3220-0036

OMB NO. 3220-0036

Justification

Supplemental Information on Accident and Insurance

RRB Forms SI-1c, SI-5, ID-3s, ID-3s-1, ID-3u, ID-30k, ID-30k-1

1. Circumstances of information collection - Under section 12(o) of the Railroad Unemployment Insurance Act (RUIA), the Railroad Retirement Board (RRB) is entitled to reimbursement of the sickness benefits paid to a railroad employee if the employee receives a sum or damages for the same infirmity for which the benefits were paid.

Section 2(f) of the RUIA requires that employers reimburse the RRB for benefits paid to an employee for days for which salary, wages, pay for time lost or other remuneration is later determined to be payable. Reimbursements under section 2(f) generally result from the award of pay for time lost or the payment of guaranteed wages. The RUIA prescribes that the amount of benefits paid be deducted and held by the employer in a special fund for reimbursement to the RRB.

The procedures for recovery of such benefits are prescribed in 20 CFR 340 and 341.

2. Purposes of collecting/consequences of not collecting the information - Under 20 CFR 341.4, an employee who has applied for sickness benefits and has reported an infirmity that was caused by a third party is to provide the name and address of the person or company who is alleged to have caused the infirmity. Moreover, the employee is to provide whatever details are reasonably needed so that the RRB may establish its lien upon any sum or damages paid or payable to that employee. Further, under 20 CFR 341.6 when a person or company makes a settlement or must satisfy a final judgment based on any injury for which the employee received sickness benefits, the person or company must notify the RRB of the settlement or judgment. That notice must be in writing and submitted within 5 days of the settlement or final judgment. The notification should contain the amount, the date, and the amount withheld to satisfy the RRB's lien.

Similarly, if a payment subject to section 2(f) of the RUIA is to be made, employers must contact the RRB to obtain the amount of benefits paid for the period so that the proper reimbursement is made to the RRB.

The RRB forms currently used for these purposes are Forms SI-1c, SI-5, ID-3s, ID-3u, ID‑30k, and ID-30k-1. Details about each of the forms follow:

Form SI-1c, Supplemental Information on Accident and Insurance is used by the RRB to obtain specific information from a claimant about the identity of the person or persons who may be responsible for the payment of damages to the claimant. Form SI-1c is used when the application for sickness benefits, Form SI-1a, Application for Sickness Benefits (OMB No. 3220-0039), or another source indicates that the claimant may receive a sum or damages for the same injury for which sickness benefits are claimed and the person or company to whom a notice of lien should be sent is not on record. Completion of Form SI-1c is self-explanatory.

The RRB proposes no changes to Form SI-1c.

Form SI-5, Report of Payments to Employee Claiming Sickness Benefits Under the Railroad Unemployment Insurance Act, is used by the RRB to obtain the information needed to determine the amount of reimbursement to which the RRB is entitled from a railroad employer. Form SI-5 obtains information not only on sums or damages paid or payable to the employee, but also on pay for time lost and workers' compensation, since under sections 2(f) and 4(a-1)(ii) of the RUIA, these payments can affect the amount of reimbursement. The form is mailed to the railroad employer who could be liable for the personal injury settlement based on information supplied by the employee on Form SI‑1a, Application for Sickness Benefits, or Form SI-1c.

Forms SI-5 is computer generated. Each form is accompanied by a computer-generated Form ID-30b, Notice of Lien, which serves as a transmittal letter. The employee's name and other identifying information on the ID-30b and SI-5 are pre-filled by the RRB. Completion of the form is self-explanatory.

The RRB proposes no changes to Form SI-5.

Form ID-3s, Request for Lien Information; Report of Settlement, is used by a railroad employer to obtain section 12(o) information and to report personal injury settlements by facsimile machine. The form is sent by a railroad employer to the RRB when a personal injury claim is nearing settlement and information regarding the amount of the RRB's lien is required so that proper reimbursement can be made to the RRB. Based on identifying information entered on the form by the railroad employer in items 1-8, the RRB computes the amount of the lien, enters it in items 9 and 10, and then transmits the completed form to the railroad employer by fax. The form can also be used to provide notice of a settlement to the RRB.

We estimate that the RRB faxes the completed Form ID-3s in over 90% of the cases involving employer requests for lien information. The remaining employer requests are made by telephone. The identifying information provided by employers when making telephone requests is identical to the information provided by employers on Form ID-3s. Completion of Form ID-3s is self-explanatory.

The E-mail equivalent provides employers the option of transmitting and receiving ID-3s information electronically via E-mail. Details regarding the process follow.

