Information Collection

Medical Reports

IC 33854 under ICR 202312-3220-002 · OMB 3220-0038.

Documents and Forms

Document Name Document Type
Form G-3EMP Medical Reports Form and Instruction
G-3EMP Report of Medical Condition by Employer Form G-3EMP (01-21).pdf Form and Instruction
G-3EMP Report of Medical Condition by Employer Form G-3EMP (01-21).pdf Form and Instruction
G-250 Medical Assessment Form G-250 (01-21).pdf Form and Instruction
G-250 Medical Assessment Form G-250 (01-21).pdf Form and Instruction
G-250A Medical Assessment of Residual Functional Capacity Form G-250A (01-21).pdf Form and Instruction
G-250A Medical Assessment of Residual Functional Capacity Form G-250A (01-21).pdf Form and Instruction
G-260 Report of Seizure Disorder Form G-260 (01-21).pdf Form and Instruction
G-260 Report of Seizure Disorder Form G-260 (01-21).pdf Form and Instruction
RL-11B Disclosure of Hospital Medical Records Form RL-11B (01-21).pdf Form and Instruction
RL-11B Disclosure of Hospital Medical Records Form RL-11B (01-21).pdf Form and Instruction
RL-250 Request for Medical Assessment Form RL-250 (01-21).pdf Form and Instruction
RL-250 Request for Medical Assessment Form RL-250 (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	Available Electronically?	Electronic Capability
Form and Instruction	G-3EMP	Report of Medical Condition by Employer	Form G-3EMP (01-21).pdf	No	Paper Only
Form and Instruction	G-250	Medical Assessment	Form G-250 (01-21).pdf	No	Paper Only
Form and Instruction	G-250A	Medical Assessment of Residual Functional Capacity	Form G-250A (01-21).pdf	No	Paper Only
Form and Instruction	G-260	Report of Seizure Disorder	Form G-260 (01-21).pdf	No	Paper Only
Form and Instruction	RL-11B	Disclosure of Hospital Medical Records	Form RL-11B (01-21).pdf	No	Paper Only
Form and Instruction	RL-250	Request for Medical Assessment	Form RL-250 (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: 30,250	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	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

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.