Information Collection

Application For Sickness Benefits And Statement Of Sickness

IC 176975 under ICR 197504-3220-011 · OMB 3220-0039.

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Documents and Forms

Documents and forms in this information collection
Document Name	Document Type

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IC Title:

APPLICATION FOR SICKNESS BENEFITS AND STATEMENT OF SICKNESS

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	SI-1A				No	No
Form	SI-1B				No	No

Line of Business:

Subfunction:

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	100,000	100,000
Annual IC Time Burden (Hours)	13,333	13,333
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded

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