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	2014-08-01

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: 201407-3220-004
Status: Historical Active	Previous ICR Reference No: 201203-3220-001
Agency/Subagency: RRB	Agency Tracking No:
Title: Supplemental Information on Accident and Insurance
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/19/2014
	Date Received in OIRA: 08/01/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2017	36 Months From Approved	08/31/2015
Responses	10,802	0	17,382
Time Burden (Hours)	561	0	892
Cost Burden (Dollars)	0	0	0

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

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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

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 27940	05/15/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 42842	07/23/2014
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Supplemental Information on Accident and Insurance	SI-1C (03-09), ID-30K (03-02)	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), ID-3S (Internet) (proposed), ID-3U (Internet) (proposed)	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 ,   Request for Lien Information; Report of Settlement ,   Request for Section 2(f) Information

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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	10,802	17,382	0	2,500	-9,080	0
Annual Time Burden (Hours)	561	892	0	125	-456	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: The overall burden estimated for the collection has decreased significantly primarily due to improved tracking capabilities that allow the RRB's to more accurately determine the amount of annual responses. The annual responses for the information collection have decreased from 17,382 to 10,805 (6,580) and the burden hours from 892 to 561 (-331). The burden was calculated by taking the overall reduction (against the current amount) of - 9,080 responses and - 456 hours which the RRB has shown as an adjustment and offsetting that amount with the addition of the burden for the two new Internet equivalent forms (ID-3s and ID-3u) an increase of +2,500 responses and +125 burden hours which the RRB has shown as a program change.

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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

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Common Form ICR:  No

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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: 08/01/2014

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