3220-0039

OMB NO. 3220-0039

Justification

Railroad Unemployment Insurance Act Applications

RRB Forms SI-1a, SI-1b, SI-3, SI-3 (Internet),

SI-7, SI-8, ID-7H, ID-11A and ID-11B

1. Circumstances of information collection - Under Section 2 of the Railroad Unemployment Insurance Act (RUIA), sickness benefits are payable to qualified railroad employees who are unable to work because of illness or injury. In addition, sickness benefits are payable to qualified female employees if they are unable to work, or if working would be injurious, because of pregnancy, miscarriage, or childbirth. Under Section 1(k) of the RUIA, a statement of sickness, with respect to days of sickness of an employee, is to be filed with the Railroad Retirement Board (RRB) within a 10-day period from the first day claimed as a day of sickness. The RRB's authority for requesting supplemental medical information is Section 12(i) and 12(n) of the RUIA.

The procedures for claiming sickness benefits and for the RRB to obtain supplemental medical information needed to determine a claimant's eligibility for such benefits are prescribed in 20 CFR Part 335.

2. Purpose of collecting the information - The forms currently used by the RRB to obtain the information needed to determine eligibility for, and the amount of, sickness benefits due a claimant follow.

Forms SI-1a, Application for Sickness Benefits and SI-1b, Statement of Sickness, are submitted to the RRB when a railroad employee wishes to claim sickness benefits. Form SI‑1a acts as an application and the first claim. To satisfy a one-week waiting period requirement, no benefits are payable to an employee for his or her first 7 days of sickness in the first claim period of continuing sickness unless they have already satisfied the waiting period requirement in the benefit year. However, if the employee has at least 5 days of sickness in the 14-day registration period, he or she should file a Form SI-1a and have an SI‑1b completed by his or her doctor. Even though no benefits would be payable, the filing of the SI-1a, along with the medical evidence provided on the SI-1b serves, in most cases, as the employee's first claim in the benefit year. Future benefits may then be claimed and received by the employee in subsequent registration periods for any sick days more than four in each registration period during the remaining benefit year.

Form SI-1a, which is completed by the employee or by someone else on the employee's behalf, requests identifying information, data about the employee's last employer, accident and insurance information, other benefits received for days of sickness, and direct deposit information. Form SI-1b is completed by the railroad employee's doctor to support the employee's claim of the inability to work because of illness or injury. As a convenience, on the reverse side of Form SI-1b is Form SI-10, Statement of Authority to Act for Employee (OMB No. 3220-0034), which enables a spouse or other person to complete and sign RRB sickness benefit forms on behalf of the employee who is incapable of signing forms. Only a small percentage of applicants will need to have Form SI-10 completed.

The RRB proposes no changes to Form SI-1a and Form SI-1b.

Form SI-3, Claim for Sickness Benefits, which is used to claim additional sickness benefits, is sent by the RRB to a claimant who has previously filed for sickness benefits on Forms SI‑1a/1b. The form notifies the claimant of the registration period covered by the claim (normally 14 days) and instructs the claimant to furnish information regarding days of sickness, days worked, and other benefits. In addition, space is provided for the claimant to report receipt of various payments that affect benefit eligibility. The form is used by a claimant for sickness benefits due to pregnancy just as in any other sickness benefit cases.

When the claimant returns a completed Form SI-3, the RRB sends another Form SI-3 for the next 14-day period, and so on, until (1) the probable ending date of inability to work is reached, (2) the claimant reports returning to work, or (3) sickness benefits are exhausted, whichever occurs first.

In circumstances where the probable ending date of inability to work is reached first, the claimant is advised that no further sickness benefits will be paid unless additional medical evidence is submitted.

The RRB proposes no changes to Form SI-3.

Form SI-3 (Internet), Claim for Sickness Benefits, provides railroad employees with an Internet filing option as part of the RRB’s overall plan to provide its customers with the option to submit information or to transact business electronically, when practical, as a substitute for paper.

Before Form SI-3 (Internet) can be filed electronically, a claimant must apply for a Password Request Code (PRC) from the RRB. After receiving the PRC the claimant must establish a PIN/Password (OMB approved 3220-0198) online to gain access to the sickness application and claim forms.

Form SI-3 (Internet) essentially collects the same information collected on the manual SI-3, however, it takes advantage of opportunities to electronically edit and skip unnecessary items. If the last day of the claim is more than 30 days after the current date, a pop-up screen asks the claimant to explain why the claim is being filed late. A claimant that files timely does not see the pop-up screen.

