Information Collection

Medical Reports

IC 185885 under ICR 201412-3220-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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 RL-11D Medical Reports	Form and Instruction
RL-11D Disclosure of Medical Records from a State Agency Form RL-11D (12-11).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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	RL-11D	Disclosure of Medical Records from a State Agency	Form RL-11D (12-11).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: 79 FR 58874

Number of Respondents: 250

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	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

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.