Railroad Unemployment Insurance Act Applications

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form SI-1b (02-01) Railroad Unemployment Insurance Act Applications Form and Instruction
SI-1b (02-01) Statement of Sickness SI-1b (02-01).pdf http:www.rrb.gov/pdf/PandS/ub11.pdf Form and Instruction
SI-7 (03-04) Supplemental Doctor's Statement Form SI-7 (03-04).pdf Form and Instruction
SI-8 (02-01) Verification of Medical Information SI-8 (02-01).pdf Form and Instruction
SI-7 (proposed) Supplemental Doctor's Statement Form SI-7 (proposed).pdf Form and Instruction
SI-8 (proposed) Verification of Medical Information Form SI-8 (proposed).pdf Form and Instruction
SI-1b (proposed) Statement of Sickness Form SI-1b (proposed).pdf Form and Instruction
Form UB-11 (11-06).pdf Sickness Benefits for Railroad Employees IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Railroad Unemployment Insurance Act Applications	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 355

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SI-1b (02-01)	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 (03-04)	Supplemental Doctor's Statement	Form SI-7 (03-04).pdf		No		Paper Only
Form and Instruction	SI-8 (02-01)	Verification of Medical Information	SI-8 (02-01).pdf		No		Paper Only
Form and Instruction	SI-7 (proposed)	Supplemental Doctor's Statement	Form SI-7 (proposed).pdf		No		Paper Only
Form and Instruction	SI-8 (proposed)	Verification of Medical Information	Form SI-8 (proposed).pdf		No		Paper Only
Form and Instruction	SI-1b (proposed)	Statement of Sickness	Form SI-1b (proposed).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 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	44,850	-11,000	55,850
Annual IC Time Burden (Hours)	5,977	-1,467	7,444
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.