UI-38S (current) School Attendance and Availability Questionnaire

I

SCHOOL ATTENDANCE AND AVAILABILITY QlIESrIONNAIRE

INSTRUCTIONS
Print all answers in ink as neatly as possible. If you need more space for answers, attach a separate sheet of
paper identified with your name and social security number. If you do not know the answer to a question, print
"UIVKNOWN" in the answer space. If you do not understand this form or need help to complete it, contact the
RRB office shown below.
Complete items 1 through 12 of this form unless the instructions tell you to skip to another item. Stop after
.
completing item 13. Do not skip items unless instructed to skip.
If this form was mailed to you, return it using the enclosed envelope. If you do not have the preaddressed
envelope, mail the form with sufficient postage to the following office of the U.S. Railroad Retirement Board:

Paperwork ReductionlPrivacy Act Notice
This notice is given under the Privacy Act of 1974 and the Paperwork Reduction Act of 1995. Under section 12( 1 ) of the
Railroad Unemployment Insurance Act, the RRB is authorized to collect the information requested on this form. The
information will be used to determine your availability for work, and your eligibility for benefits. While you are not required
to provide us with this information, your failure to do so may prevent us from paying you additional benefits.
We estimate this form takes an average of 6 to 10 minutes per response to complete, including the time for reviewing the
completed form. Federal agencies may not conduct or sponsor, and respondents are not required to respond to, a
collection of information unless it displays a valid OMB number. If you wish, send comments regarding the accuracy of our
estimate or any other aspects of this form, including suggestions for reducing the completion time to
Chief of Information Resources Management, Railroad Retirement Board, 844 North Rush Street, Chicago, IL 60611-2092.

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

FORM APPROVED
O.M.B. N0.3220-0164

SOCIAL SECURITY NUMBER

SCHOOL ATTENDANCE AND
AVAILABILITY QUESTIONNAIRE

SECTION 1 - SCHOOL INFORMATION
1. a. Are you now attending school or are you planning to attend school
within the next 6 months .................................................................

Yes

a

No

a

IF "NO," go to item 13.
b. If you answered "YES," complete the following:
NAME OF SCHOOL
LOCATION
COURSE OF STUDY
DATE SCHOOL BEGINS
DATE SCHOOL ENDS
2.

What are your present class hours?

P.M.

A.M.

P.M.

A.M.

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

3.

How far do you reside from school?

4.

Are you willing to quit school at once to accept full-time work with your last railroad employer,
No
other railroad employer or non-railroad employer?
Yes
If "NO," please explain:

5. a.

Has your school attendance prevented you from accepting any full-time job since you began claiming
No
benefits?
Yes

miles.

a

a

a

a

b.

Has your school attendance caused you to refuse a call to work or to miss a call
to work? Yes
No
If "NO," go to item 6a.

c.

Please show the date(s) on which the event(s) occurred. Please explain the circumstances
in detail:

6. a.

a

a

Show the amount you paid for tuition and books for the present semester or term: $

b.

Give the date this amount was paid:

c.

How much of this amount could you recover if you quit school now? $
Do you receive any education allowances such as payments under the GI Bill, etc?
Yes
No
If "YES," please specify:

7.

a

a

SECTION 2 - PROSPECTS FOR EMPLOYMENT
8. a.

b.

9.

When do you expect to return to work? If unknown, please estimate.

If you expect to return to work within 30 days, please furnish the name and address of your
expected employer:

List the names and addresses of employers whom you have contacted for full-time work and the
dates of application: (Use the back of this form if necessary).
DATE APPLIED

10.

NAME AND ADDRESS OF EMPLOYER

Would you work a regular full-time job for one of the above employers or any other employer
offering suitable work and continue your school attendance while working?
No
If "YES," please explain:
Yes

a

a

SECTION 3 - PREVIOUS EMPLOYMENTIREMARKS
11. Have you previously worked full-time while attending school?
YesQ
NoQ
If "YES," please answer the following questions:
If "NO," go to item 12.
a. Name and address of employer:
b.
c.
d.
e.
f.

How many hours per week did you work?
What months and years were you so employed?
How many credit hours did you carry in school at the time?
How many credit hours do you carry now?
What caused the previous work-school situation to end?

12. Remarks (include any other information you wish to add):

SECTION 4 - CERTIFICATION
13. 1 CERTIFY THAT THE INFORMATION I HAVE PROVIDED ON THIS FORM IS TRUE AND
COMPLETE. I KNOW THAT I MUST IMMEDIATELY REPORT TO THE RAILROAD RETIREMENT
BOARD ANY CHANGES WHICH MIGHT AFFECT MY ENTITLEMENT TO BENEFITS. I
UNDERSTAND THAT A SUBSTANTIAL PENALTY MAY BE IMPOSED ON ME FOR FALSE OR
FRAUDULENT STATEMENTS OR CLAIMS.

SIGNATURE

DATE SIGNED

STOP HERE. Item 13 is the last item for you to complete on this form. Take time now to go back over this
form to make sure you answered each item accurately and completely. If you are about to be interviewed,
give this form to the RRB representative who will interview you. If you received this form by mail, return it in
the enclosed preaddressed envelope.
FOR BOARD USE ONLY
Interviewed by:
Remarks: