Information Collection

Railroad Unemployment Insurance Act Applications

IC 33857 under ICR 201007-3220-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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-1a (02-01) Railroad Unemployment Insurance Act Applications	Form
SI-1a (02-01) Application for Sickness Benefits SI-1a (02-01).pdf www.rrb.gov/pdf/PandS/ub11.pdf	Form
SI-3 (07-04) Claim for Sickness Benefits SI-3 (07-04).pdf	Form
ID-7H (09-99) Non-Entitlement to Sickness Benefits and Information on Form ID-7H (09-99).pdf	Form and Instruction
ID-11A (07-07) Requesting Reason for Late Filing of Sickness Benefit Form ID-11A (current).pdf	Form and Instruction
ID-11B (07-07) Notice of Insufficient Medical and Late Filing Form ID-11B (current).pdf	Form and Instruction
SI-3 (Internet)(pr Claim for Sickness Benefits SI-3 (Internet)(proposed) .pdf	Form and Instruction
UB-11 (06-09).pdf UB-11, Sickness Benefits for Railroad Employees	IC Document
Form UB-11 (proposed).pdf UB-11, 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: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 335

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	SI-1a (02-01)	Application for Sickness Benefits	SI-1a (02-01).pdf	http://www.rrb.gov/pdf/PandS/ub11.pdf	Yes	No	Printable Only
Form	SI-3 (07-04)	Claim for Sickness Benefits	SI-3 (07-04).pdf		No		Paper Only
Form and Instruction	ID-7H (09-99)	Non-Entitlement to Sickness Benefits and Information on Unemployment Insurance Benefits	Form ID-7H (09-99).pdf		No		Paper Only
Form and Instruction	ID-11A (07-07)	Requesting Reason for Late Filing of Sickness Benefit	Form ID-11A (current).pdf		No		Paper Only
Form and Instruction	ID-11B (07-07)	Notice of Insufficient Medical and Late Filing	Form ID-11B (current).pdf		No		Paper Only
Form and Instruction	SI-3 (Internet)(proposed)	Claim for Sickness Benefits	SI-3 (Internet)(proposed) .pdf		Yes	Yes	Fillable Fileable Signable

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: 17,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	157,850	20,850	-32,050	169,050
Annual IC Time Burden (Hours)	14,541	1,738	-3,104	15,907
Annual IC Cost Burden (Dollars)	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
UB-11, Sickness Benefits for Railroad Employees	UB-11 (06-09).pdf	07/26/2010
UB-11, Sickness Benefits for Railroad Employees	Form UB-11 (proposed).pdf	07/26/2010

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