The E-mail equivalent ID-3s collects essentially the same information as the manual Form ID-3s. The E-mail is sent by a railroad employer to the RRB when a personal injury claim is nearing settlement and information regarding the amount of the RRB’s lien is required so that proper reimbursement can be made to the RRB. Based on the information provided, the RRB computes the amount of the lien and then transmits a response to the railroad employer via E-mail. An E-mail can also be used to provide notice of a settlement from an employer to the RRB.

The E-mail equivalent ID-3s is formatted and filed in accordance with procedures outlined in the enclosed Program Letter No. 2006-05 titled “E-mail Requests for 12(o) and 2(f) Reimbursement Amounts” (see exhibits). In addition to outlining informational requirements for each transaction (response), the program letter conveys information necessary to ensure that the transactions are conducted in a secure environment.

The RRB proposes no changes to Form ID-3s.

Form ID-3s-1, Lien Information under Section 12(o) of the RUIA, is similar to Form ID-3s, and is used by an attorney and/or the insurer responsible for paying personal-injury damages to the railroad employee for third-party liability cases. The form is used to obtain section 12(o) information from the RRB and provides for the reporting of personal-injury settlements by facsimile machine (fax). Internal RRB reviews show that a small group of attorneys and insurance companies represent a substantial number of railroad employees or liable parties where the provisions of section 12(o) are applicable. The form is for their use in order to provide improved customer service. Initially, an attorney or insurer requesting lien information completes items 1 through 5 of Form ID-3s-1 and then transmits the form via to the RRB. The RRB provides the lien amount information and then sends a fax of the completed Form ID-3s-1 back to the inquirer.

We estimate that the RRB faxes the completed Form ID-3s-1 in about 80% of the cases involving attorney/insurer requests for lien information. The remaining attorney/insurer requests are made by telephone. The identifying information provided by the attorneys/insurers when making telephone requests is identical to the information provided by the attorneys/insurers on Form ID-3s-1. Completion of Form ID-3s-1 is self-explanatory.

The RRB proposes no changes to Form ID-3s-1.

Form ID-3u, Request for Section 2(f) Information, is used by railroad employers to obtain section 2(f) information by facsimile machine (fax). The form is transmitted by railroad employers to the RRB when salary, wages, pay for time lost or other remuneration is determined to be payable for days for which benefits under the RUIA may also have been paid to an individual. Based on identifying information entered on the form by the railroad employer in items 1‑7, the RRB computes the amount of benefits to be reimbursed, enters it in item 8, and returns the completed form to the railroad employer by fax.

We estimate that the RRB faxes the completed Form ID‑3u in over 80% of the cases involving employer requests for section 2(f) information. The remaining employer requests are made by telephone. Completion of Form ID-3u is self-explanatory.

The E-mail equivalent ID-3u collects essentially the same information as the manual Form ID-3u. The E-mail is sent by railroad employers when salary, wages, pay for time lost or other remuneration is determined to be payable for days in which benefits under the RUIA may also have been paid to an individual. Based on the information provided by the railroad employer, the RRB computes the amount of benefits to be reimbursed, and then transmits a response to the railroad employer via E-mail.

The E-mail equivalent ID-3u, is filed in accordance with procedures outlined in Program Letter No. 2006-05 titled “E-mail Requests for 12(o) and 2(f) Reimbursement Amounts” (see exhibits). In addition to outlining informational requirements for each transaction (response), the program letter conveys information necessary to ensure that the transactions are conducted in a secure environment.

The RRB proposes no changes to Form ID-3u.

Form ID-30k, Notice to Request Supplemental Information on Injury or Illness, is released by the RRB when notice of a monetary settlement (Form SI-5) has not been received from the responsible third party after a year has elapsed and is used to obtain up-to-date information from the claimant regarding the status of the monetary settlement. If, after approximately 6 months, the first ID-30k has not been completed and returned to the RRB a follow-up ID-30k is sent to the claimant. Completion of Form ID-30k is self-explanatory.

The RRB proposes no changes to Form ID-30k.

Form ID-30k-1, Request Supplemental Information on Injury or Illness, is released by the RRB along with transmittal letter ID-30D-1, Request for Information on Injury or Illness, to obtain section 12(o) information directly from the third party or from the insurer responsible for paying personal-injury damages to the railroad employee. Similar to the ID‑30k, which is sent to the RUIA claimant, Form ID-30k-1 is sent when notice of a monetary settlement (Form SI-5) has not been received from the responsible third party after a year has elapsed. The form is released at the same time as the ID-30k.

The RRB has the authority under section 12(a) of the RUIA to subpoena such information in cases where the railroad employee, the attorney, the liable party and third party's insurance company, willfully fail to provide information about the employee's personal injury claim. Before the RRB can request service of a subpoena, however, it must show that it has exhausted all other attempts to obtain the necessary information. Form ID-30k-1 makes it possible to meet this requirement because it provides the RRB with the means to request 12(o) settlement information directly from the insured (third party), or from the insurer responsible for paying the personal-injury damages. Experience has shown that the rate of response from insurance companies, with respect to 12(o) settlement inquiries, is generally high--close to 100%. The response rate to the ID-30k from the RUIA claimant, however, is much lower. Therefore, use of Form ID-30k-1 also facilitates the collection of benefits recoverable under section 12(o).

