorization folder, the director or supervisor will review the form and 

either approve or deny the exclusion.

Approved: 

If the exclusion is approved, the director or supervisor will release the form to 

imaging and send an email back to the examiner advising that the exclusion was 

approved and imaged. 

Denied: 

If the exclusion is denied, the director or supervisor will send an email to the 

examiner with the reason for the denial. 

See DCM 4.3.9.2B for further details.

 G-250, Medical Assessment

See FOM1 1720, G-250. 

G-250A, Medical Assessment Of Residual Functional Capacity

See FOM1 1720, G-250A. 

G-250(sup), Request For Medical Information From Treating Source In 

Cardiovascular Cases

Use

Form G-250(sup) should be included with all G-250's sent to treating physicians 

whenever a cardiovascular impairment is claimed by the applicant. This includes 

cases where the cardiovascular problem is not the primary impairment.

Completion

Prepare an original only. Send each form with each G-250 being sent to each 

treating physician.

Disposition

Mail the forms directly to the treating physician. As in all cases where 

development action is being initiated by headquarters, coordination between 

headquarters and the field office is necessary.

G-251, Vocational Report

 G-251_Vocational_Report
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DCM Part_11 DPS Forms Instructions Revised September 22, 2023 Page 31 of 63

Use

Form G-251, Vocational Report, is given to railroad employees who are applying 

for a disability annuity, a period of disability (disability freeze) and/or early 

Medicare. It is also given to a legal surviving spouse, a surviving divorced 

spouse, or a remarried surviving spouse who is applying for a disability annuity 

and/or early Medicare, provided they have had some railroad or nonrailroad 

employment. It should not be routinely furnished to disabled children. However, 

there may be an occasional request from the Disability Benefits Division (DBD) to 

obtain a G-251 for a specific disabled child case.

It is not necessary to furnish Form G-251 for employees filing for a period of 

disability and/or early Medicare if they have previously filed a G-251 and have 

not worked since they last filed for disability.

Completion

See FOM1 1720 “G” Forms for more information on how Form G-251 should be 

completed.

Adjudication

Form G-251, Vocational Report, should be completed so that the last 15 years of 

work (from the date the form is completed) is reflected on the form. The DBD 

examiner will use several evidence sources to compare information, such as 

employment dates, job duties, hours worked, etc., that are provided by the 

applicant on Form G-251. The DBD examiner will also compare the information 

provided on Form G-251 to other source documents in file, including, but not 

limited to; Form AA-1D, Application For Determination of Employee’s Disability; 

Form G-626A, Field Office Personal Observation Record; wage records; form G31 Activities of Daily Living Worksheet; and references to work in the medical 

evidence of record.

For employee Occupational cases, the DBD examiner will compare the 

information provided by the employee on Form G-251 with the employer’s 

description of the physical requirements and environmental factors as indicated 

on Form G-251A, Railroad Job Information (for more information on Form 

G-251A, see DCM 11.2, G-251A, Railroad Job Information). If there are material 

inconsistencies that may impact the outcome of the decision, the DBD examiner 

must resolve the inconsistencies. Actions to resolve include, but are not limited 

to:

• contacting the employee and reviewing the information provided on Form 

G-251; and/or
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DCM Part_11 DPS Forms Instructions Revised September 22, 2023 Page 32 of 63

• contacting the employer and reviewing the information provided on Form 

G-251A. The employer should only be contacted for clarification, if after 

discussion with the employee material inconsistencies still exist.

.

After discussing the details of the job description in question, if the discrepancy 

between the employee and employer’s job descriptions cannot be resolved, use 

OccuBrowse or other sources of job information for the job duties in question.

NOTE: All conversations with the employee and the railroad employer must be 

documented and imaged.

The G-251 asks for information regarding essential job duties. An essential job 

duty is a key function of employment that is unique to that job position. Without 

the function, the position would not exist. For example, the essential job duty for 

a locomotive engineer would be to confer with the conductor or traffic control 

center personnel via radiophone to issue or receive information or instructions 

concerning stops, delays, or oncoming trains. Essential job duties for a 

locomotive engineer would not include compiling payroll data, such as hours 

worked, taxes and employee identification number, from time sheets and other 

records.

The DBD examiner must consider the employee’s essential job duties when 

assessing his/her functional capacity for work activities. 

The G-251 also asks for information regarding permanent accommodations for 

the employee’s regular railroad job. A permanent accommodation from railroad 

work is defined as changes in work at the request of the employer that impact the 

essential functions of the occupation for at least a 5-year period. The permanent 

accommodations listed are: Job Duties, Work Schedule, Overtime Schedule, 

Attendance Schedule, and Other. Dates are also requested regarding when the 

restriction began and ended.

• Review Items 15, 19, and 23 of the G-251 carefully to ensure the 

permanent accommodation for railroad work was in place for at least 5 

years.

• If a G-251A response was received, compare the information provided on 

the employee’s G-251 to be sure that the information pertaining to 

permanent restrictions is consistent. (See above concerning how to 

resolve inconsistencies).

 

Examples of Permanent Accommodations are as Follows:
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DCM Part_11 DPS Forms Instructions Revised September 22, 2023 Page 33 of 63

• Job Duties – A 55-year-old brake repairer files for an occupational 

disability annuity in December 2016 on the basis of degenerative disc 

disease of the lumbar spine. A 50-pound lifting restriction has been placed 

on them by their treating physician. Their railroad employer has provided 

them with a permanent accommodation of no lifting of objects weighing 

over 50 pounds. Their team of co-workers handles heavy lifting duties 

during his shift. The accommodation was place in June 2010 through the 

present.

• Work Schedule – A 48-year-old ticket agent files for a total and 

permanent disability annuity in October 2016. They are status post cancer 

resection surgery. They experience fatigue related to their ongoing cancer 

treatment since September 2011. Their employer has provided a 

permanent accommodation in work schedule, allowing them to go for 

treatments and doctor appointments since September 2011. 

• Mandatory Overtime – A 50-year-old railroad locomotive engineer files 

for an occupational disability annuity in April 2016. Their job requires 

mandatory overtime as the need arises. The requirement has been in 

place since they started in January 1996.

• Non-Mandatory Overtime – A 47-year-old locomotive engineer is an 

“extra board” hire since March 2009. Depending on the assignment and 

the shift they receive, they may be required to work overtime hours. 

