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Application And Claim For Sickness Insurance Benefits
APPLICATION AND CLAIM FOR SICKNESS INSURANCE BENEFITS
OMB: 3220-0039
IC ID: 157398
OMB.report
RRB
OMB 3220-0039
ICR 199005-3220-003
IC 157398
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0039 can be found here:
2023-08-02 - No material or nonsubstantive change to a currently approved collection
2020-08-24 - Revision of a currently approved collection
Documents and Forms
Document Name
Document Type
no available documents/forms check other ICs listed under this ICR
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
APPLICATION AND CLAIM FOR SICKNESS INSURANCE BENEFITS
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:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
SI-3
No
No
Form
SI-7
No
No
Form
SI-7A
No
No
Form
ID-7H
No
No
Form
ID-11A
No
No
Form
SI-1A/1B
No
No
Federal Enterprise Architecture Business Reference Module
Line of Business:
Subfunction:
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
115,500
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
412,550
0
0
-35,876
0
448,426
Annual IC Time Burden (Hours)
19,579
0
0
929
0
18,650
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.