Upon completion of Questions 1 through 5, a review screen, which recaps the information provided, appears to give the claimant an opportunity to review and/or modify any of the information provided to that point. Question 6 provides for the certification of the information and the submission of the claim, or the deletion of the claim. It also enables a claimant who has already chosen payments by direct deposit to update bank information, or to switch to payment by check due to hardship.

Form ID-11A, Notice of Late Filing, is a computer-generated form letter which the RRB sends a claimant when Forms SI-1a/1b are not received within 30 days from the first day that sickness benefits were claimed. If the claimant tried to file the application on time but was unable to do so, the form requests the claimant provide an explanation in items 1‑9 on the form. Prior to releasing the form, the RRB prefills the earliest date for which the claimant could start receiving sickness benefits because of the late filing. 20 CFR 355.4 provides conditions for which the RRB considers a form “timely filed.” The RRB may consider circumstances “beyond a claimant’s control” as “timely filed” even if it was not received by the RRB during the prescribed time limits.

The RRB proposes no changes to Form ID-11A.

Form ID-11B, Notice of Insufficient Medical and Late Filing, is sent to a claimant whose sickness application does not contain sufficient medical information to make a filing determination and is received after the 10-day time limit as prescribed under the RUIA.

An RRB sickness claims examiner will release this letter when initially adjudicating a sickness application that does not contain sufficient medical evidence or an acceptable statement of late filing. If the claimant tried to file the application on time but was unable to do so, the reverse side of the form requests the claimant provide an explanation by completing items 1-9. 20 CFR 355.4 provides conditions for which the RRB considers a form “timely filed.” The RRB may consider circumstances “beyond a claimant’s control” as “timely filed” even if it was not received by the RRB during the prescribed time limits.

The RRB is deleting Form ID-11B from the information collection due to less than 10 annual responses.

Form SI-7, Supplemental Doctor's Statement, is completed by a doctor to obtain medical evidence needed to supplement the medical information submitted by the employee's doctor on Form SI-1b. Supplemental medical evidence is needed when the medical evidence of record is insufficient to continue benefit payments. Instructions are printed on the form for the claimant and the claimant's doctor.

The claimant's name, address, social security number and the estimated ending date of sickness benefits are entered by the RRB on the front side. Codes relative to the claimant's medical and benefit information of record are also entered at the bottom on the reverse side (for RRB use only). Form SI-7 is also used by the RRB in situations where more detailed medical evidence is required to make a determination concerning a claimant's eligibility to work and his or her continued eligibility for sickness benefits. Form ID-7L, Notice to Claimant, is used to transmit Form SI-7 to the claimant in these cases.

The RRB proposes no changes to Form SI-7.

Form SI-8, Verification of Medical Information, is mailed to a doctor of a sickness benefit claimant to verify medical statements and information provided to the RRB by the railroad employee. The doctor is selected on the basis of a random sample check of Forms SI-1b and SI-7 received by the Office of Programs.

A photocopy of a medical report received by the RRB from the claimant's doctor is attached to the SI-8. The SI-8 requests the doctor to examine the medical report to verify that:

 the person cited in the report is a current patient;

 the doctor's office actually completed the report; and

 the report was accurate when made.

If, upon review of the medical report by the doctor, the report meets these three criteria, the doctor is instructed to discard both the Form SI-8 and the report itself. However, if the report does not meet one or more of these three criteria, the doctor is requested to provide an explanation or comments, along with appropriate report corrections in the bottom portion of the form. The completed SI-8 is then returned to the RRB in the return envelope provided.

Form SI-8 is also mailed on a routine basis to doctors who do not provide National Provider Identifiers on completed medical statements.

The RRB proposes no changes to Form SI-8.

Form ID-7H, Non-Entitlement to Sickness Benefits and Information on Unemployment Benefits, is a computer-generated form letter in which the claimant is advised that, according to their Application for Sickness Benefits, they do not have a sufficient number of days of sickness to establish a valid claim. The letter also informs the claimant that if they were unable to work for a longer period of time, they can request a reconsideration of our determination. This request must include a statement from the claimant’s doctor indicating the date that the claimant was able to return to work, or is expected to be able to work. Form ID‑7H also advises that if the claimant is unemployed, able to work and available for work, they may be eligible for unemployment benefits and where to seek an application.

The RRB is deleting Form ID-7H from the information collection due to less than 10 annual responses.

NOTE 1: Form UB-11, Sickness Benefits for Railroad Employees, is an informational booklet which contains copies of Forms SI-1a and SI-1b/SI-10, and a pre-addressed envelope to the Office of Programs at RRB headquarters. The booklet also contains the Paperwork Reduction Act and Privacy Act notifications for Forms SI-1a, SI‑1b, SI-3 and ID-7h and instructions for the filing of sickness benefits and claims for this collection.

To our knowledge no other agency uses forms similar to the SI-1a, SI-1b, SI-3, SI-3 (Internet) SI-7, SI-8, ID-7H, ID-11a or ID-11b.

NOTE 2: The RRB is requesting only an 18 month authority for the information collection as we continue to evaluate program integrity enhancements. It is likely that the RRB will revise the information collection during that timeframe.

3. Planned use of improved information technology or technical/legal impediments to further burden reduction - Not practicable for Forms SI-1a, SI-1b, SI-7 and SI-8 as they are part of larger process that will not be automated. Not practicable for Forms ID-11a, because RRB initiates the form and it has pre-filled data. Form SI-3 is now programmed for Internet processing.

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

5. Small business respondents - N.A.

6. Consequences of less frequent collection - Not applicable to Forms SI-1a, SI-1b, or ID-11A, since the RUIA requires a claimant to apply for benefits once during each spell of sickness. Consequently, less frequent collection of the information by these forms would be contrary to law. Under RRB regulations, a Form SI-3 must be filed for each 14-day registration period in which sick days are claimed. Failure to file a claim form would result in a loss of sickness benefits to the employee for that particular registration period. Also, not applicable to Form SI-8 since the information obtained by this form is solicited only once. Less frequent use of Form SI-7 would result in erroneous benefit payments for days on which the claimant is able to work.

7. Special circumstances - None

8. 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 57421 of the September 18, 2013, Federal Register. No comments or requests for additional information were received.

9. Payments or gifts to Respondents – None

10. Confidentiality - Privacy Act System of Records, RRB-21, Railroad Unemployment and Sick-ness Insurance Benefit System http://www.rrb.gov/bis/privacy_act/SORN_2010/RRB21.pdf. 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.

11. Sensitive questions - N.A.

12. Estimate of respondent burden - The current and proposed burden for the information collection follows:

Current Burden

Form Number	Annual Responses	Time (Minutes)	Burden (Hours)
SI-1a/1b (ee) (#)	17,000	10	2,833
SI-1a/1b* (doctor)	17,000	8	2,267
SI-3 (#)	118,150	5	9,846
SI-3 (Internet)	20,850	5	1,738
SI-7*	22,600	8	3,013
SI-8*	50	5	4
ID-7H (#)	50	5	4
ID-11A (#)	800	4	53
ID-11B (#)	1,000	4	67
Total	197,500		19,825

^(#) IC - Individuals or Households

^(*) IC - Business or other for profit

Proposed Burden

Form Number	Annual Responses	Time (Minutes)	Burden (Hours)
SI-1a (Employee) #	16,000	10	2,667
SI-1b (Doctor) *	16,000	8	2,133
SI-3 (Manual) #	126,490	5	10,541
SI-3 (Internet) #	33,443	5	2,787
SI-7*	21,472	8	2,863
SI-8*	26	5	2
ID-11A#	518	4	35
Total	213,949		21,028

^(#) IC - Individuals or Households

^(*) IC - Business or other for profit

Responses Hours

Total Change +16,449 +1,203

Adjustment +16,449 +1,203

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

14. Estimate of cost to the Federal Government - N.A.

15. Explanation for change in burden – The RRB has enhanced its tracking and reporting systems. Actual responses received (instead of estimates) can now be calculated and has resulted in a more accurate and increased overall burden estimate for the information collection. Notable changes were observed in the amount of claimants using our web-site as the SI-3 (Internet) showed an increase of 12,593 responses and 1,049 burden hours from previous estimates. Conversely, Forms ID-7H and ID-11B are being deleted from the information collection due to less than 10 responses per year being received. We are showing the overall increase of 16,449 responses an 1.203 burden hours as an adjustment.

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

17. Request not to display OMB expiration date - Given the costs associated with reprogramming, redrafting, reprinting, and distributing the forms in this collection in order to keep the appropriate expiration date in place, the RRB requests the authority to not display the OMB expiration date on the forms associated with this collection.

18. Exceptions to Certification Statement - None

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