UI-38s (proposed) School Attendance and Availablity Questionnaire

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

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FORMAPPROVED

O.M.B. N0.3220-0164

SCHOOL ATTENDANCE AND AVAILABILITY QUESTIONNAIRE

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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 "LINKNOWN" in the answer space. If you do not
understand this form or need help to complete it, contact the RRB office shown below.
tell you to "Go to" another item.
Complete Items 1 through 12 of this form unless the instr~~ctions
Do not skip items unless instructed to skip. Stop after completing Item 13.
If this form was mailed to you, return it using the enclosed preaddressed envelope. If you do
not have the envelope, mail the form with sufficient postage to the following office of the U.S.
Railroad Retirement Board:

Paperwork Reduction ActIPrivacy Act Notices
This notice is given under the Paperwork Reduction Act of 1995 and the Privacy Act of 1974. 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 instructions, getting the needed data, and reviewing the completed form. Federal
agencies may not conduct or sponsor, and respondents are not required to respond to, a collection of
information unless it displays a valid OMB number. If you wish, send comments regarding the accuracy
o f our estimate or any other aspect of this form, including suggestions for reducing the compl'etion
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
OMB N0.3220-0164

1 SOCIAL SECURITY NUMBER

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SCHOOL ATTENDANCE AND
AVAlLABlLlTY QLIES'TIONNAIRE

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NAME (First, Middle Initial, Last)

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

a

Yes - Complete ltem I b .

NO - Go to ltem 13.

b. NAME OF SCHOOL:
LOCA-rION:
COURSE OF STUDY:
DATE SCHOOL BEGINS:
DATE SCHOOL ENDS:

2. What are your present class hours?
FROM
A.M.

TO
P.M.

A.M.

P.M.

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
3. How far do you reside from school?

miles.

4. Are you willing to quit school at once to accept full-time work with your last railroad employer,
other railroad employer, or nonrailroad employer?
No - Explain below.
Yes

0

5. a. Has your school attendance prevented you from accepting any full-time job since you began
ayes
claiming benefits?

L]NO

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5. b. Has your school attendance caused you to refuse a call to work or to miss a call to work?
Yes
[7 NO- Go to Item 6.

0

c.

Enter the date(s) on which the event(s) occurred and explain the circumstances in detail.

6. a.

Enter the amount you paid for tuition and books for the present semester or term. $

b. Enter the date this amount was paid.
c. Enter how much of this amount you could recover if you quit school now. $
7. Do you receive any education allowances such as payments under the GI Bill, etc?
Yes - Specify below.
No

0

SECTION 2 - PROSPECTS FOR EMPLOYMENT
8. a. Enter when you expect to return to work. If unknown, estimate.

b. If you expect to return to work within 30 days, enter the name and address of your expected
employer.

9. 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

NAME AND ADDRESS OF EMPLOYER

10. 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?
a y e s - Explain below.

0 No

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UI-38s (xx-08)

SECTION 3 - PREVIOUS EMPLOYMENTIREMARKS
11. Have you previously worked full-time while attending school?
D y e s - Complete Items 1la-f.

ONO
- Go to ltem 12.

a. Name and address of employer:
b.

How many hours per week did you work?

c.

What months and years were you so employed?

d.
e.
f.

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. ltem 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 onlLY

Interviewed by:
Remarks:

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