Information Collection

Medical Reports

IC 33854 under ICR 200807-3220-002 · OMB 3220-0038.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0038 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form G-3EMP (07-00) Medical Reports	Form and Instruction
G-3EMP (07-00) Report of Medical Condition by Employer Form G-3EMP (07-00).pdf	Form and Instruction
G-250 (09-05) Medical Assessment Form G-250 (09-05).pdf	Form and Instruction
G-250A (09-05) Medical Assessment of Residual Functional Capacity Form G-250A (09-05).pdf	Form and Instruction
G-260 (07-00) Report of Seizure Disorder Form G-260 (07-00).pdf	Form and Instruction
RL-11B (09-05) Disclosure of Hospital Miedicare Records Form RL-11B (09-05).pdf	Form and Instruction
RL-250 (09-05) Request for Medical Assessment Form RL-250 (09-05).pdf	Form and Instruction

IC Title:

Medical Reports

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 20 CFR 220

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form and Instruction	G-3EMP (07-00)	Report of Medical Condition by Employer	Form G-3EMP (07-00).pdf	No	Paper Only
Form and Instruction	G-250 (09-05)	Medical Assessment	Form G-250 (09-05).pdf	No	Paper Only
Form and Instruction	G-250A (09-05)	Medical Assessment of Residual Functional Capacity	Form G-250A (09-05).pdf	No	Paper Only
Form and Instruction	G-260 (07-00)	Report of Seizure Disorder	Form G-260 (07-00).pdf	No	Paper Only
Form and Instruction	RL-11B (09-05)	Disclosure of Hospital Miedicare Records	Form RL-11B (09-05).pdf	No	Paper Only
Form and Instruction	RL-250 (09-05)	Request for Medical Assessment	Form RL-250 (09-05).pdf	No	Paper Only

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title: RRB-22, Railroad Retirement, Survivor and Pension Benefit System

FR Citation: 72 FR 73516

Number of Respondents: 29,650

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	29,650	-5,350	35,000
Annual IC Time Burden (Hours)	8,959	-1,042	10,001
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.