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⚠️ Notice: This information collection may be referencing outdated material.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 RL-11d (11-02) Medical Reports Form and Instruction
RL-11d (11-02) Disclosure of Medical Records from a State Agency Form RL-11D (11-02).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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	RL-11d (11-02)	Disclosure of Medical Records from a State Agency	Form RL-11D (11-02).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: 75 FR 43727

Number of Respondents: 250	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	250	250
Annual IC Time Burden (Hours)	42	42
Annual IC Cost Burden (Dollars)	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.