APPLICATION AND STATEMENT OF SICKNESS - PREGNANCY, MISCARRIAGE, OR CHILDBIRTH

ICR 198102-3220-007

OMB: 3220-0095

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
3220-0095 198102-3220-007
Historical Active 197912-3220-005
RRB
APPLICATION AND STATEMENT OF SICKNESS - PREGNANCY, MISCARRIAGE, OR CHILDBIRTH
Reinstatement with change of a previously approved collection   No
Regular
Approved without change 02/19/1981
Retrieve Notice of Action (NOA) 02/19/1981
  Inventory as of this Action Requested Previously Approved
03/31/1981 03/31/1981
2,000 0 0
833 0 0
0 0 0

THE RAILROAD UNEMPLOYMENT INSURANCE ACT PROVIDES FOR THE PAYMENT OF SICKNESS BENEFITS TO QUALIFIED WOMEN RAILROAD EMPLOYEES FOR PREGNANCY, MISCARRIAGE OR CHILDBIRTH. THE APPLICATION AND STATEMENT WILL OBTAIN INFORMATION ABOUT THE APPLICANT'S EMPLOYMENT AND CONDITION. THE INFORMATION WILL BE USED FOR DETERMINING ENTITLEMENT TO AND ESTIMATED ENDING DATE OF THE BENEFITS APPLIED FOR.

None
None


No

1
IC Title Form No. Form Name
APPLICATION AND STATEMENT OF SICKNESS - PREGNANCY, MISCARRIAGE, OR CHILDBIRTH SI-2

  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 2,000 0 0 0 2,000 0
Annual Time Burden (Hours) 833 0 0 0 833 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.
02/19/1981


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