• Attendance Schedule – A 57-year-old conductor with chronic kidney 

disease, who does not require treatment with dialysis, files for an 

occupational disability annuity in December 2015. Their railroad employer 

has given them a permanent accommodation in his attendance schedule 

due to their symptoms. They are allowed to work a part-time schedule of 

4 days a week. This accommodation has been in place since September 

2010.

For Occupational disability cases, the employee may work over 40 hours per 

week, which may include mandatory overtime. Consider this in the evaluation. 

For Total and Permanent disability cases, work must be evaluated using a 40-

hour workweek, as it is commonly done in the national economy. 

The DBD examiner must consider the employee’s permanent job 

accommodations when assessing their functional capacity for work activities.
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DCM Part_11 DPS Forms Instructions Revised September 22, 2023 Page 34 of 63

Disposition

The DBD examiner will explain how the applicant’s job duties impacted the 

disability decision in D-Brief. The form should be imaged. 

G-251A, Railroad Job Information Form

 G-251A_Railroad_Job_Information_Form

Use

Form G-251A is completed at the time of filing by the field office and released to 

the employee's railroad employer when an employee is eligible for an 

occupational disability annuity. By completing the form, the railroad employer is 

given the opportunity to provide job information about the employee to the 

Railroad Retirement Board. Effective April 3, 2017, the Railroad Retirement 

Board (RRB) introduced a revised Form G-251A in accordance with the Disability 

Program Improvement Plan that will ask railroad employers to provide job 

information about applicants who apply for an occupational disability benefit 

under Section 2 (a)(1)(iv) of the Railroad Retirement Act (45 U.S.C. § 

231a(a)(1)(iv)). Collection of job information from the employers will assist the 

disability examiner with making an accurate disability determination. Prior to this 

date, the RRB used Form G-251a and G-251b Job Information reports to collect 

this information. Form G-251a was released to employers for employees with a 

generic job description attached. Generic job descriptions were used for a select 

number of railroad occupations and were some of the more common types of 

railroad jobs. The generic job description described how select occupations 

were generally performed in the railroad industry for employees. Form G-251b 

was released to employers for employees who did not have a generic job 

description. 

Completion

See FOM 1720 “G” Forms for more information on how Form G-251A should be 

completed.

Adjudication

The disability examiner must wait 30 days from the original date the G-251A was 

released before adjudicating the claim.

In instances where the disability examiner determines that the employee’s 

regular railroad occupation differs from the one entered on Form G-251A, the 

disability examiner should request that the field office release a new G-251A with 

the correct regular railroad job entered. If the request is made to the field office 

at least 30 days after the original G-251A was released, it is not necessary to 

wait an additional 30 days for receipt of the corrected form. For information on 

determining the employee’s regular railroad occupation, see DCM 3.2.2. 
DCM Part 11

DCM Part_11 DPS Forms Instructions Revised September 22, 2023 Page 35 of 63

For employee Occupational cases, the DBD examiner will compare the 

information provided by the employer on Form G-251A with the employee’s 

description of the physical requirements and environmental factors as indicated 

on Form G-251, Vocational Report (for more information on Form G-251, see 

DCM 11.2, G-251, Vocational Report). If there are material inconsistencies that 

may impact the outcome of the decision, the DBD examiner must resolve the 

inconsistencies. Actions to resolve include, but are not limited to:

• contacting the employer and reviewing the information provided on Form 

G-251A; and/or

• contacting the employee and reviewing the information provided on Form 

G-251. The employee should only be contacted for clarification, if after 

discussion with the employer material inconsistencies still exist.

. 

After discussing the details of the job description in question, if the discrepancy 

between the employer and employee’s job descriptions cannot be resolved, use 

OccuBrowse or other sources of job information for the job duties in question.

Section 1, Completion Instructions - The disability examiner should verify that 

the information on the upper right side on page 1 of the form, including if the 

regular railroad job determination is correct. It is acceptable for Form G-251A to 

be handwritten or typed by the field office. 

Section 2, Disqualification Information - The disability examiner should check 

to see that a G-3EMP was released by the field office if the employer indicates 

the employee was disqualified. If the G-3EMP was not released to the railroad, 

contact the field office to have them release the form. 

Section 3, Summary of Duties - This information should be compared to the job 

duties listed on Form G-251 by the disability examiner to verify that there is 

consistency between the employee and employer’s descriptions. 

Section 4, Machinery, Tools, Equipment - The disability examiner should verify 

that there is consistency between the employee provided the same information 

on Form G-251 regarding the use of machinery, tools, and equipment. 

Section 5, Environmental Conditions - These conditions listed by the employer 

should be compared to the G-251 job description by the disability examiner to 

verify there is consistency between the railroad description and the employee’s 

description. 

Section 6, Job Accommodations - The disability examiner should compare the 

information provided by the employer and employee to verify there is 

consistency, and investigate if there is a discrepancy. 
DCM Part 11

DCM Part_11 DPS Forms Instructions Revised September 22, 2023 Page 36 of 63

Section 7, Sensory Requirements - This should be compared to Form G-251 to 

verify consistency between the railroad description and the employee’s 

description. 

Section 8, Physical Actions - This must be compared to the G-251 job 

description provided by the employee to verify there is consistency between the 

railroad description and the employee’s description. 

Section 9, Remarks - Provides space for continuation of answers that pertain to 

the various job actions. 

Section 10, Employer Certification - Requests an employer certification. The 

disability examiner should check to verify that all items in this section are 

completed. 

Disposition

The disability examiner will explain how employee’s job duties for their regular 

railroad job as described on Form G-251 compares with the employer’s 

description of the employee’s G-251A in D-Brief. If the outcome of the decision is 

impacted by material discrepancies between the employee and employer job 

description, an explanation as to how the conflicting information was resolved 

should be indicated in D-Brief. (See DCM 12.5.5.2 for additional information on 

D-Brief.) The form should be imaged.

G-252, Self-Employment/Corporate Officer Work and Earnings Monitoring

Use

Form G-252 should be used in disability cases in which the disability claims 

examiner has questions concerning the annuitant’s claim of self-employment 

and/or work as a corporate officer. It will be used when the information contained 

on the AA-4, Self-Employment and Substantial Service Questionnaire, and within 

the file, do not provide sufficient information regarding the annuitant’s claims. It 

will be released by the Disability examiner. Refer to DCM 8.5.14, Using Form G252, Self-Employment/Corporate Officer Work and Earnings Monitoring. 

Access

The form is on RRAILS only.

Completion

Prepare an original only. The examiner is to complete Items 1-6, and 11-12. 

