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United States of America

Form Approved

Railroad Retirement Board

OMB No. 3220-0039

Statement of Sickness

Instructions:

This form is to be executed by (1) a doctor trained in medical, surgical, dental or psychological diagnosis of

the infirmity described, (2) a certified nurse/midwife in cases of pregnancy or childbirth, (3) a supervisory official of a

hospital or similar institution, (4) a chiropractor, (5) a Physician Assistant - Certified, or (6) a nurse practitioner. This form

should be completed and returned to the patient immediately for prompt mailing; otherwise he/she may lose benefits.

Supplementary medical information may be attached or furnished directly to the Railroad Retirement Board (RRB) at the

address shown below. If such information is furnished, please include the patient's social security number and name on the

report. Please complete section 2 on the reverse side if patient is incapable of signing forms.

The RRB is not liable for any charge in connection with completing this form.

Patient's Name (First, Middle, and Last)

Patient's Social Security Number

Have you examined or treated the patient for his or her injury or illness?

Yes

No – Go to Item 9

Date patient became sick or injured

List all dates of examination and treatment for this infirmity

Probable date of next examination

Diagnosis and concurrent conditions

Does the patient's condition require surgery?

Yes

No – Go to Item 6

Date on which surgery was or will be performed

Surgical procedure that was or will be performed

Does the patient's condition require hospitalization?

Yes – Enter the period of hospital confinement: From

If patient is not working because of maternity or childbirth, complete 7a and 7b.

a. Date patient became unable to work

b. Estimated or actual date of delivery

Give the date you believe the patient became or will become able to resume work in his or her occupation.

(If indefinite or unknown, please give an estimated date.)

I certify that the information I am giving is true, complete, and correct. I understand that criminal and civil penalties may be imposed

.....on me for false or fraudulent statements or for withholding information to cause or prevent payment of benefits by the RRB.

Please print or type:

Name of Doctor

Degree/ Title

Signature of Doctor

Address

Date

Office Telephone Number (Include Area Code)

(

)

National Provider Identifier

PAPERWORK REDUCTION ACT NOTICE TO DOCTOR

Medical evidence is needed to support the payment of claims for sickness benefits under the Railroad Unemployment Insurance Act (RUIA). The RRB is

authorized to collect this information under section 12(i) of the RUIA. You are not required to furnish this information. If you do not, however, no benefits

can be paid to your patient. We estimate this form and the form on the back of this page take an average of 8 and 6 minutes to complete, respectively.

The estimates include the time for reviewing the instructions, getting the needed data, and reviewing the completed forms. Federal agencies may not

conduct or sponsor, and respondents are not required to respond to, a collection of information unless it displays a valid OMB number. If you wish, send

comments regarding the accuracy of our estimate or any other aspect of this form, including suggestions for reducing completion time, to the Chief of

Information Resources Management, Railroad Retirement Board, 844 N Rush Street, Chicago, Illinois, 60611-2092. Send completed forms to:

U.S. RAILROAD RETIREMENT BOARD

OFFICE OF PROGRAMS — OPERATIONS

POST OFFICE BOX 10695

CHICAGO, ILLINOIS 60610-0695

FORM SI-1b (06-09)

Doctor: See Reverse Side