Railroad Unemployment Insurance Act Applications

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form SI-3 (Internet) (x Claim for Sickness Benefits	Form and Instruction	Modified	Repair queued
Form SI-3 (02-09) Claim for Sickness Benefits	Form	Modified	Repair queued
Form SI-1A (03-12) Application for Sickness Benefits	Form	Modified	Repair queued
Form SI-3 (Internet)(10 Claim for Sickness Benefits	Form and Instruction	Modified	Repair queued
Form ID-11A (04-17) Requesting Reason for Late Filing of Sickness Benefit	Form and Instruction	Modified	Repair queued
Form SI-1A (03-12) Railroad Unemployment Insurance Act Applications	Form	Modified	Repair queued
Form SI-1b (xx-xx) Statement of Sickness	Form and Instruction	Modified	Repair queued
Form SI-8 (02-17) Verification of Medical Information	Form and Instruction	Modified	Repair queued
Form SI-7 (03-17) Supplemental Doctor's Statement	Form and Instruction	Modified	Repair queued
Form SI-1b (06-09) Statement of Sickness	Form and Instruction	Modified	Repair queued
Form SI-8 (02-17) Railroad Unemployment Insurance Act Applications	Form and Instruction	Modified	Repair queued
3220-0039.docx	Supporting Statement A	Uploaded 2020-08-21	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
33857	Railroad Unemployment Insurance Act Applications	Form and Instruction	Modified	Claim for Sickness Benefits
33857	Railroad Unemployment Insurance Act Applications	Form	Modified	Claim for Sickness Benefits
33857	Railroad Unemployment Insurance Act Applications	Form	Modified	Application for Sickness Benefits
33857	Railroad Unemployment Insurance Act Applications	Form and Instruction	Modified	Claim for Sickness Benefits
33857	Railroad Unemployment Insurance Act Applications	Form and Instruction	Modified	Requesting Reason for Late Filing of Sickness Benefit
33857	Railroad Unemployment Insurance Act Applications	Form	Modified
179107	Railroad Unemployment Insurance Act Applications	Form and Instruction	Modified	Statement of Sickness
179107	Railroad Unemployment Insurance Act Applications	Form and Instruction	Modified	Verification of Medical Information
179107	Railroad Unemployment Insurance Act Applications	Form and Instruction	Modified	Supplemental Doctor's Statement
179107	Railroad Unemployment Insurance Act Applications	Form and Instruction	Modified	Statement of Sickness
179107	Railroad Unemployment Insurance Act Applications	Form and Instruction	Modified

ICR Details

OMB Control No: 3220-0039	ICR Reference No: 202007-3220-001
Status: Historical Active	Previous ICR Reference No: 201706-3220-001
Agency/Subagency: RRB	Agency Tracking No:
Title: Railroad Unemployment Insurance Act Applications
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 07/28/2021
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/24/2020
Terms of Clearance: In response to comments, Agency updated forms to state that a "health care provider" could complete form instead of using the term "doctor."

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2024	36 Months From Approved	07/31/2021
Responses	245,724	0	245,724
Time Burden (Hours)	23,604	0	23,604
Cost Burden (Dollars)	0	0	0

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Abstract: Under Section 2 of the Railroad Unemployment Insurance Act, sickness benefits are payable to qualified railroad employees who are unable to work because of illness or injury. The collection obtains information from railroad employees and physicians needed to determine eligibility to and the amount of such benefits.

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Authorizing Statute(s): US Code: 45 USC 362 (i) Name of Law: Railroad Unemploment Insurance Act
   US Code: 45 USC 362(n) 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:
	85 FR 36888	06/18/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 51795	08/21/2020
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
Railroad Unemployment Insurance Act Applications	SI-8 (02-17), SI-7 (03-17), SI-1b (06-09), SI-1b (xx-xx)	Statement of Sickness ,   Supplemental Doctor's Statement ,   Verification of Medical Information ,   Statement of Sickness
Railroad Unemployment Insurance Act Applications	SI-1A (03-12), SI-3 (02-09), SI-3 (Internet)(10-10) , ID-11A (04-17), SI-3 (Internet) (xx-xx)	Requesting Reason for Late Filing of Sickness Benefit ,   Claim for Sickness Benefits ,   Application for Sickness Benefits ,   Claim for Sickness Benefits ,   Claim for Sickness Benefits

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ICR Summary of Burden

table that charts list 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	245,724	245,724	0	0	0	0
Annual Time Burden (Hours)	23,604	23,604	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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? No

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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: 08/24/2020

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