Items 11-12 – The disability claims examiner will need to enter the year(s) being 

requested. Box items are shown for two years’ worth of information. If there are 

three or more years needed, the annuitant can enter those years in Section 7 – 

Remarks and/or on a separate sheet of paper (see Note below). 
DCM Part 11

DCM Part_11 DPS Forms Instructions Revised September 22, 2023 Page 37 of 63

In some situations, the annuitant may need to show their work and earnings 

information from their ABD based on conflicting, confusing and/or discrepant 

information from other sources (i.e., AA-4, G-254, letters, or questionnaires, etc.). 

This means that the annuitant may need to show more than 2 years’ worth of 

information based on what the disability examiner determines is necessary (i.e., 

specific year(s) or period in question, or all year(s) from annuitant’s ABD). 

NOTE: If the information being requested in items 11-12 are for the same year 

as the information included in an AA-4 that has already been submitted, check 

the box prior to item 11. This will prevent the annuitant from completing duplicate 

information. 

Disposition

After completion of the necessary items, print the form from RRAILS. The form is 

to be released with Form RL-252, Cover Letter for Form G-252, and a return 

envelope. An e-mail should be released to the corresponding field office group 

mailbox informing them of the release of these forms and the years entered in 

items 11 and 12.

G-254, Continuing Disability Report

Use

Form G-254, Continuing Disability Report, is released to disability annuitants by 

the field office, at the request of the Disability Benefits Division (DBD). The 

Disability Benefits Division (DBD) will request the field office to secure Form 

G-254 when:

1. Determining if a disability annuitant continues to meet the requirements for 

a disability annuity prior to full retirement age; or

2. A report of work or a change in physical condition is received in 

headquarters, and the issue of continuing disability must be resolved. For 

Example: EDP policing, self-reporting, or third-party reporting. 

Completion

See FOM 1720, G-254. 

Adjudication

DBD examiners must compare the information provided on the G-254 to all 

relevant sources in file, including recent medical evidence submitted with the G254, and information from employers regarding dates worked/earnings 

breakdowns. If there are material inconsistencies on the G-254 that may have an 

impact on the decision, the disability examiner must resolve the discrepancies.
DCM Part 11

DCM Part_11 DPS Forms Instructions Revised September 22, 2023 Page 38 of 63

NOTE: If any suspicious patterns or inconsistencies are noted, such as the use 

of technical/descriptive terms or copied dialogue that cannot be resolved while 

examining the disability claim, the disability examiner should notify their lead 

examiner or supervisor as soon as possible. For more information on the 

elements of fraud, refer to DCM 8.8. 

Section 1, General Instructions: The date entered in Section 1 is provided by 

the disability post examiner handling the continuing disability review (CDR) 

development. The examiner should consider the annuitant’s onset date, ABD, 

and date of any prior G-254. 

Section 2, Identifying Information: will prefill from RRAILS. 

Section 3, Information about Your Work for an Employer: This section 

contains information about the annuitant’s employment after the date provided in 

Section 1. The disability examiner should consider the relevant factors in 

assessing the nature, intensity, persistence, and the limiting effects of the 

individual’s symptoms. In addition, the examiner should consider:

• Item 7: Consider all sources pertaining to work activity, such as the 

Detailed Earnings Query (DEQY), The Work Number (TWN), self-reported 

work, and any work report(s) from a third party. Make sure the annuitant 

provides information regarding the details of this work. 

• Item 11: When the entry is “Yes” in regard to returning to work with the 

same hours, duty and pay as the annuitant had before their disabling 

conditions began, possible medical improvement should be considered as 

part of the CDR decision. An example would be an occupational case in 

which the employee was able to return to their regular railroad job. 

• Items 12 and 13: Consider whether the work was done under special 

conditions, such as a sheltered. For more information, refer to CFR 

404.1573 or DCM 5.2.12. 

• Item 14: If the annuitant does not list any impairment-related work 

expenses (IRWE), review Section 5 item 27 for possible M.D. co-pays and 

item 28 for possible prescription co-pays. When the employee earns over 

the annual Disability Work Deduction (DWD) amount, additional 

verification may be needed to determine if IRWE can be used to reduce 

the countable earnings for work deduction purposes. FOM I 1125.5.2

provides a chart with yearly DWD amounts. For development of IRWE, 

refer to DCM 10.8 and FOM I 310.55.1 for more information. 

Section 4, Information about Self-Employment: If the annuitant reports 

working in self-employment, the disability examiner should:

• Determine whether an AA-4, Self-Employment and Substantial Service 

Questionnaire, and possible G-252, Self-Employment/Corporate Office 

Work and Earnings Monitoring, should be developed for review. Refer to 

DCM 10.4.5 for more information on self-employment determinations. 
DCM Part 11

DCM Part_11 DPS Forms Instructions Revised September 22, 2023 Page 39 of 63

Section 5, Information about Your Condition before Full Retirement Age: 

Consider what the annuitant claims about their current medical condition(s) and 

review the following items listed below to determine if there is possible medical 

improvement:

• Types of treatment

• Medications

• Restrictions in Activities of Daily Living 

o If the annuitant was found disabled due to a mental impairment, 

neurological impairment, chronic pain, or chronic fatigue, or if any 

of those are alleged/suspected; then check if there is a form G-31 

worksheet completed in conjunction with G-254. If a G-31 is not in 

file, contact the field office to develop one.

• Whether a doctor has released the annuitant to return to work

• Report of recent higher education and how it might affect the disability 

annuity. Did the annuitant receive a degree since their disability annuity 

was awarded? Have they received any special training since their 

disability annuity was awarded? Refer to DCM 5.4 for educational 

consideration and DCM 3.6.1 under step 5 of the sequential evaluation 

process. In addition, please refer to Form AA-1d Section 5 instructions in 

DCM 11.2 for more information on the effects of recent education and/or 

vocational training received to determine if this affects the employee’s 

ability to perform work. 

Section 6, Continuation and Remarks: Review this section for any additional 

details regarding the information provided in the other sections of the G-254. 

Section 7, Authorization and Certification: Identify who the report was 

completed by and verify the form is signed and dated. 

Disposition

The Disability Post Section (DPS) examiners will review the G-254, along with all 

the other documentation needed for the CDR process, and prepare a decision for 

review, which will be authorized by another DPS examiner. The form should be 

imaged.

G-260, Report Of Seizure Disorder

See FOM1 1720, G-260. 

