Information Collection

Railroad Unemployment Insurance Act Applications

IC 179107 under ICR 200703-3220-001 · OMB 3220-0039.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0039 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SI-1b Railroad Unemployment Insurance Act Applications	Form and Instruction
SI-1b Statement of Sickness SI-1b (02-01).pdf http:www.rrb.gov/pdf/PandS/ub11.pdf	Form and Instruction
SI-7 Supplemental Doctor's Statement SI-7 (02-01).pdf	Form and Instruction
SI-8 Verification of Medical Information SI-8 (02-01).pdf	Form and Instruction
Form UB-11 (11-06).pdf Sickness Benefits for Railroad Employees	IC Document

IC Title:

Railroad Unemployment Insurance Act Applications

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 355

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SI-1b	Statement of Sickness	SI-1b (02-01).pdf	http:www.rrb.gov/pdf/PandS/ub11.pdf	Yes	No	Printable Only
Form and Instruction	SI-7	Supplemental Doctor's Statement	SI-7 (02-01).pdf		No		Paper Only
Form and Instruction	SI-8	Verification of Medical Information	SI-8 (02-01).pdf		No		Paper Only

Line of Business: Income Security

Subfunction: Unemployment Compensation

Privacy Act System of Records

Title: RRB-21, Railroad Unemployment and Sickness Insurance Benefit System

FR Citation: 40 FR 36275

Number of Respondents: 22,200

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	55,850	55,850
Annual IC Time Burden (Hours)	7,444	7,444
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Sickness Benefits for Railroad Employees	Form UB-11 (11-06).pdf	11/01/2006

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.