Supplemental Information on Accident and Insurance

ICR 200511-3220-004

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
33850 Migrated
ICR Details
3220-0036 200511-3220-004
Historical Active 200504-3220-001
RRB
Supplemental Information on Accident and Insurance
Revision of a currently approved collection   No
Regular
Approved without change 01/11/2006
Retrieve Notice of Action (NOA) 11/28/2005
  Inventory as of this Action Requested Previously Approved
01/31/2009 01/31/2009 06/30/2008
28,500 0 28,500
1,693 0 1,691
0 0 0

The Railroad Unemployment Insurance Act provides for the recovery of sickness benefits paid if an employee receives a settlement for the same injury for which benefits were paid. The collection obtains information about the person or company responsible for such payments that is needed to determine the amount of the RRB's entitlement.

None
None


No

1
IC Title Form No. Form Name
Supplemental Information on Accident and Insurance ID-3S, SI-1C, SI-5, ID-3S-1, ID-3U, ID-30K, ID-30K-1

  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 28,500 28,500 0 0 0 0
Annual Time Burden (Hours) 1,693 1,691 0 0 2 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.
11/28/2005


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