G-321, Employee Initial Rating Checklist 

Use
DCM Part 11

DCM Part_11 DPS Forms Instructions Revised September 22, 2023 Page 40 of 63

Form G-321 is used by initial disability examiners as a job aid to evaluate items 

for consideration or action when processing employee disability claims. This is 

an optional use form.

Access

The form is on RRAILS only.

Completion

Items 1-43 of Form G-321 are completed by the disability examiner if the 

employee disability claim is for an occupational disability. Items 1-32 and 44-56 

are completed by the disability examiner if the employee disability claim is for a 

total and permanent disability.

Disposition

After completion of the necessary items, print the form from RRAILS. File the 

form on the left side of the folder. The form is not imaged. The form may be 

discarded after review.

G-321a, Widow/Child Information Checklist 

Use

Form G-321a is used by initial disability examiners as a job aid to evaluate items 

for consideration or action when processing surviving spouse and children 

disability claims. This is an optional use form.

Access

The form is on RRAILS only.

Completion

Items 1-7, 9, 10 and 12-21 are completed by the disability examiner if the 

disability claim is for a Surviving spouse. Items 1-17 and 21 of Form G-321a are 

completed by the disability examiner if the disability claim is for a child. 

Disposition

After completion of the necessary items, print the form from RRAILS. File the 

form on the left side of the folder. The form is not imaged. The form may be 

discarded after review.
DCM Part 11

DCM Part_11 DPS Forms Instructions Revised September 22, 2023 Page 41 of 63

G-325TCO, Disability Briefing Document

Use

When an application begins as Total and Permanent at filing and is entered on 

the Disability Briefing Document Program (D-Brief), but is converted to 

Occupational at time of adjudication because the claimant now meets the 

occupational eligibility requirements (i.e. change in age or additional service 

months earned) use Form G-325TCO to explain the decision. For example, the 

rationale should include explanation of earlier onset before attainment of age 60, 

cite listings used, occupational standards, and other rules and regulations as 

necessary. 

Access 

The form can be found on RRAILS.

Completion

Claim Number, Applicant Name and Applicant SSA will be pre-filled by RRAILS. 

Basis for Decision

Type the basis for the decision. Explain in detail the relevant facts that were 

taken into considerations during the adjudication process (See DCM 5.1.6 for 

more detailed information). If a listing is used in the decision, state whether it is 

met or equaled. If a vocational rule is used in the decision, state whether it is 

used as a framework.

Reviewer’s Comments (Optional)

This section is completed by the authorizing reviewer and is optional. Explain in 

detail any additional findings to support the decision of the adjudicating examiner.

Disposition

• The examiner sends the form to the initial auth folder and the reviewer sends 

the form to imaging.

G-325.1, Disability Decision Rationale

Use

Form G-325.1 is used to give rationales and citation of used listings, standards, 

rules etc. for disability determinations in post entitlement cases.
DCM Part 11

DCM Part_11 DPS Forms Instructions Revised September 22, 2023 Page 42 of 63

Completion

Items 1-5 of this form are completed by the disability examiner. Items 6 and 7 

are completed by the reviewing disability examiner.

Item Entry

1 Claimant- Enter the first name of the person for whom the 

determination is made.

2 RRB Claim No. - Enter the six or nine digit RRB claim number.

3 Basis for Decision - Show the basis for the decision. Make a 

statement of causes and effects that documents the considerations 

and conclusions in reaching the decision. (See DCM 5.1.6 for 

more detailed information). If you are using a listing in your 

decision, state whether it is met or equaled. If you are applying a 

vocational rule as a framework, that should be stated.

4 Explanation of Actual Onset Date (If Different from Claimed Onset 

Date) - Complete this item only when the applicant is found 

disabled and the onset date determined is earlier or later than the 

onset date shown in the application being adjudicated. 

5 Signature of Disability Examiner - The name of the disability 

examiner who completed items 1-4 and the date are entered by 

RRAILS.

6 Any Additional Rationale by Reviewing Examiner - This item is 

used by the reviewing disability examiner when there is additional 

rationale to be offered that leads to a similar decision. If there is no 

additional rationale, leave this item blank.

7 Signature of Reviewing Examiner - The reviewing examiner ‘s 

name and the date are entered by RRAILS.

Citations of Listings Standards, Rules, etc. - Identify any 

established and published criteria used in reaching the decision. 

Any published criteria, including manual references, may be 

entered. Specifically, enter listings (whether met or equaled) 

and/or vocational rules used (whether applied strictly or as a

framework).
DCM Part 11

DCM Part_11 DPS Forms Instructions Revised September 22, 2023 Page 43 of 63

Disposition

File the forms on the left side of the claim folder. In all cases the form must be 

imaged.

If:

• The case is a “self-auth” case, the examiner sends the form to imaging.

• The case is being reviewed, the examiner sends the form to the post auth 

folder and the reviewer sends the form to imaging.

• The case is a joint disability freeze case, the form is saved until after SSA 

signs off on the case and then sent to imaging.

G-383, Authorization Return Form

Use

Form G-383 is used by authorizers to identify adjudicative actions that may be 

incorrect, inconsistent, or incomplete with current procedure or if the authorizer 

disagrees with the proposed disability rating or continuing disability 

determination. This form is part of and initiates the reviewer return process 

(DCM 3.4.303) and is meant to:

• Track adjudicative issues and provide significant data to the Training 

Section regarding areas that may require additional training or clarification 

of current procedure, and

• Identify adjudicative issues which should be addressed by the rating 

claims examiner before a disability determination is authorized.

Form G-383 is a Microsoft Word document.

Access

Access Form G-383 from the Main Screen for RRAILS. Ensure that the RRAILS 

Shelf is open.

IMPORTANT: The G-383 is best viewed using a screen resolution of 1024 x 768 

pixels. Monitors currently set to a screen resolution of 800 x 600 pixels result in 

images that appear larger than in other screen resolution settings. As a result, 

users may have difficulty viewing this form when the screen resolution is set to 

800 x 600 pixels.
DCM Part 11

DCM Part_11 DPS Forms Instructions Revised September 22, 2023 Page 44 of 63

Adjustments to your monitor’s screen resolution are done through the “Control 

Panel” in Microsoft Windows. In order to change the screen resolution of your 

monitor, click on the START button and look for “Control Panel.”

1. “Control Panel” IS visible

Click on Control Panel / Display (icon) / Settings (tab) / move the slider 

arrow in the Screen Resolution area to 1024 x 768 pixels using your mouse. 

Click the APPLY button. After the resolution is temporarily set, click OK to 

make the resolution change permanent.

