UI-38S (11-08) School Attendance and Availability Questionnaire

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

FORM APPROVED
O.M.B. NO.3220-0164

SCHOOL ATTENDANCE AND AVAILABILITY QUESTIONNAIRE

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 "UNKNOWN" 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 "Go to" another item.
Do not skip items unless instructed to skip. Stop after completing Item 13.
If this form was mailed to you, retum 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 Act/Privacy Act Notices

This notice is given under the Paperwork Reduction Act of 1995 and the Privacy Act of 1974. Under
section 12( I) 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
of our estimate or any other aspect 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.

UI-38s (11-08)

UNITED STATES OF AMERICA
RAILROAD RETIREMENT BOARD

FORM APPROVED

OMB NO.322Q-0164

SOCIAL SECURITY NUMBER

SCHOOL ATTENDANCE AND
AVAILABILITY QUESTIONNAIRE

NAME (First, Middle Initial, Last)

SECTION 1 - SCHOOL INFORMATION

1. a. Are you now attending school or are you planning to attend school within the next 6 months?
DYes - Complete Item 1b.

0

No - Go to Item 13.

b. NAME OF SCHOOL: _____________________________________________
LOCATION: ________________________________________________
COURSE OF STUDY: __________________________________________
DATE SCHOOL BEGINS: __________________________________________
DATE SCHOOL ENDS: __________________________________________

2. What are your present class hours?
TO

A.M.

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,
Yes
No - Explain below.
other railroad employer or nonrailroad employer?

0

0

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

0

UI-38s (11-08)

0

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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?
DYes

c.

6. a.

0

No - Go to Item 6a.

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

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.

T

_ _ _ _ _ _ _ __

7. Do you receive any education allowances such as payments under the GI Bill, etc?

0

DYes - Specify below. '

No

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?
DYes - Explain below.

0

No

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UI-38s (11-08)

SECTION 3 - PREVIOUS EMPLOYMENT/REMARKS

11. Have you previously worked full-time while attending school?

o Yes - Complete Items 11 a-f.

o No - Go to Item 12.

a. Enter the name and address of the employer. _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
b.

How many hours per week did you work? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

c.

What months and years were you so employed? _ _ _ _ _ _ _ _ _ _ _ _ _ __

d.

How many credit hours did you carry in school at the time? _ _ _ _ _ _ _ _ _ __

e.

How many credit hours do you carry now? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

f.

What caused the previous work-school situation to end? _ _ _ _ _ _ _ _ _ _ __

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

SECTION 4 - CERTIFICATION

13. I 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 RRB USE ONLY

Interviewed by: _ _ _ _ _ _ _ _ _ _ _ _ _ __

Remarks:

UI-38s (11-08)

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