3220-0038

OMB NO. 3220-0038

Justification

Medical Reports

RRB Forms G-3EMP, G-197, G-250, G-250a, G-260, RL-11b, RL-11d and RL-250

1. Circumstances of information collection - Under Sections 2(a)(1)(iv), of the Railroad Retirement Act (RRA), annuities are payable to qualified railroad employees whose physical or mental condition is such that they are unable to (1) work in their regular occupation (occupational disability) or (2) work at all (permanent total disability). The requirements for establishment of disability and proof of continuance of disability under the RRA are prescribed in 20 CFR 220.

Under Sections 2(c) and 2(d) of the RRA, annuities are also payable to qualified spouses and survivors of the employee. Under sections 2(c)(1)(ii)(C) and 2(d)(1)(ii), annuities are payable to spouses and widow(ers), respectively, who have a qualified child who is under a disability which began before age 22. Annuities are also payable to surviving children on the basis of disability under Section 2(d)(1)(iii)(C) if the child’s disability began before age 22 and to widow(ers) on the basis of disability under section 2 (d)(1)(1)(B). To meet the disability standard, the Railroad Retirement Act provides that individuals must have a permanent physical or mental condition such that they are unable to engage in any regular employment.

Under section 2(d)(1)(v) of the RRA, annuities are also payable to remarried and surviving divorced spouses on the basis of, inter alia, disability or having a qualified disabled child in care. However, the disability standard applicable in these cases is that found in the Social Security Act. That is, individuals must be unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment. The RRB also determines entitlement top a period of disability and early Medicare entitlement for qualified claimants in accordance with section 216 of the Social Security Act.

When making disability determinations, the RRB needs evidence from acceptable medical sources (See 20 CFR 220.46.404.1513).

2. Purposes of collecting/consequences of not collecting the information - To enable the RRB to determine the eligibility of an applicant or annuitant for disability benefits under the Railroad Retirement Act, the RRB requests supportive medical evidence from railroad employers, personal physicians, private hospitals, and state agencies. Obtaining needed medical evidence is currently accomplished by the use of request Forms G-3EMP, G-197, G-250, G-250a, G-260, RL-11b and RL-11d.

Information about the medical reports forms follow:

Form G-3EMP, Report of Medical Condition by Employer, obtains medical information relevant to an employee's inability to work from the medical officer or official of an applicant's or annuitant's railroad employer.

Form G-3EMP is initiated by an RRB field office and is transmitted by Form RL-11. The RL-11 includes instructions for furnishing the requested information, identifying employee information, and the employee's consent for the disclosure of the medical records. The consent statement, Form G-197, is enclosed with Forms RL-11 and G-3EMP, as well as a self-addressed return envelope. The RRB field office enters the identifying employee information requested in the top portion of the Form G-3EMP as well as the return address, before it is released. After completing the G-3EMP, the employer mails it back to the RRB field office.

The RRB proposes no changes to Form G-3EMP.

Form G-250, Medical Assessment is sent by an RRB field office to a disability claimant’s treating physician or consulting physician to obtain a medical assessment of the claimant’s ability to perform basic mental and/or physical work-related activities. The physician is asked to describe any limitations and cite specific medical findings. Form G-250 is transmitted to the treating physician by proposed Form RL-250, Request for Medical Assessment, either:

• at the time of the initial application for a disability annuity or

• when making a determination concerning the continuance of a disability annuity.

In some situations, the RRB may request a consulting physician to conduct a medical examination of a disability claimant. This is done when a disability claimant’s treating physician is not available or when the medical information provided by the treating physician in response to the Form RL-250 is incomplete or inconsistent.

Based on the impairments identified by the physician, Form G-250 obtains a medical assessment in one or more of the following areas:

• musculoskeletal system

• cardiovascular system

• respiratory system

• neurological system

• vision/hearing/speech

• mental functions

• other systems and impairments

• exertional restrictions

• environmental restrictions

The physician would answer an initial Yes/No question. If there is an impairment or restriction in that particular system, the physician would (1) answer a series of related questions, (2) provide a brief synopsis of the medical findings, and, in some cases, (3) be asked to provide copies of specific medical records for inclusion with the form.

After completing the G-250, the physician signs it and returns it to the initiating RRB field office.

Form G-250 is similar to and is modeled after RRB Form G-250a, SSA–4737 and SSA-4734-F4-SUP.

The RRB proposes no changes to Form G-250

Form G-250a, Medical Assessment of Residual Functional Capacity, is used by the RRB Bureau of Hearings and Appeals (H&A) to assist hearings officers at the appeals stage in making residual functional capacity determinations which require a more precise level of information beyond merely that he claimant is limited in his ability to walk, sit, stand etc that the G-250 may not. It is sent to a disability claimant's treating physician or to a consulting physician, along with a personalized cover letter, to obtain a medical assessment of the claimant's ability to perform basic mental and/or physical work-related activities. The physician is also asked to relate any limitations to specific medical findings.

Completion of Form G-250a is self-explanatory. The G-250a obtains a medical assessment of a claimant's residual functional capacity in one or more of the three following areas.

• exertional restrictions for all claimants with physical impairments;

• environmental restrictions for all claimants as applicable; or

• mental restrictions for all claimants with mental impairments.

The physician indicates these restrictions through the use of check blocks provided on the form. Additional space is also provided for the physician to furnish a brief narrative relating the medical findings which support the restrictions assessed.

After completing the G-250a, the physician signs it and returns it to the initiating RRB field office.

Form G-250a is similar to and is modeled after Forms SSA-4734 and SSA-4734-F4-SUP, OMB No. 0960-0431.

The RRB proposes no changes to Form G-250a.

