Information Collection

Medical Reports

IC 185885 under ICR 202312-3220-002 · OMB 3220-0038.

Documents and Forms

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 (01-21).pdf Form and Instruction
RL-11D Disclosure of Medical Records from a State Agency Form RL-11D (01-21).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	Disclosure of Medical Records from a State Agency	Form RL-11D (01-21).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 %

	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.