Medical Reports

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0038 can be found here:

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 (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
RL-11D1 Request for Medical Evidence from Employers Form RL-11D1 (Proposed).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 (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

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 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	30,250	600	29,650
Annual IC Time Burden (Hours)	9,159	200	8,959
Annual IC Cost Burden (Dollars)	0	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.