Medical Reports

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form G-260 Report of Seizure Disorder	Form and Instruction	Modified	Available
Form G-250A Medical Assessment of Residual Functional Capacity	Form and Instruction	Modified	Available
Form G-250 Medical Assessment	Form and Instruction	Modified	Available
Form RL-250 Request for Medical Assessment	Form and Instruction	Modified	Available
Form RL-11B Disclosure of Hospital Medical Records	Form and Instruction	Modified	Repair queued
Form G-260 Report of Seizure Disorder	Form and Instruction	Modified	Available
Form G-250A Medical Assessment of Residual Functional Capacity	Form and Instruction	Modified	Available
Form G-250 Medical Assessment	Form and Instruction	Modified	Available
Form G-3EMP Report of Medical Condition by Employer	Form and Instruction	Modified	Available
Form G-197 Authorization to Disclose Information to the Railroad Retirement Board	Form and Instruction	Modified	Available
Form G-197 Authorization to Disclose Information to the Railroad Retirement Board	Form and Instruction	Modified	Available
Form RL-11D Disclosure of Medical Records from a State Agency	Form and Instruction	Modified	Available
3220-0038.doc	Supporting Statement A	Uploaded 2015-02-25	Available
SSA-827 (11-12).pdf	Supplementary Document	Uploaded 2014-12-05	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
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	Request for Medical Assessment
33854	Medical Reports	Form and Instruction	Modified	Disclosure of Hospital Medical 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	Modified	Authorization to Disclose Information to the Railroad Retirement Board
185886	Authorization to Disclose Information to the Railroad Retirement Board	Form and Instruction	Modified	Authorization to Disclose Information to the Railroad Retirement Board
185885	Medical Reports	Form and Instruction	Modified	Disclosure of Medical Records from a State Agency

ICR Details

OMB Control No: 3220-0038	ICR Reference No: 201412-3220-001
Status: Historical Active	Previous ICR Reference No: 201111-3220-002
Agency/Subagency: RRB	Agency Tracking No:
Title: Medical Reports
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/27/2015
Retrieve Notice of Action (NOA)	Date Received in OIRA: 02/25/2015
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2018	36 Months From Approved	04/30/2015
Responses	35,900	0	35,900
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:
	79 FR 63653	10/24/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 78506	12/30/2014
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, G-197	Authorization to Disclose Information to the Railroad Retirement Board ,   Authorization to Disclose Information to the Railroad Retirement Board
Medical Reports	G-250, G-250A, G-250, G-3EMP, G-250A, G-260, RL-11B, RL-250, G-260	Report of Medical Condition by Employer ,   Medical Assessment ,   Medical Assessment of Residual Functional Capacity ,   Report of Seizure Disorder ,   Disclosure of Hospital Medical Records ,   Request for Medical Assessment ,   Medical Assessment ,   Medical Assessment of Residual Functional Capacity ,   Report of Seizure Disorder
Medical Reports	RL-11D	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	35,900	0	0	0	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? Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

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: 02/25/2015

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