To return the screen resolution of your monitor back, follow the same 

instructions but move the slider arrow to the position that it was in originally.

2. “Control Panel” IS NOT visible

Click on Settings / Control Panel / Display (icon) / Settings (tab) / move 

the slider arrow in the Screen Resolution area to 1024 x 768 pixels using your 

mouse. Click the APPLY button. After the resolution is temporarily set, click 

OK to make the resolution change permanent.

To return the screen resolution of your monitor back, follow the same 

instructions but move the slider arrow to the position that it was in originally.

Completion

The claim number, prefix, and beneficiary symbol (bene sym) can either be 

prefilled into the G-383 by downloading it from RRAILS or it can be manually 

typed into the form. See FOM1 1596.20 for instructions how to download 

information into the G-383 from RRAILS.

Completion of Form G-383 is generally self-explanatory and shall be done using 

the following steps:

Ste

p

Action

1 To open Form G-383, either:

a) Double click on G-383 Authorization Return Form in the RRAILS 

shelf,

Or

b) Single click on G-383 Authorization Return Form in the RRAILS 

shelf AND then click the Open button.
DCM Part 11

DCM Part_11 DPS Forms Instructions Revised September 22, 2023 Page 45 of 63

2 Click on ***Select Type of Case*** or the down arrow.

Click “DISABILITY” from the drop down menu. The image will change 

to the image shown below.

Press TAB on the keyboard.

Then either press ENTER on the keyboard OR use the mouse and click 

on OK to verify that the Disability version of the G-383 should be 

opened.

NOTE: Clicking on Cancel will disable the rest of the Disability 

programming.

If Disability was inadvertently selected and you wanted to enable the 

Medicare, Retirement, or Survivor programming instead, click on the 

word DISABILITY (as shown in the second image above). Then select 

of the correct version of the form. Otherwise just close the G-383 Word 

Document.

3 Type the examiner’s name in the large box (REQUIRED) and the 

examiner’s adjudicating unit in the smaller box (OPTIONAL).

NOTE: The authorizer’s name and RRB unit number are prefilled next 

to “Authorizer Name / Unit”.

4 Select the Type of Action by clicking the appropriate radio buttons.

a) If the “Occupational Only,” “T and P Only,” “Widow,” or “Child” radio 

button was selected, then also select either the “Allowance” or 

“Denial” radio button. (REQUIRED)
DCM Part 11

DCM Part_11 DPS Forms Instructions Revised September 22, 2023 Page 46 of 63

b) If the “Occupational and SF” radio button was selected, then also 

select the “Allowance” (if both disability determinations are 

allowances), “Denial” (if both are denials), or “Occ. Allowance/SF 

Denial” radio button. (REQUIRED).

c) If the “T and P and SF” radio button was selected, then also select 

the “Allowance” (if both disability determinations are allowances), 

“Denial” (if both are denials), or “TP Allowance/SF Denial” radio 

button. (REQUIRED)

d) If the “SF and/or Medicare Only” radio button was selected, then 

also select the “Allowance” (if both disability determinations are 

allowances), “Denial” (if both are denials), or “SF Denial/Medicare” 

(if the single freeze is denied based on earnings but Medicare is 

allowed based on the 1974 Railroad Retirement Act amendments or 

government employment) radio button. (REQUIRED)

e) If CDR was selected, no other radio button needs to be selected.

5 Select the appropriate reference manual(s) by clicking the appropriate 

box(es) on the left side. (OPTIONAL)
DCM Part 11

DCM Part_11 DPS Forms Instructions Revised September 22, 2023 Page 47 of 63

If a reference manual is selected, then cite the section(s) of the manual 

by typing it in the space provided on the right side. (REQUIRED)

If a reference is not listed, click the “Other” box and type the appropriate 

information in the space provided.

6 Click in the “Save Changes” box OR press ENTER.

All selections and typed information will then fill into the G-383.

7 Type in the bene sym, prefix, claim number, and if necessary, the payee 

code if it was not prefilled into the G-383.

8 Click in the area below “Authorizer Comments:” and begin typing a 

detailed explanation of why the claim is being returned.

NOTE: The “Authorizer Comments:” box will expand in height to 

accommodate comments of any length.
DCM Part 11

DCM Part_11 DPS Forms Instructions Revised September 22, 2023 Page 48 of 63

Disposition

The authorizer will prepare three copies of the G-383. Copies should be 

distributed to the:

• Rating examiner with the claims folder.

NOTE: The authorizer shall log the claim file into the rating examiner’s 

AFCS location and return the claim file to the rating examiner’s work 

station.

• Rating examiner’s supervisor, and

• Disability training specialist.

The authorizer shall prepare and distribute a fourth copy of the G-383 for his or 

her supervisor if the case being returned was completed by an examiner in the 

Initial Section of the Disability Benefits Division.

See DCM 3.4.303 for additional information about the reviewer return process.

G-405, Notice of Medicare Entitlement Action

See RCM 11_G405

G-460, Tracing on Request for SSA Medical or Other Evidence

Use

This form is to be used when tracing on a Form RR-5 and Form G-26f, or

requesting medical evidence or other types of documentation with the Social 

Security Administration. The form is to be used for the first tracing of those 

forms.

Access

The form is on RRAILS only.

Completion

Complete the form as follows:

Item Entry

SSA Claim Number Enter the SS claim number of the applicant. 

This will usually be a social security number 

followed by a one or two letter suffix.
DCM Part 11

DCM Part_11 DPS Forms Instructions Revised September 22, 2023 Page 49 of 63

RRB Claim Number Enter the RRB claim number of the applicant. 

This would usually be a social security number 

preceded by a one, two or three letter prefix

RR Employee's Name Enter the name of the railroad employee

Disabled Person's Name Enter the name of the disabled person who is 

applying for disability benefits

Disabled Person's Date 

of Birth

Enter the date of birth of the disabled person 

who is filing for disability benefits

Date of (RR-5/G-26f) 

Sent to SSA

Select either RR-5 or G-26f depending on which 

form you are tracing. After making the selection 

enter the date the original form was released

Remarks Enter any remarks that are pertinent to the case 

(i.e. congressional or critical case) or that should 

be known by SSA

Sign and date the form next to the appropriate spaces and print. The bottom half 

of the form SSA Reply will be completed by SSA.

Disposition

1. Email the G-460 document to SSA. For instructions on scanning and 

sending the form by email to SSA, click here: How to Scan and Email 

Documents. 

