3220-0079

OMB NO. 3220-0079

Justification

Certification Regarding Rights to Unemployment Benefits

RRB Form UI-45

1. Circumstances of information collection - Under Section 4 of the Railroad Unemployment Insurance Act (RUIA), an employee who leaves work voluntarily is disqualified for unemployment benefits unless the employee left work for good cause and is not qualified for unemployment benefits under any other law.

The procedures covering determinations when an employee leaves work voluntarily are contained in instructions issued by the Director of Policy and Systems under authority prescribed in 20 CFR 320.5. These instructions are contained in Article 15 of the Adjudication Instructional Manual (AIM) and Chapter 315 of Part II of the Field Operating Manual (FOM).

2. Purposes of collecting/consequences of not collecting the information - Form UI-45, Claimant Statement-Voluntary Leaving of Work, is used by the Railroad Retirement Board (RRB) to obtain the claimant’s statement when there is an indication that the claimant voluntarily left work. This indication can come from the claimant, the claimant’s employer, or another source; such as from information the claimant puts on Form UI-1, Application for Unemployment Benefits, or Form UI-3, Claim for Unemployment Benefits (OMB No. 3220-0022), or from a state wage match discrepancy or a railroad employer's protest.

Form UI-45 is used to obtain:

 information from a claimant regarding the nature of the job left and the reason(s) for leaving. This information is used by RRB office personnel to determine whether or not a claimant left work voluntarily and with good cause;

 information concerning the claimant's work history outside of the railroad industry during the last two years; and,

 "Yes/No" responses from the claimant regarding potential entitlement to state unemployment or other unemployment benefits payable under any law other than the RUIA. This information includes whether the claimant has filed a claim for state or other unemployment benefits since voluntarily leaving the job. If denied these benefits we ask that a copy of the benefit award notice or decision be provided. This information assists the RRB office in determining whether a claimant should be disqualified for RUIA benefits because of entitlement to state unemployment benefits.

Form UI-45 is usually used during a personal interview by RRB office personnel. Occasionally, it is mailed to the claimant in response to information the claimant provided on Form UI-3. The claimant’s social security number, name, and appropriate RRB office return address are prefilled before the form is released. The completed form is returned to the RRB office in a preaddressed un-franked envelope provided for that purpose. Completion of Form UI-45 is self-explanatory.

After receipt of the completed form or after the personal interview, the RRB office representative contacts the railroad employer by telephone to verify the information given by the employee in Section 1, Item C of Form UI-45, “Reason(s) for Leaving,” and records the verification on Form UI-33, District Office Record of Determinations as to Voluntary Quit. Form UI-33 is also used by the RRB office representative to record any determinations made about the case.

The RRB proposes no changes to Form UI-45.

To our knowledge no other agency uses forms similar to Form UI-45.

3. Planned use of improved information technology or technical/legal impediments to further burden reduction - Not cost effective due to low volume.

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 since the information is solicited only once for each investigation involving a claimant who has voluntarily left work.

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 89521 of the December 12, 2016, 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-6, Unemployment Insurance Records, and RRB-21, Railroad Unemployment and Sickness Insurance Benefits System. 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 - None

12. Estimate of respondent burden - The current burden for this collection is not changed.

Current Burden

Form Number	Annual Responses	Time (Minutes)	Burden (Hours)
UI-45	200	15	50
Total	200		50

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

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

15. Explanation for changes in burden - N.A.

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

17. Request not to display OMB expiration date - The form associated with this collection is seldom revised. Given the costs associated with redrafting, reprinting, and distributing the form 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 form.

18. Exceptions to Certification Statement - None

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