Form G-260, Report of Seizure Disorder, is furnished by an RRB field office to a disability applicant or annuitant who indicates that the disabling condition includes seizures. The form is used to obtain evidence to support the claim of disability from the individual's personal physician. The items on Form G-260 are designed to guide the physician in furnishing medical information relating to the applicant's seizure disorder.

Completion of the G-260 is self explanatory. The identifying information is entered by the RRB field office before it releases the form. After completing the form, the physician mails it directly to the RRB field office.

The RRB proposes no changes to Form G-260.

Form RL-11b, Disclosure of Hospital Medical Records, is furnished by an RRB field office to a private hospital for obtaining records pertinent to the disability of an applicant or annuitant who is or was a patient at a hospital. The form is accompanied by the consent authorization Form G-197.

Completion of Form RL-11b is self-explanatory. Identifying information, as well as a return address is entered by the initiating RRB field office before release. After completing the form, the hospital mails it directly to the field office.

The RRB proposes to no changes to Form RL-11b.

Form RL-11d, Disclosure of Medical Records from a State Agency, is used by an RRB field office to obtain medical evidence to an applicant’s or an annuitant’s disability from a state agency that pays workers' compensation or other public disability benefits. In cases where the individual was, or is, hospitalized, hospital records will not be requested (Form RL-11b), unless the evidence from the state has to be supplemented.

The consent authorization Form G-197, is enclosed with Form RL-11d.

Completion of Form RL-11d is self-explanatory. Identifying information, as well as a return address, is entered by the initiating RRB field office before release. After completing the form, the state agency mails it directly to the field office.

The RRB proposes no changes to Form RL-11d.

Form RL-250, Request for Medical Assessment, will be released by an RRB field office to a disability applicant’s treating physician to secure copies of all pertinent office records on the claimant’s treatment for at least the last 12 months, copies of all available laboratory, hospital, and consultative reports, and requests completion of Form G-250, Medical Assessment, which is enclosed along with a consent authorization, Form G-197. Identifying information, as well as a return address, is provided by the initiating RRB office before release.

The RRB proposes no changes to Form RL-250.

Form G-197, Authorization to Disclose Information to the Railroad Retirement Board, is used by the RRB to obtain consent of the applicant or annuitant for the release of medical information and related medical evidence/records. The RRB requests an applicant or annuitant complete a separate Form G-197 for each medical source to be contacted. The completed Form G-197 is then enclosed with the particular request form sent to a medical source.

The Social Security Administration has a similar need for medical evidence to support disability claims. Form G-197 closely resembles SSA’s Form-827, Authorization to Release Medical Information to the Social Security Administration. In addition, the consent statement contained on Form G-197 complies with the Health Insurance Portability and Accountability Act (HPIAA) and the special requirements for disclosure of treatment for drug abuse and/or alcoholism under the Drug Abuse Office Treatment Act and the Comprehensive Alcohol Abuse and Alcoholism, Prevention, Treatment, and Rehabilitation Acts.

The RRB proposes no changes to Form G-197.

3. Planned use of improved information technology or technical/legal impediments to further burden reduction – The G-3EMP is being planned for conversion to electronic submission at some point. However, the minimal volume of the form relegates it a relative low priority. Forms G-250, G-250a, and G-260 are not practicable because the forms are initiated by the RRB and are part of a larger process that requires a face-to-face-interview. Forms RL-11b and RL-11d are not practicable because forms are initiated by the RRB with prefilled data.

4. Efforts to identify duplication -This information collection does not duplicate any other RRB information collection.

5. Small business respondents - N.A.

6. Consequences of less frequent collections - N.A.

7. Special Circumstances - N.A.

8. Public comments/consultations outside the agency In accordance with 5 CFR 1320.8(d) comments were invited from the public regarding the information collection. The notice to the public was published on page 12476 and 12477 the March 7, 2008, Federal Register. No comments or requests for additional information were received from the public.

9. Payments or gifts to respondents - None

10. Confidentiality - RRB-22, Railroad Retirement, Survivor and Pension Benefit System.

11. Sensitive questions – The authorization to disclose was developed to better comply with the provisions regarding disclosure of medical and other information under P.L. 104-191 (the Health Insurance Portability and Accountability Act). Further, under 42 CFR Part 2, implementing the Drug Abuse Office Treatment Act and the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act, information about treatment for alcoholism or drug abuse should not be disclosed without the patient's special consent. Under these regulations, the source is responsible for determining if, and to what extent, the information is relevant to the purpose for which it is being requested. Elements necessary for meeting both of these requirements are incorporated into Form G-197

12. Estimate of respondent burden - The current burden for this collection is unchanged as follows:

Current Burden

Form #	Annual Responses	Time (Min)	Burden (Hrs)
G-3EMP	600	10	100
G-197	6,000	10	1,000
G-250	11,950	30	5,975
G-250a	50	20	17
G-260	100	25	42
RL-11b	5,000	10	833
RL-11d	250	10	42
RL-250	11,950	10	1,992
Total	35,900		10,001

13. Estimate of annual cost to respondents or record keepers - N.A.

14. Estimated cost to the Federal Government - N.A.

15. Explanation for changes in burden – There is no change to the RRB’s burden estimate. When OMB last approved the collection, they approved it “without change” from what was submitted by the RRB. The annual response data OMB entered into their automated system is erroneous. The RRB previously submitted 35,900 responses, not 35,000. Despite several attempts, we have been unable to reach anyone at OMB to correct the discrepancy.

16. Time schedule for data collection and publication - The results of this collection will not be published.

17. Request to not display OMB expiration date - The forms associated with this collection are seldom revised. Given the costs associated with redrafting, reprinting, and distributing the forms in order to keep the appropriate OMB expiration date in place, the RRB requests the authority to not display the expiration date on the forms.

18. Exceptions to Certification Statement - None