Information Collection

Medical Reports

IC 33854 under ICR 201912-3220-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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 G-3EMP Medical Reports	Form and Instruction
G-3EMP Report of Medical Condition by Employer Form G-3EMP (08-15).pdf	Form and Instruction
G-250 Medical Assessment Form G-250 (08-15).pdf	Form and Instruction
G-250A Medical Assessment of Residual Functional Capacity Form G-250A (08-15).pdf	Form and Instruction
G-260 Report of Seizure Disorder Form G-260 (08-15).pdf	Form and Instruction
RL-11B Disclosure of Hospital Medical Records Form RL-11B (09-05).pdf	Form and Instruction
RL-250 Request for Medical Assessment Form RL-250 (09-05).pdf	Form and Instruction
G-3EMP (Proposed) Report of Medical Condition by Employer G-3EMP Proposed.pdf	Form and Instruction
G-250 (Proposed) Medical Assessment G-250 Proposed.pdf	Form and Instruction
G-250A (Proposed) Medical Assessment of Residual Functional Capacity G-250A Proposed.pdf	Form and Instruction
G-260 (Proposed) Report of Seizure Deisorder G-260 Proposed (2).pdf	Form and Instruction
RL-11B (Proposed) Disclosure of Hospital Medical Records RL11B Proposed.pdf	Form and Instruction
RL-250 (Proposed) Request for Medical Assessment RL250 Proposed.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	Available 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	G-3EMP (Proposed)	Report of Medical Condition by Employer	G-3EMP Proposed.pdf	No	Paper Only
Form and Instruction	G-250 (Proposed)	Medical Assessment	G-250 Proposed.pdf	No	Paper Only
Form and Instruction	G-250A (Proposed)	Medical Assessment of Residual Functional Capacity	G-250A Proposed.pdf	No	Paper Only
Form and Instruction	G-260 (Proposed)	Report of Seizure Deisorder	G-260 Proposed (2).pdf	No	Paper Only
Form and Instruction	RL-11B (Proposed)	Disclosure of Hospital Medical Records	RL11B Proposed.pdf	No	Paper Only
Form and Instruction	RL-250 (Proposed)	Request for Medical Assessment	RL250 Proposed.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: 30,250

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 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	30,250	30,250
Annual IC Time Burden (Hours)	9,159	9,159
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.