The ID-30k-1 is also used in place of Form SI-5 (see page 2) for third-party liability cases. When released with an initial Notice of Lien (RRB Forms ID-30b-1, and ID-30b-2), the form obtains information directly from the third party or from the insurer responsible for paying personal-injury damages to the railroad employee. (The early release of this form allows the RRB to initiate collection actions sooner and increase the likelihood of recovery of monies owed the RRB under section 12(o) for third-party liability cases.)

Completion of Form ID-30k-1 is self-explanatory.

The RRB proposes no changes to Form ID-30k-1.

To our knowledge no other agency uses forms similar to Forms SI-1c, SI-5, ID-3s, ID-3s-1, ID-3u, ID-30k and ID-30k-1.

3. Planned use of improved information technology or technical/legal impediments to further burden reduction - The RRB uses the E-mail equivalents of Form ID-3s and ID-3u as a means of automating the information collection process. Forms SI-5, ID-3s.1 and ID-3k-1 are not practical because they are initiated by the RRB with pre-filled data and are not cost-effective due to low volume. Form SI-1c is part of a larger process that will not be automated.

4. Efforts to identify duplication - This data collection does not duplicate any other information collection.

5. Small business respondents - N.A.

6. Consequence of less frequent collection - Not applicable since the information is obtained only once.

7. Special circumstances - None

8. Public comments/consultations outside the agency - In accordance with 5 CFR 1320.8(d), comments were invited from the public regarding the information collection. The notice to the public was published on page 80988 of the December 27, 2011, Federal Register. No comments or requests for additional information were received.

9. Payments or gifts to respondents - None.

10. Consultations outside the agency – N.A.

11. Confidentiality - Privacy Act System of Records, RRB-21, Railroad Unemployment and Sickness Insurance Benefit System - RRB. In accordance with OMB Circular M-03-22, a Privacy Impact Assessment for this information collection was completed and can be found at http://www.rrb.gov/pdf/PIA/PIA-BPO.pdf.

12. Sensitive questions - N.A.

13. Estimate of respondent burden - The current burden and proposed for the collection is as follows.

Current Burden****

Form Number	Annual Responses	Time (Minutes)	Burden (Hours)
SI-1c	1,000	5	83
SI-5	2,500	5	208
ID-3s (paper & telephone)	9,250	3	463
ID-3s (E-mail)	9,250	3	463
ID-3s-1 (paper & telephone)	500	3	25
ID-3u (paper & telephone)	7,500	3	38 375
ID-3u (E-mail)	7,500	3	38 375
ID-30k	2,000	5	167
ID-30k-1	2,500	5	208
Total	**** 28,500 42,000		****1,693

**** Note that the current burden, which has been in place unchanged and uncorrected by either RRB or OMB since January 2006 was improperly calculated and should have been 42,000 responses (see highlight) not 28,500. The number of total burden hours in the chart is correct. However, some of the numbers used in the calculation were not (see highlight).

Proposed Burden

Form Number	Annual Responses	Time (Minutes)	Burden (Hours)
SI-1c	500	5	42
SI-5	7	5	1
ID-3s (paper & telephone)	7,000	3	350
ID-3s (E-mail)	7,000	3	350
ID-3s-1 (paper & telephone)	500	3	25
ID-3u (paper & telephone)	1,100	3	55
ID-3u (E-mail)	1,100	3	55
ID-30k	100	5	8
ID-30k-1	75	5	6
Total	17,382		892

Responses Hours

Total Burden Change -11,118 -801

Adjustment -11,118 -801

14. Estimated annual cost to respondents or record keepers - N.A.

14. Estimate of cost to Federal government - N.A.

14. Explanation for change in burden – All responses received are now maintained within the RRB’s Imaging System allowing the agency to track total responses down to the individual response.

The burden change since last approved by OMB, of -11,118 responses (from 28,500 to 17,382) and -801 burden hours (from 1,693 to 892) has been shown as an adjustment. The RRB, as stated earlier, acknowledges the miscalculation of total responses and portions of the burden hour calculations submitted and approved previously

14. Time schedule for data collection and publication - The results of this collection will not be published.

14. Request not to display OMB expiration date - Given the costs associated with redrafting, reprinting, computer programming and distribution of the forms in this collection in order to keep the appropriate OMB expiration date in place, the RRB requests the authority to not display the OMB expiration date on the forms associated with this collection.

14. Exceptions to Certification Statement - None

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