SUPPLEMENTAL INFORMATION ON ACCIDENT AND INSURANCE

ICR 199304-3220-002

OMB: 3220-0036

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
157376 Migrated
ICR Details
3220-0036 199304-3220-002
Historical Active 199205-3220-002
RRB
SUPPLEMENTAL INFORMATION ON ACCIDENT AND INSURANCE
Extension without change of a currently approved collection   No
Regular
Approved without change 06/11/1993
Retrieve Notice of Action (NOA) 04/08/1993
  Inventory as of this Action Requested Previously Approved
06/30/1996 06/30/1996 07/31/1993
12,426 0 33,550
1,970 0 1,970
0 0 0

THE RUIA PROVIDES FOR RECOVERY OF SICKNESS BENEFITS PAID IF THE EMPLOY RECEIVES A SETTLEMENT FOR THE SAME INJURY FOR WHICH BENEFITS WERE PAID THE COLLECTION OBTAINS IDENTIFYING INFORMATION ABOUT THE PERSON OR COMPANY RESPONSIBLE FOR SUCH PAYMENTS AND INFORMATION NEEDED FOR DETERMINING THE AMOUNT OF THE RAILROAD RETIREMENT BOARD'S ENTITLEMENT.

None
None


No

1
IC Title Form No. Form Name
SUPPLEMENTAL INFORMATION ON ACCIDENT AND INSURANCE SI-1C, SI-5, ID-3S, ID-30K, ID-30Q, ID-3U

  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 12,426 33,550 0 -21,124 0 0
Annual Time Burden (Hours) 1,970 1,970 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.
04/08/1993


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