Medical Reports

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.