Railroad Unemployment Insurance Act Applications

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SI-3 (Internet)(pr Claim for Sickness Benefits	Form and Instruction	Modified	Available
Form ID-11B (07-07) Notice of Insufficient Medical and Late Filing	Form and Instruction	Modified	Available
Form ID-11A (07-07) Requesting Reason for Late Filing of Sickness Benefit	Form and Instruction	Modified	Available
Form ID-7H (09-99) Non-Entitlement to Sickness Benefits and Information on Unemployment Insurance Benefits	Form and Instruction	Modified	Available
Form SI-3 (07-04) Claim for Sickness Benefits	Form	Modified	Available
Form SI-1a (02-01) Application for Sickness Benefits	Form	Modified	Available
Form SI-8 (06-09) Verification of Medical Information	Form and Instruction	Modified	Available
Form SI-7 (06-09) Supplemental Doctor's Statement	Form and Instruction	Modified	Available
Form SI-1b (06-09) Statement of Sickness	Form and Instruction	Modified	Available
3220-0039.doc	Supporting Statement A	Uploaded 2010-07-28	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
33857	Railroad Unemployment Insurance Act Applications	Form and Instruction	Modified	Claim for Sickness Benefits
33857	Railroad Unemployment Insurance Act Applications	Form and Instruction	Modified	Notice of Insufficient Medical and Late Filing
33857	Railroad Unemployment Insurance Act Applications	Form and Instruction	Modified	Requesting Reason for Late Filing of Sickness Benefit
33857	Railroad Unemployment Insurance Act Applications	Form and Instruction	Modified	Non-Entitlement to Sickness Benefits and Information on Unemployment Insurance Benefits
33857	Railroad Unemployment Insurance Act Applications	Form	Modified	Claim for Sickness Benefits
33857	Railroad Unemployment Insurance Act Applications	Form	Modified	Application for Sickness Benefits
179107	Railroad Unemployment Insurance Act Applications	Form and Instruction	Modified	Verification of Medical Information
179107	Railroad Unemployment Insurance Act Applications	Form and Instruction	Modified	Supplemental Doctor's Statement
179107	Railroad Unemployment Insurance Act Applications	Form and Instruction	Modified	Statement of Sickness

ICR Details

OMB Control No: 3220-0039	ICR Reference No: 201007-3220-001
Status: Historical Active	Previous ICR Reference No: 200812-3220-003
Agency/Subagency: RRB	Agency Tracking No:
Title: Railroad Unemployment Insurance Act Applications
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/16/2010
Retrieve Notice of Action (NOA)	Date Received in OIRA: 07/28/2010
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2013	36 Months From Approved	02/29/2012
Responses	197,500	0	213,900
Time Burden (Hours)	19,825	0	21,884
Cost Burden (Dollars)	0	0	0

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Abstract: Under Section 2 of the Railroad Unemployment Insurance Act, sickness benefits are payable to qualified railroad employees who are unable to work because of illness or injury. The collection obtains information from railroad employees and physicians needed to determine eligibility to and the amount of such benefits.

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Authorizing Statute(s): US Code: 45 USC 362 (i) Name of Law: Railroad Unemploment Insurance Act
   US Code: 45 USC 362(n) Name of Law: Railroad Unemployment Insurance Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 15464	03/29/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 42469	07/21/2010
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Railroad Unemployment Insurance Act Applications	SI-8 (06-09), SI-7 (06-09), SI-1b (06-09)	Statement of Sickness ,   Supplemental Doctor's Statement ,   Verification of Medical Information
Railroad Unemployment Insurance Act Applications	SI-3 (Internet)(proposed) , ID-11A (07-07), SI-1a (02-01), SI-3 (07-04), ID-7H (09-99), ID-11B (07-07)	Application for Sickness Benefits ,   Claim for Sickness Benefits ,   Non-Entitlement to Sickness Benefits and Information on Unemployment Insurance Benefits ,   Requesting Reason for Late Filing of Sickness Benefit ,   Notice of Insufficient Medical and Late Filing ,   Claim for Sickness Benefits

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ICR Summary of Burden

table that charts list of burden

	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	197,500	213,900	0	20,850	-37,250	0
Annual Time Burden (Hours)	19,825	21,884	0	1,738	-3,797	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Enhanced RRB program tracking capabilities allows the RRB to reduce the estimate of Forms SI-1ab and SI-3 filed to reflect actual usage (adjustment). Part of the reduction in the estimate of SI-3’s filed is offset by the increased burden associated with the implementation of the proposed Internet SI-3 (program change). Overall, there is a decline of 16,400 responses and 2,059 hours of burden for the collection.

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 07/28/2010

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