SUPPLEMENTAL INFORMATION ON ACCIDENT AND INSURANCE

ICR 197909-3220-011

OMB: 3220-0047

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
157430 Migrated
ICR Details
3220-0047 197909-3220-011
Historical Active 197907-3220-024
RRB
SUPPLEMENTAL INFORMATION ON ACCIDENT AND INSURANCE
Extension without change of a currently approved collection   No
Regular
Approved without change 10/17/1979
Retrieve Notice of Action (NOA) 09/28/1979
  Inventory as of this Action Requested Previously Approved
10/31/1980 10/31/1980 10/31/1979
20,000 0 20,000
1,667 0 1,667
0 0 0

SECTION 12(0) OF THE RAILROAD UNEMPLOYMENT INSURANCE ACT PROVIDES FOR REIMBURSEMENT OF SICKNESS BENEFITS PAID IF THE EMPLOYEE RECIEVES A SETTLEMENT FOR THE SAME INJURY FOR WHICH THE BENEFITS WERE PAID. THE COLLECTION WILL OBTAIN INFORMATION ABOUT ANY PERSON OR COMPANY RESPONSIBLE FOR THE INJURY. THE INFORMATION WILL BE USED BY THE BOARD TO SEND A NOTICE OF LIEN TO THE PERSON OR COMPANY INVOLVED.

None
None


No

1
IC Title Form No. Form Name
SUPPLEMENTAL INFORMATION ON ACCIDENT AND INSURANCE SI-1C

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 20,000 20,000 0 0 0 0
Annual Time Burden (Hours) 1,667 1,667 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
09/28/1979


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