2. Send the G-460 document to IMAGING. 

G-626A, Field Office Personal Observation Record

Form G-626A is obtained by the field office for all initial disability applicants to 

record personal observations. Initial disability applicants include employees, 

surviving spouses, surviving divorced spouses, surviving remarried spouses, 

children and post applications for disability annuity conversion (DAC) children, 

Medicare only surviving spouses, Medicare only DAC, OM DAC, and Disability 

Freeze only employees. Personal observations may be the result of an in-person 

or telephone interview. The G-626A must accompany the initial disability 

application package. 

For more information on completion and disposition by the field office, see FOM 

1310 and FOM 1 1720, G-626A . For more detail on the high risk questions with 

examples, see FOM1 Article 13, Appendix E. 
DCM Part 11

DCM Part_11 DPS Forms Instructions Revised September 22, 2023 Page 50 of 63

This procedure pertains to examiner handling of Item 1, which lists 5 criteria for 

possible high-risk scenarios. The five criteria are listed below with guidelines for 

examiner handling:

1. Prior Earnings Fraud: The applicant was previously reviewed for 

earnings fraud due to unreported work activity and such action was 

determined to be fraudulent. Disability examiners are required to review 

Contact Log and Imaging for any past history of fraud under the Railroad 

Retirement Act (RRA) and Railroad Unemployment Insurance Act (RUIA). 

Note: If there is a prior history of fraud under RUIA, there will be a contact 

alert message that reads “Prior RUIA Fraud G-626A required for Disability 

EE applicants - see FOM1 Article 13 Appendix E.” In addition, check 

OLDDS to see if Form G-325A has been completed for a Continuing 

Disability Review (CDR) determination. In these cases, verify whether the 

CDR action was the result of fraud by the disability annuitant. 

2. LAG Earnings Needed: The applicant needed lag earnings to attain 240 

cumulative service months (except for settlement cases) and the 

employee is under age 51 at time of filing or is entitled to a private 

pension from the railroad employer and is under age 56 at time of filing. 

Refer to FOM1 209.10 for the definition of Lag. Disability examiners 

should review the DEQY to determine if a private pension is payable. In 

addition, the pension is indicated on the APPLE application, and 

sometimes also in the remarks section of APPLE. 

3. Possible Work/Earnings: The field office staff identifies possible 

work/earnings from an incorporated business, limited liability corporation 

or self-employment with reported levels of income below the earnings 

limitations established for disability annuitants. Disability examiners should 

refer to FOM1 1125.5.2 for the amount of disability work deductions 

applicable for a particular year. 

4. No Earnings in Last 5 Years: Examiners can verify this information by 

checking EDMA, obtaining a DEQY and checking The Work Number to 

see if the applicant has had earnings in the last 5 years. 

5. Uniform Responses/Patterns: Entries on the disability application are 

uniform or other material information provided by the applicant appears 

inconsistent or is in need of further review. If this criteria appears to apply, 

examiners should review DCM 8.8.2, Elements of Fraud, for further 

information. 

G-841C, Background Medical Evidence Transmittal Memorandum

See FOM1 1720, G-841C. 
DCM Part 11

DCM Part_11 DPS Forms Instructions Revised September 22, 2023 Page 51 of 63

11.3 "RL" Forms

RL-11, Letter for G-3EMP Disqualification Request for Medical Evidence 

from Railroad Employers 

See FOM1 1745, RL-11. 

RL-11B, Letter Requesting A Transcript Of Hospital Records

See FOM1 1745, RL-11B. 

RL-11D, Letter Requesting Medical Records from Worker's Compensation 

Or Other Agency Or Institution

See FOM1 1745, RL-11D. 

RL-11D1, Request for Medical Evidence from Employers

See FOM1 1745, RL-11D1. 

RL-27, Notice to Employer of Disability Annuity Application Denial

Use

Use the RL-27 to notify railroad employers when an employee disability annuity 

application is denied. The RL-27 is only released to the railroad employers listed 

below:

RAILROAD BA NUMBER

Amtrak 8301

Arkansas Midland 3889

Bessemer & Lake Erie 1303

Birmingham Southern 4507

Florida Central 2586

Florida Midland 5511

Florida Northern 5522

Indiana Harbor Belt 4217

Kankakee, Beaverville & Southern 2337
DCM Part 11

DCM Part_11 DPS Forms Instructions Revised September 22, 2023 Page 52 of 63

Lake Terminal 4221

McKeesport Connecting 4334

Metro North Commuter 3345

MG Rail, Inc. 3357

Mid-Michigan 4268

Pinsly RR Co. 7105

Pioneer Valley Co. 3113

Pittsburgh & Conneaut Dock 4249

Transtar 9237

Union RR Co. (Pitts PA) 4351

Completion

The RL-27 is available on RRAILS. The initial examiner should complete the RL27. Enter the BA number in the block on the left side of the form. The BA 

number and RR employer name can be found on the EMPLOYEE/ SPOUSE 

WORK INFORMATION screen on APPLE. On that screen the BA number is 

listed under ER NO. Enter the RRB claim number, name, address, date last 

worked, occupation, and location on the right side of the form. Send it to the 

imaging folder and notate in “Remarks” on the route slip that a RL-27 was 

completed.

Disposition

The authorizer should print out one copy of the RL-27 after authorizing the case, 

send the RL-27 to imaging, and put the printed copy in the outgoing mail tray.

RL-69, RRB Medical Consultants for DF/CDR

Purpose

This letter is used when scheduling examinations for the purpose of a disability 

freeze (DF) decision or a continuing disability review (CDR). This letter provides 

information to the annuitant as to whom the RRB contracts with for scheduling 

exams, and alerts them that the medical provider may be calling them by 

telephone to schedule an appointment.
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Completion

Use RRAILS features as usual to open the letter with annuitant information 

included. Click on the greeting and then press the tab key. Dialogue boxes will 

open asking for information to complete the rest of the letter. Enter the 

requested information and click on “OK”.

Completion of the dialogue boxes will provide an explanatory sentence as to 

whether this is a DF decision or a CDR decision and an explanatory sentence as 

to why additional medical information is needed.

Disposition

Release original to the annuitant. Make a copy for the file. Send to imaging.

RL-121f, Disability Allowance Notice

Purpose 

The RL-121f is a notice to claimants informing them that their claim for a 

disability has been approved or that additional information has been reviewed in 

order to determine whether an earlier onset date can be established. The letter 

is released when the disability rating is approved. 

