Medical Reports

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form RL-250 (09-05) Request for Medical Assessment	Form and Instruction	Modified	Repair queued
Form RL-11B (09-05) Disclosure of Hospital Miedicare Records	Form and Instruction	Modified	Available
Form G-260 (07-00) Report of Seizure Disorder	Form and Instruction	Modified	Available
Form G-250A (09-05) Medical Assessment of Residual Functional Capacity	Form and Instruction	Modified	Available
Form G-250 (09-05) Medical Assessment	Form and Instruction	Modified	Available
Form G-3EMP (07-00) Report of Medical Condition by Employer	Form and Instruction	Modified	Available
Form G-197 (09-05) Authorization to Disclose Information to the Railroad Retirement Board	Form and Instruction	New	Available
Form RL-11d (11-02) Disclosure of Medical Records from a State Agency	Form and Instruction	New	Repair queued
3220-0038.doc	Supporting Statement A	Uploaded 2008-09-29	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
33854	Medical Reports	Form and Instruction	Modified	Request for Medical Assessment
33854	Medical Reports	Form and Instruction	Modified	Disclosure of Hospital Miedicare Records
33854	Medical Reports	Form and Instruction	Modified	Report of Seizure Disorder
33854	Medical Reports	Form and Instruction	Modified	Medical Assessment of Residual Functional Capacity
33854	Medical Reports	Form and Instruction	Modified	Medical Assessment
33854	Medical Reports	Form and Instruction	Modified	Report of Medical Condition by Employer
185886	Authorization to Disclose Information to the Railroad Retirement Board	Form and Instruction	New	Authorization to Disclose Information to the Railroad Retirement Board
185885	Medical Reports	Form and Instruction	New	Disclosure of Medical Records from a State Agency

ICR Details

OMB Control No: 3220-0038	ICR Reference No: 200807-3220-002
Status: Historical Active	Previous ICR Reference No: 200504-3220-002
Agency/Subagency: RRB	Agency Tracking No:
Title: Medical Reports
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/03/2008
Retrieve Notice of Action (NOA)	Date Received in OIRA: 09/29/2008
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2011	36 Months From Approved	10/31/2008
Responses	35,900	0	35,000
Time Burden (Hours)	10,001	0	10,001
Cost Burden (Dollars)	0	0	0

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Abstract: The Railroad Retirement Act provides disability annuities for qualified railroad employees whose physical or mental condition renders them incapable of working in their regular occupation (occupational disability) or any occupation (total disability). The medical reports obtain information needed for determining the nature and severity of the impairment.

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Authorizing Statute(s): US Code: 45 USC 231f Name of Law: Railroad Retirement Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 12476	03/07/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 55881	09/26/2008
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
Authorization to Disclose Information to the Railroad Retirement Board	G-197 (09-05)	Authorization to Disclose Information to the Railroad Retirement Board
Medical Reports	G-3EMP (07-00), G-250 (09-05), G-250A (09-05), G-260 (07-00), RL-11B (09-05), RL-250 (09-05)	Report of Medical Condition by Employer ,   Medical Assessment ,   Medical Assessment of Residual Functional Capacity ,   Report of Seizure Disorder ,   Disclosure of Hospital Miedicare Records ,   Request for Medical Assessment
Medical Reports	RL-11d (11-02)	Disclosure of Medical Records from a State Agency

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	35,900	35,000	0	0	900	0
Annual Time Burden (Hours)	10,001	10,001	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 09/29/2008

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