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Supplemental Information on Accident and Insurance
Supplemental Information on Accident and Insurance
OMB: 3220-0036
IC ID: 33850
OMB.report
RRB
OMB 3220-0036
ICR 201203-3220-001
IC 33850
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0036 can be found here:
2024-06-27 - Revision of a currently approved collection
2020-11-24 - Revision of a currently approved collection
Documents and Forms
Document Name
Document Type
Form SI-1C (03-09)
Supplemental Information on Accident and Insurance
Form and Instruction
SI-1C (03-09) Supplemental Information on Accident and Insurance
Form SI-1c (03-09).pdf
Form and Instruction
ID-30K (03-02) Notice to Request Supplemental Information on Injury or
Form ID-30K (03-02).pdf
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Supplemental Information on Accident and Insurance
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 341
20 CFR 340
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form and Instruction
SI-1C (03-09)
Supplemental Information on Accident and Insurance
Form SI-1c (03-09).pdf
No
Paper Only
Form
ID-30K (03-02)
Notice to Request Supplemental Information on Injury or Illness
Form ID-30K (03-02).pdf
No
Paper Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Litigation and Judicial Activities
Subfunction:
Resolution Facilitation
Privacy Act System of Records
Title:
RRB-21, Railroad Unemployment and Sickness Insurance Benefit System
FR Citation:
75 FR 43725
Number of Respondents:
600
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
600
0
0
-2,400
0
3,000
Annual IC Time Burden (Hours)
50
0
0
-200
0
250
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
No associated records found
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.