Access

This letter is available on RRAILS

Information regarding the navigation of the RRAILS screens, dialogue boxes, and 

the text and order of paragraphs on the letter is contained in DCM 12.4. 

Completion

Required entries on the RL-121f are described below.

In all cases: 

• Enter the name and address;

• Enter the claim number;

• Enter the disability onset date; and

• Sign the Director of Operations’ name above the typed name.

An explanation of how the onset date was determined must always be given in 

the case of an employee, surviving spouse, surviving divorced spouse, surviving 

remarried spouse, or survivor child in which the onset date is different from that 
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claimed. Examiners may compose a special paragraph or use a code

paragraph. In the following situations, other information will also need to be 

given.

• The letter must state that the difference between the claimed onset date 

and the determined onset date has no effect on the ABD, if this is the 

case.

• The letter must state that additional information is being developed in an 

attempt to substantiate an earlier onset date, if this is the case. 

• The letter must always include the reconsideration paragraph. 

Other situations:

• The applicant must be told that the first payment should be received within 

45 days of the estimated annuity beginning date if the annuity beginning 

date is in the future. This could occur in employee and widow cases in 

which the waiting period has not expired. The estimated annuity 

beginning date would be a date six months after the disability onset date. 

In advanced filing dates, the estimated annuity beginning date would be 

the day after the last day of compensated service. Also, state that the 

applicant should receive a letter explaining more about the monthly 

benefits at that time.

• There must be a statement that factors other than the onset date affect the 

ABD.

In the case of an employee, surviving spouse, surviving divorced spouse, 

surviving remarried spouse, or survivor child in which a disability annuity is 

already being paid and additional medical evidence has been requested in order 

to determine whether an earlier onset date is possible, the type of information to 

be included in the letter is determined by the situation, as shown below. 

• In cases in which additional information has been requested but has not 

been received, this must be stated in the letter. Include the statement that 

there will be no change in the current annuity.

• Give an explanation in cases in which additional information has been 

received, but there is no change in the onset date. Include the statement 

that there will be no change in the current annuity.

• The letter must give both the old and the new onset dates in cases in 

which a new onset date is set as a result of additional information. Explain 

that another letter will be sent concerning payment adjustments.
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• Give an explanation in cases in which an onset date is established that is 

later than the date claimed. 

• Always include the reconsideration paragraph.

Disposition

The original letter, with envelope, is for the annuitant. The initial disability 

examiner types the letter on RRAILS and sends it to an authorization folder. The 

authorizer approves the letter, prints out 2 copies, and sends to imaging before 

releasing one to the annuitant and placing the other in the file. 

RL-213E, Continuing Disability 

Use 

Effective September 25, 2017, Form RL-213E is released by the Disability 

Benefits Division (DBD) to an employee disability annuitant acknowledging 

receipt and review of information submitted in response to any of the following 

forms that were released to them:

• G-254a, Continuing Disability Update Report;

• RL-4, Disability Reminder Notice - Retirement;

• RL-5, Disability Reminder Notice - Survivor; and

• RL-7, Disability Reminder Notice - Under Earnings.

After reviewing the response(s) submitted, DBD will release the RL-213E to the 

annuitant if it is determined that no other action is necessary. Prior to the above 

date, the RL-213E was only released in response to the Form G-254a.

Completion 

The RL-213E is on RRAILS. RRAILS will prefill the name, address, and claim 

number. Verify that the entries are correct. The form has two dialog boxes and 

one drop down menu. In the first dialog box, select whether the form is going to 

a third party. If "No" is selected, the text prefills with "your condition," etc. If 

"Yes" is selected, a second dialog box appears that asks if the disabled person is 

the male or female employee or the male or female annuitant. Select the 

appropriate gender and status and the verb tense will prefill accordingly 

throughout the letter. From the drop down menu, select the form type the 

annuitant responded to. 
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Disposition 

After completion of the necessary items, print the form from RRAILS and release 

to the applicant. Image a copy of the RL-213E to WorkDesk via the imaging 

button in RRAILS. 

RL-250, Request for Medical Assessment

See FOM1 1745, RL-250. 

RL-252, Cover Letter for Form G-252

Use

This form is to be released in conjunction with Form G-252, SelfEmployment/Corporate Officer Work and Earnings Monitoring.

Access

The form is on RRAILS only.

Completion 

The name, address and claim number are to be completed. Also select from the 

drop-down menu, the appropriate response for the second sentence in 

paragraph one. The dropdown concerns whether the person is self-employed, a 

corporate officer or both.

Disposition

Upon completion of the necessary items, print the form. The form should be sent 

to the addressee along with Form G-252, Self-Employment/Corporate Officer 

Work and Earnings Monitoring and a return envelope. This form is to be imaged 

and a paper copy is to be placed on the right side of the folder.

RL-259 Letter to US Embassy to Request Medical Exam for Applicant

Use

Form RL-259, Letter to US Embassy to Request Medical Exam for Applicant, is 

used by DBD staff to secure a specialized medical examination for an individual 

residing in a foreign country (other than Canada or, in some situations, Mexico). 

The form is released to the US Embassy or Consulate that P&S - RAC provided 

to DBD. (See DCM 4.3.6) 

Access

The form can be found in RRAILS.
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Completion

Move through the letter using the TAB button.

The name and address of the embassy or consulate are typed in the area below 

the RRB seal. Do not use abbreviations unless indicated by P&S - RAC.

The name and claim number of the individual are typed below “In reply refer to”.

Ensure that the claimant’s name and full address were prefilled in the appropriate 

area of the body of the letter.

List the names of all of the specialized medical examinations being requested in 

the area.

Type the total number of specialized medical examinations in the pop-up box that 

will appear:

Type the total cost of all requested specialized medical examinations in the 

space provided after “$”. The total cost of all specialized medical examinations 

can be found by accessing the EXMC table of FFS. See DCM 12.2.2 for 

instructions how to access FFS. After FFS is accessed, access the EXMC table 

by typing “N” in the ACTION field and then typing “EXMC” in the TABLEID field. 

(The first 4 characters of your USERID will be shown. Do not change the 

USERID.) The screen should look like this:
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Press ENTER. The screen will look like this:

Press ENTER again and the first page of examinations will be shown. Press 

ENTER again to page through the list of examinations.

