Supplemental Information on Accident and Insurance

Forms and Documents

Document Name	Status
Form SI-1C (03-09) Supplemental Information on Accident and Insurance Form and Instruction	Modified
Form SI-5 (12-93) Supplemental Information on Accident and Insurance Form and Instruction	Modified
3220-0036.doc Supporting Statement A	2012-03-30

IC Document Collections

IC ID	Document Title	Status
33850	Supplemental Information on Accident and Insurance Form and Instruction	Modified
187866	Supplemental Information on Accident and Insurance Form and Instruction	Modified

ICR Details

OMB Control No: 3220-0036	ICR Reference No: 201203-3220-001
Status: Historical Active	Previous ICR Reference No: 200901-3220-002
Agency/Subagency: RRB	Agency Tracking No:
Title: Supplemental Information on Accident and Insurance
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/02/2012
	Date Received in OIRA: 03/30/2012
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2015	36 Months From Approved	08/31/2012
Responses	17,382	0	28,500
Time Burden (Hours)	892	0	1,693
Cost Burden (Dollars)	0	0	0

---

Abstract: 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 that is needed to determine the amount of the RRB's reimbursement from the person or company responsible for such payments.

---

Authorizing Statute(s): US Code: 45 USC 362(o) Name of Law: Railroad Unemployment Insurance Act
   US Code: 45 USC 362(l) Name of Law: Railroad Unemployment Insurance Act
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 80988	12/27/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 16870	03/22/2012
Did the Agency receive public comments on this ICR? No

---

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

IC Title	Form No.	Form Name
Supplemental Information on Accident and Insurance	ID-30K (03-02), SI-1C (03-09)	Supplemental Information on Accident and Insurance ,   Notice to Request Supplemental Information on Injury or Illness
Supplemental Information on Accident and Insurance	ID-30K-1 (03-02), SI-5 (12-93), ID-3S-1 (03-09), ID-3S (03-09), ID-3U (03-09)	Report of Payments to Employee Claiming Sickness Benefits Under the RUIA ,   Request for Lien Information; Report of Settlement ,   Lien Information Under Section 12(o) of the RUIA ,   Request for Section 2(f) Information ,   Request for Supplemental Information on Injury or Illness - 3rd party

---

ICR Summary 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	17,382	28,500	0	0	-11,118	0
Annual Time Burden (Hours)	892	1,693	0	0	-801	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement:

---

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? Yes

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]? No

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

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  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:

(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: 03/30/2012

---