Medical Reports

Medical Reports

OMB: 3220-0038

IC ID: 33854

Information Collection (IC) Details

View Information Collection (IC)

Medical Reports
 
No Modified
 
Voluntary
 
20 CFR 220

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction G-3EMP Report of Medical Condition by Employer Form G-3EMP (08-15).pdf No   Paper Only
Form and Instruction G-250 Medical Assessment Form G-250 (08-15).pdf No   Paper Only
Form and Instruction G-250A Medical Assessment of Residual Functional Capacity Form G-250A (08-15).pdf No   Paper Only
Form and Instruction G-260 Report of Seizure Disorder Form G-260 (08-15).pdf No   Paper Only
Form and Instruction RL-11B Disclosure of Hospital Medical Records Form RL-11B (09-05).pdf No   Paper Only
Form and Instruction RL-250 Request for Medical Assessment Form RL-250 (09-05).pdf No   Paper Only
Form and Instruction RL-11D1 Request for Medical Evidence from Employers Form RL-11D1 (Proposed).pdf No   Paper Only

Income Security General Retirement and Disability

RRB-22, Railroad Retirement, Survivor and Pension Benefit System   79 FR 58874

30,250 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 30,250 0 600 0 0 29,650
Annual IC Time Burden (Hours) 9,159 0 200 0 0 8,959
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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

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