Disposition

Upon completion of the necessary fields and items, print the form and send it to 

the addressee. This form is to be imaged and a paper copy is to be placed on 

the right side of the claims folder. 
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11.4 "RR" Forms 

RR-5, Request for SSA Medical Evidence

Use

Form RR-5, Request for SSA Medical Evidence, is used by Field Service and 

Disability staff to secure medical evidence and the disability decision from SSA

when a disability applicant has filed for or is receiving disability benefits under 

Title II (Disability Insurance Benefit; DIB) or Title XVI (Supplemental Security 

Income: SSI). It is not needed when, the SSA evidence is in the RRB claim 

folder. In most cases Field Service will release the form at the time of the 

applicant's filing. Disability may need to release the form in cases where it is 

determined the person has filed at SSA after having already filed at RRB.

Access

The form can be found on RRAILS.

Completion

Complete the RR-5 as follows:

Item Entry

1. SS Claim Number(s) Enter the social security claim number of 

the applicant

2. RRB Claim Number Enter the RRB claim number of the 

applicant

3. RR Employee’s Name Enter the name of the railroad employee

4. Disabled Person’s Name Enter the name of the applicant filing for 

disability benefits

5. Filed at SS District Office Enter the location of the SS field office 

where the applicant applied for SS benefits 

if known. Otherwise leave blank

6. Disabled Person’s Date of Birth Enter the applicant's date of birth

At the end of Part I the examiner should ensure the name of the requesting office

and the date the form is being released is correct and their name is entered. 

SSA will complete Part II of the form.
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Disposition

1. Email the RR-5 document to SSA. For instructions on scanning and sending 

the form by email to SSA, click here: How to Scan and Email Documents. 

2. Send the RR-5 document to IMAGING.

The adjudicating headquarters office is responsible for tracing for Form RR-5. 

See DCM 4.3.8C2 for tracing instructions.

11.5 SSA Forms

SSA-831-U3, Disability Determination and Transmittal (Social Security 

Administration)

Use

SSA-831-U3 is used to record joint freeze (JF) and Financial Interchange (FI) 

disability decisions. It is available on RRAILS. (See DCM 6.7.3 to determine 

when a JF and FI decision is made.) Instructions for items to be completed by

the RRB disability examiner or reconsideration specialist are shown below. 

Completion

RRB entries are 1 - 7, 9, 12, 15 - 16, 19 - 20, 25A, 27 (partial), 28 - 31, and 34

Item Entry

1 “DRS” is pre-filled

2 DDS code “992” is pre-filled

3 Self-explanatory

4 Enter the employee’s SSA number in the block labeled “SSN”. 

Leave the block labeled BIC empty.

5 Self-explanatory

6 Self-explanatory. Entry is only made for a widow or child with 

claim numbers ending in 30 (FI cases).

7 Check the FZ box for employees; check the DWD box for 

widows; check the CDB-D box for children.

9 Self-explanatory
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12 “RRB” is pre-filled

15 Complete if the decision is a grant and enter onset date. Check 

and complete Box B if the decision is a closed period of 

disability and enter the date the disability ceased.

16A & 16B Enter primary and secondary (if any) diagnoses. Leave Body 

Sys Box Blank. Enter 6-digit diagnostic code in CODE NO box. 

(See DCM 3, Appendix B for diagnostic codes.)

19 Complete in denial cases

• Check box A if the railroad employee’s DF insured status 

ends after the date of adjudication and in all widow and 

child cases.

• Check box B where the date that insured status is last 

met before the date of the current determination and the 

railroad employee is found not disabled on or before the 

date last insured (DLI). Enter the DLI after checking this 

box.

20 For employee, enter railroad job title, years of railroad service, 

and years of education. For widows and children, enter the 

corresponding information with job title and years of service for 

last non-railroad job in PRW period, if applicable. In all cases, 

enter “(91-40)” after the job title.

25A Self-explanatory

27 Enter RRB letter number to be released (e.g. RL-210 or RL-260 

for employees, NLN for widow or child) in the far right of the 

box. SSA fills out the other portions of this item.

28A Check box for employees and enter first full month of disability 

above the box.

28B Check box only for widows and children with a closed period of 

disability.

28C Check box in all allowances and enter onset date.

28D Check box for all allowances that are not closed periods.

28E Check box in all cases that are closed periods of disability and 

enter the last day of the second month after the disability 

ceased.
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29 If the railroad employee is not insured for a SSA Disability 

Insurance Benefit (DIB; cash annuity), enter the SSA letter 

number to be released (e.g. “SSA-810” or “SSA 813.1”). 

Enter “NLN” for railroad employees who are insured for a DIB 

as well as widows and children.

30 RRAILS should pre-fill your name. All decisions must be signed 

or initialed.

31 Self-explanatory

34 For employees enter onset date and Medicare effective date. If 

applicable, enter “20/40 insured for DIB”.

For widows and children, type “FI#” (FI Number) and 

“dependent RR annuitant”, and enter the claimant’s SS# and 

whether the annuitant is a widow or child.

NOTE: The SSA disability examiners will complete items 8, 10-11, 13-14, part of 

16, 17-18, 21-24, 26-27, 32-33, 35-38 as appropriate for the type of decision.

Disposition

The form is placed on the left side in the claims folder before sending to SSA for 

JF or FI decision. Items 32, 33, and 37 will be completed when SSA agrees with 

the decision proposed by RRB. SSA will make a copy of the SSA-831 for their 

records. The form remains in the file when returned to RRB.

SSA-2506-BK, Psychiatric Review Technique Form (Social Security 

Administration) 

Use 

SSA-2506-BK is used by SSA (Disability Determination Services doctors and 

Administrative Law Judges) in assessing mental impairments. The form is also 

used by the medical consultants of the Railroad Retirement Board when 

assessing mental impairments in disability cases. The form is not completed by 

RRB disability examiners but is completed and forwarded from the RRB medical 

consultant in response to the request for G-137 Medical Consultant Opinion.

Disposition 

The form is placed on the right side of the folder, usually directly above the G137 series documents.
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SSA-4734-F4-SUP, Mental Residual Functional Capacity Assessment 

(Social Security Administration)

Use 

SSA-4734-F4-SUP is used by SSA (Disability Determination Services doctors and 

Administrative Law Judges) in assessing mental residual functional capacity in 

mental impairment cases. The form is also used by the medical consultants of the 

Railroad Retirement Board when assessing mental residual functional capacity in 

mental impairment cases. The form is not completed by RRB disability examiners, 

but is completed and forwarded from the RRB medical consultant in response to 

the request for G-137 Medical Consultant Opinion.

Disposition 

The form is placed on the right side of the folder, usually directly above the G137 series documents.